The Role of Dairy in Effectiveness and Cost of Treatment of Children With Moderate Acute Malnutrition: A Narrative Review

Enrichment of Biscuits with Andaliman and Fermented Buffalo Milk Biscuits for the Intervention of Malnutrition in Children Under Five

BACKGROUND: Nutritional problems in children under 5 in Indonesia are very large and need effective intervention. Local ingredient is potential to create enrichment biscuits. AIM: This study aims to produce biscuits enriched with Andaliman (Zanthoxylum acanthopodium) and fermented buffalo milk and to perform organoleptic tests on the taste, color, aroma, and texture of the biscuits. METHODS: Three types of biscuits were made, namely, biscuits without Andaliman and fermented buffalo milk, biscuits with 2 g of Andaliman and 200 g of fermented buffalo milk, and biscuits with 3 g of Andaliman and 200 g of fermented buffalo milk. The all three biscuits were then tested organoleptically in the form of preferences by a panel of expert teachers to see choices for taste, color, aroma, and texture. The biscuits are then tested in a laboratory to assess their nutritional content. RESULTS: Biscuits with 2 g of Andaliman and 200 g of fermented buffalo milk had the greatest preference. Statistically, the three groups of biscuits differed in taste, aroma, and texture (p < 0.05). The nutritional content of biscuits is above the standards set by the Ministry of Health. CONCLUSION: Biscuits containing 2 g of Andaliman and 200 g of fermented buffalo milk have the potential to be produced as one of the intervention methods for under 5-year-old children malnutrition in Indonesia.

Protein quality in ready-to-use supplementary foods for moderate wasting

There are no guidelines for the optimal protein quality of ready-to-supplementary food (RUSF) for moderate acute malnutrition (MAM). This randomized, controlled, double-blinded, clinical effectiveness trial evaluated two RUSFs in the treatment of MAM. Both foods contained greater than 7% dairy protein, but the protein-optimized RUSF had a calculated digestible indispensable amino acid score (DIAAS) of 95%, whereas the control RUSF had a calculated DIAAS of 63%. There were 1,737 rural Malawian children 6-59 months of age treated with 75 kcal/kg/day of either control or protein quality-optimized RUSF for up to 12 weeks. There was no difference in the proportion of children who recovered from MAM between the group that received protein-optimized RUSF (759/860, 88%) and the group that received control RUSF (766/877, 87%, difference 1%, 95% CI, -2.1 to 4.1, p = 0.61). There were no differences in time to recovery or average weight gain; nor were adverse effects reported. Both RUSFs showed indistinguishable clinical outcomes, with recovery rates higher than typically seen in treatment for MAM. The DIAAS of these two RUSFs was measured using a pig model. Unexpectedly, the protein quality of the optimized RUSF was inferior to the control RUSF: DIAAS = 82% for the protein quality optimized RUSF and 96% for control RUSF. The controlled conditions of this trial suggest that in supplementary food products for MAM, protein quality is not an independent predictor of clinical effectiveness.

Acute malnutrition recovery energy requirements based on mid-upper arm circumference: Secondary analysis of feeding program data from 5 countries, Combined Protocol for Acute Malnutrition Study (ComPAS) Stage 1

Background

Severe and moderate acute malnutrition (SAM and MAM) are currently treated with different food products in separate treatment programs. The development of a unified and simplified treatment protocol using a single food product aims to increase treatment program efficiency and effectiveness. This study, the first stage of the ComPAS trial, sought to assess rate of growth and energy requirements among children recovering from acute malnutrition in order to design a simplified, MUAC-based dosage protocol.

Methods

We obtained secondary data from patient cards of children aged 6–59 months recovering from SAM in outpatient therapeutic feeding programs (TFPs) and from MAM in supplementary feeding programs (SFPs) in five countries in Africa and Asia. We used local polynomial smoothing to assess changes in MUAC and proportional weight gain between clinic visits and assessed their normalized differences for a non-zero linear trend. We estimated energy needs to meet or exceed the growth observed in 95% of visits.

Results

This analysis used data from 5518 patients representing 33942 visits. Growth trends in MUAC and proportional weight gain were not significantly different, each lower at higher MUAC values: MUAC growth averaged 2mm/week at lower MUACs (100 to <110mm) and 1mm/week at higher MUACs (120mm to <125mm); and proportional weight gain declined from 3.9g/kg/day to 2.4g/kg/day across the same MUAC values. In 95% of visits by children with a MUAC 100mm to <125mm who were successfully treated, energy needs could be met or exceeded with 1,000 kilocalories a day.

Conclusion

Two 92g sachets of Ready-to-Use Therapeutic Food (RUTF) (1,000kcal total) is proposed to meet the estimated total energy requirements of children with a MUAC 100mm to <115mm, and one 92g sachet of RUTF (500kcal) is proposed to meet half the energy requirements of children with a MUAC of 115 to <125mm. A simplified, combined protocol may enable a more holistic continuum of care, potentially contributing to increased coverage for children suffering from acute malnutrition.

Cost-Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso: A Geographically Randomized Trial

BACKGROUND

There is a variety of specialized nutritious foods available for use in programs targeting undernutrition, but evidence supporting the choice of product is limited.

OBJECTIVES

We compared the cost-effectiveness of 4 specialized nutritious foods to prevent stunting and wasting in children aged 6-23 mo in Burkina Faso.

METHODS

Four geographic regions were randomly assigned to 1 of 4 intervention arms: Corn-Soy Blend Plus (CSB+) programmed with separate fortified vegetable oil (the reference food), Corn-Soy-Whey Blend (CSWB; a new formulation) with oil, SuperCereal Plus (SC+), and ready-to-use supplementary food (RUSF). We compared the effects of each intervention arm on growth (length-for-age z score (LAZ), weight-for-length z score (WLZ), end-line stunting (LAZ < -2), and total monthly measurements of wasting (WLZ < -2). Rations were ∼500 kcal/d, distributed monthly. Children were enrolled in the blanket supplementary feeding program at age ∼6 mo and measured monthly for ∼18 mo. Average costs per child reached were linked with effectiveness to compare the cost-effectiveness of each arm with CSB+ with oil.

RESULTS

In our sample of 6112 children (CSB+, n = 1519; CSWB, n = 1503; SC+, n = 1564; RUSF, n = 1526), none of the foods prevented declines in growth. Children in the SC+ and RUSF arms were not significantly different than those in the CSB+ with oil arm. Children in the CSWB with oil arm experienced higher end-line (measurement at age 22.9-23.9 mo) stunting (OR: 2.07; 95% CI: 1.46, 2.94) and more months of wasting (incidence rate ratio: 1.29; 95% CI: 1.09, 1.51). CSB+ with oil was the least-expensive ration in all costing scenarios ($113-131 2018 US dollars/enrolled child) and similar in effectiveness to SC+ and RUSF, and thus the most cost-effective product for the defined purposes.

CONCLUSIONS

CSB+ with oil was the most cost-effective ration in the prevention of wasting and stunting in this trial. This trial was registered at clinicaltrials.gov as NCT02071563.

Factors that May Influence the Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso

BACKGROUND

A trial in Burkina Faso compared the cost-effectiveness of 4 specialized nutritious foods (SNFs) used to prevent stunting and wasting in children aged 6-23 mo.

OBJECTIVES

This article explores differences in SNF use that may have influenced effectiveness, specifically in relation to consumption by the recipient child and by any other person (i.e., sharing), other diversion from the recipient child, preparation, storage, and hygiene.

METHODS

Subsamples from a geographically clustered, longitudinal trial with random assignment to Corn Soy Blend Plus with oil (CSB+ w/oil), Corn Soy Whey Blend with oil (CSWB w/oil), Super Cereal Plus (SC+), or ready-to-use supplementary food (RUSF) were selected for in-depth interviews, in-home observations, and focus group discussions.

RESULTS

Sharing was common in all arms, with the highest reported in SC+ (73%) and highest observed in CSWB w/oil (36%). Some reported giving the ration away (highest in SC+ at 17%) or using it for other purposes (highest in CSWB w/oil at 17%). The recipient child was observed consuming the ration in 49% of households on average (38-60% by arm in CSB+ w/oil and RUSF, respectively). Qualitative reports of bitterness and spoilage emerged in the CSWB w/oil arm. Most observed households (excluding RUSF) did not prepare porridge daily as instructed (35-46% by arm). Household water samples showed either high-risk or unsafe contamination with Escherichia coli (72-78% by arm). Low percentages were observed handwashing (both child and server) before consuming the porridge.

CONCLUSIONS

The SNFs were not prepared or served as intended and diversion from the recipient was common. Storage conditions may have resulted in spoilage of the ration containing whey before reaching recipients. This article provides context about factors that may have influenced the effectiveness of these SNFs. Programming and household use of SNFs are as important as their nutrient composition. This trial was registered at clinicaltrials.gov as NCT02071563.

Effects of animal protein supplementation of mothers, preterm infants, and term infants on growth outcomes in childhood: a systematic review and meta-analysis of randomized trials

BACKGROUND

Child stunting is a major public health problem, afflicting 155 million people worldwide. Lack of animal-source protein has been identified as a risk, but effects of animal protein supplementation are not well established.

OBJECTIVE

The aim of this study was to investigate effects of animal protein supplementation in mothers, preterm infants, and term infants/children on birth and growth outcomes.

METHODS

PubMed, EMBASE, Cochrane library, Web of Science, Cumulative Index of Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature were searched for randomized controlled trials of animal protein supplementation in mothers or infants and children (≤age 5 y), evaluating measures of anthropometry (≤age 18 y). Main outcomes included birth weight, low birth weight, small for gestational age at birth; height, height-for-age, weight, weight-for-age, weight-for-length, stunting, and wasting ≤18 y of age. Data were extracted independently in duplicate, and findings pooled using inverse variance meta-analysis. Heterogeneity was explored using I2, stratified analysis, and meta-regression, and publication bias by funnel plots, Egger's test, and fill/trim methods.

RESULTS

Of 6808 unique abstracts and 357 full-text articles, 62 trials were included. The 62 trials comprised over 30,000 participants across 5 continents, including formula-based supplementation in infants and food-based supplementation in pregnancy and childhood. Maternal supplementation increased birth weight by 0.06 kg, and both formula and food-based supplementation in term infants/young children increased weight by ≤0.14 kg. Neither formula nor food-based supplementation for term infants/young children increased height, whereas the height-for-age z-score was increased in the food-based (+0.06 z-score) but not formula-based (-0.11 z-score) trials reporting this outcome. In term infants, the weight-for-length z-score was increased in trials of formula (+0.24 z-score) and food supplementation (+0.06 z-score), whereas food supplementation was also associated with reduced odds of stunting (-13%).

CONCLUSIONS

Supplementation of protein from animal-source foods generally increased weight and weight-for-length in children, but with more limited effects on other growth outcomes such as attained height.

Useful Tools for Food Aid: Linear Programming and Protein Quality Tools

The development of a superior treatment option for severe acute malnutrition (SAM) which allowed for home-based therapy put in place constraints that are crucial for ensuring the feasibility and nutritional integrity of the treatment. Soon after the initial success of ready-to-use therapeutic food (RUTF), there were attempts to modify the formulation for cost and other areas of acceptability. While alternative formulations have been taken on in clinical trials, they have been inferior to the standard RUTF recipe. Linear programming (LP) technology, however, has streamlined the formulation process allowing the user to account for the crucial constraints required to maintain the feasibility and nutritional integrity of standard RUTF. With the aid of an LP tool and other functional tools for assessing nutrient quality, nutrition researchers can use innovative approaches in food development that could potentially revolutionize food aid products.

Growth Components of Cow's Milk: Emphasis on Effects in Undernourished Children

BACKGROUND

Cow's milk is a core ingredient in foods for prevention and treatment of undernutrition in children. It promotes growth, but there is limited knowledge of which components in milk have growth-stimulating effects.

OBJECTIVE

To discuss the growth-stimulating effects of milk in undernourished children with emphasis on protein, lactose, and minerals.

METHODS

We reviewed literature on dairy and growth in undernourished children.

RESULTS

Cow's milk has a specific stimulating effect on linear growth, even in well-nourished children, and it may stimulate weight gain and muscle accretion in wasted children. Dairy protein has high protein quality scores with no major differences between whey protein concentrate and dried skimmed milk. Lactose has potential growth-stimulating effects, and the high content of potassium, phosphorus, magnesium, and zinc in milk is also likely to stimulate growth. Furthermore, a high dairy content reduces the amount of antinutrients from plant protein.

CONCLUSIONS

Dairy protein, lactose, and bioavailable minerals all have potential growth-stimulating effects, which make cow's milk an important ingredient in foods for undernourished children. Different dairy ingredients vary with regard to protein amount and quality, content of lactose, and minerals, and thereby growth stimulating effects. This should be taken into consideration when deciding which dairy ingredient to use. Challenges include the relatively high cost of dairy. Therefore, future studies should include cost-effectiveness analysis and assessment of the desirable content of each growth-promoting milk component.

Milk products in the dietary management of childhood undernutrition - a historical review

The present narrative review outlines the use of milk products in infant and young child feeding from early history until today and illustrates how research findings and technical innovations contributed to the evolution of milk-based strategies to combat undernutrition in children below the age of 5 years. From the onset of social welfare initiatives, dairy products were provided by maternal and child health services to improve nutrition. During the last century, a number of aetiological theories on oedematous forms of undernutrition were developed and until the 1970s the dogma of protein deficiency was dominant. Thereafter, a multifactorial concept gained acceptance and protein quality was emphasised. During the last decades, research findings demonstrated that the inclusion of dairy products in the management of severe acute malnutrition is most effective. For children suffering from moderate acute malnutrition the evidence for the superiority of milk-based diets is less clear. There is an unmet need for evaluating locally produced milk-free alternatives at lower cost, especially in countries that rely on imported dairy products. New strategies for the dietary management of childhood undernutrition need to be developed on the basis of research findings, current child feeding practices, socio-cultural conditions and local resources. Exclusive and continued breast-feeding supported by community-based nutrition programmes using optimal combinations of locally available complementary foods should be compared with milk product-based interventions.

Sufficient Protein Quality of Food Aid Varies with the Physiologic Status of Recipients

Protein quality scores use the amino acid (AA) requirements of a healthy North American child. AA requirements vary with physiologic status. We estimated AA requirements for healthy North American children, children with environmental enteric dysfunction, children recovering from wasting, and children with an acute infection. The protein quality of food aid products was then calculated to determine whether it was sufficient in all these groups, and we found that it may not be adequate for all of them. Physiologic status is important when assessing the protein quality of food aid. Rates of weight gain from 8 published trials treating children with moderate acute malnutrition were abstracted, and protein quality scores from the corresponding food aid products were calculated with the use of the digestible indispensable amino acid score (DIAAS). Two DIAAS values were calculated, one in healthy children aged 1-3 y as a reference population and the other in malnourished children aged 1-3 y as a reference population. These data were used to calculate the best fit regression line between weight gain and protein quality. The slope of the regression line was greater when malnourished children were used as a reference population than when healthy children were used (0.128; 95% CI: 0.118, 0.138 compared with 0.097; 95% CI: 0.090, 0.105 measured in g · kg-1 · d-1 · DIASS U-1). These findings suggest that adjusting AA requirements for physiologic status may more accurately estimate the minimum protein quality of food aid products.