1
|
Beggs B, Bustos M, Brubacher LJ, Little M, Lau L, Dodd W. Facilitators and barriers to implementing complex community-based interventions for addressing acute malnutrition in low- and lower-middle income countries: A scoping review. Nutr Health 2024; 30:447-462. [PMID: 38767155 PMCID: PMC11401341 DOI: 10.1177/02601060241253327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background: Community-based nutrition interventions have been established as the standard of care for identifying and treating acute malnutrition among children 6-59 months in low- and lower-middle-income countries. However, limited research has examined the factors that influence the implementation of the community-based component of interventions that address severe acute malnutrition and moderate acute malnutrition among children. Aim: The objective of this review was to identify and describe the facilitators and barriers in implementing complex community-based nutrition interventions to address acute malnutrition among children in low- and lower-middle-income countries. Methods: This review used a systematic search strategy to identify existing peer-reviewed literature from three databases on complex community-based interventions (defined as including active surveillance, treatment, and education in community settings) to address severe acute malnutrition and moderate acute malnutrition in children. Results: In total, 1771 sources were retrieved from peer-reviewed databases, with 38 sources included in the review, covering 26 different interventions. Through an iterative deductive and inductive analysis approach, three main domains (household and interpersonal, sociocultural and geographical; operational and administrative) and eight mechanisms were classified, which were central to the successful implementation of complex community-based interventions to address acute child malnutrition. Conclusion: Overall, this review highlights the importance of addressing contextual and geographical challenges to support participant access and program operations. There is a need to critically examine program design and structure to promote intervention adherence and effectiveness. In addition, there is an opportunity to direct resources towards community health workers to facilitate long-term community trust and engagement.
Collapse
Affiliation(s)
- Bridget Beggs
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Monica Bustos
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | - Matthew Little
- School of Public Health and Social Policy, University of Victoria, Victoria, BC, Canada
| | - Lincoln Lau
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
- International Care Ministries, Manila, Philippines
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Warren Dodd
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| |
Collapse
|
2
|
Maru Y, Tamiru D, Baye K, Chitekwe S, Lailou A, Darsene H, Abdulai R, Worku M, Belachew T. Effect of a simplified approach on recovery of children 6-59 months with wasting in Ethiopia: A noninferiority, cluster randomized controlled trial. MATERNAL & CHILD NUTRITION 2024:e13670. [PMID: 38800892 DOI: 10.1111/mcn.13670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
Worldwide, nearly 45 million children under the age of 5 years were affected by wasting in 2022. Ethiopia has been challenged by disasters increasing the caseload of children with wasting. This study aimed to determine the effect of a simplified approach on recovery of children with acute malnutrition as compared with the standard protocol. A cluster randomized, controlled, noninferiority trial was carried out in three regions of Ethiopia from December 4, 2021, to July 30, 2022. A total of 58 clusters (health posts) were randomized into intervention and control groups. Children with SAM in the intervention groups received two sachets of Ready-to-Use Therapeutic Food (RUTF), whereas children in the control groups received RUTF based on their body weight. Children with moderate acute malnutrition (MAM) received one sachet of RUTF and one sachet of Ready-to-Use Supplementary Food (RUSF) daily in the intervention and control groups, respectively. Per protocol (PP) and intention-to-treat analysis were used to compare recovery at a noninferiority margin of 15%. Data were collected from 55 health posts and 1032 children. In the PP analysis, the recovery rate of children with wasting among the simplified group (97.8%) was noninferior to the standard protocol group (97.7%), p = 0.399. The RUTF cost per treatment of child with SAM was 56.55 USD for the standard versus 42.78 USD for the simplified approach. The simplified approach is noninferior to the standard protocol in terms of recovery and has a lower cost of RUTF. Further study is recommended to assess the effectiveness of the simplified approach in emergency contexts.
Collapse
Affiliation(s)
- Yetayesh Maru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Arnaud Lailou
- UNICEF West and Central Africa Regional Office, Nutrition Section, Dakar, Senegal
| | - Hiwot Darsene
- Nutrition Coordination Office, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Rashid Abdulai
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Mesfin Worku
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Tefera Belachew
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| |
Collapse
|
3
|
Maru Y, Tamiru D, Baye K, Chitekwe S, Kifle YG, Lailou A, Belachew T. Comparing time to recovery in wasting treatment: simplified approach vs. standard protocol among children aged 6-59 months in Ethiopia-a cluster-randomized, controlled, non-inferiority trial. Front Pediatr 2024; 12:1337370. [PMID: 38840802 PMCID: PMC11150620 DOI: 10.3389/fped.2024.1337370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Wasting occurs when the body's nutritional needs are unmet due to insufficient intake or illness. It represents a significant global challenge, with approximately 45 million infants and children under 5 years of age suffering from wasting in 2022. Methods A cluster-randomized, controlled, non-inferiority trial was conducted in three regions of Ethiopia. A non-inferiority margin of 15%, along with a recovery rate of 90% and a minimum acceptable recovery rate of 75%, were considered alongside an intra-cluster correlation coefficient of 0.05 and an anticipated loss to follow-up of 10% in determining the total sample size of 1,052 children. Children with severe acute malnutrition (SAM) in the simplified group received two sachets of ready-to-use therapeutic food (RUTF) daily, while the standard group received RUTF based on their body weight. For moderate acute malnutrition (MAM) cases, the simplified group received one sachet of RUTF, whereas the standard group received one sachet of ready-to-use supplementary food daily. A non-parametric Kaplan-Meir curve was utilized to compare the survival time to recovery. Results A total of 1,032 data points were gathered. For SAM cases, the average length of stay was 8.86 (±3.91) weeks for the simplified protocol and 8.26 (±4.18) weeks for the standard protocol (P = 0.13). For MAM cases, the average length of stay was 8.18 (±2.96) weeks for the simplified approach and 8.32 (±3.55) weeks for the standard protocol (P = 0.61). There was no significant difference (P = 0.502) observed between the simplified protocol [8 weeks, interquartile range (IQR): 7.06-8.94] and the standard protocol [9 weeks (IQR: 8.17-9.83)] among children with SAM on the median time to cure. There was no significant difference (P = 0.502) in the time to cure between the simplified approach [8 weeks (IQR: 7.53-8.47)] and the standard protocol [8 weeks (IQR: 7.66-8.34)] among children with MAM. The survival curves displayed similarity, with the log-rank test not showing significance (P > 0.5), indicating the non-inferiority of the simplified approach for cure time. Conclusion The findings showed that the simplified and standard protocols demonstrated no significant differences in terms of the average duration of stay and time required for recovery. Clinical Trial Registration https://pactr.samrc.ac.za/, Identifier (PACTR202202496481398).
Collapse
Affiliation(s)
- Yetayesh Maru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
- Nutrition and Food Systems Division, Research Center for Inclusive Development in Africa (RIDA), Addis Ababa, Ethiopia
| | | | - Yehenew G. Kifle
- Department of Mathematics and Statistics, University of Maryland Baltimore County, Baltimore, MD, United States
| | - Arnaud Lailou
- Nutrition Section, UNICEF West and Central Africa Regional Office, Dakar, Senegal
| | - Tefera Belachew
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| |
Collapse
|
4
|
Bridge R, Lin TK. Evidence on the impact of community health workers in the prevention, identification, and management of undernutrition amongst children under the age of five in conflict-affected or fragile settings: a systematic literature review. Confl Health 2024; 18:16. [PMID: 38413996 PMCID: PMC10900658 DOI: 10.1186/s13031-024-00575-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/28/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Malnutrition, specifically undernutrition, is a significant global challenge that contributes to nearly half of deaths in children under the age of five. The burden of undernutrition is disproportionately borne by conflict-affected, fragile settings (CAFS); children living in a conflict zone being more than twice as likely to suffer from malnourishment. Community health worker (CHW) models have been employed in CAFS to improve healthcare coverage and identify and treat illnesses. However, there lacks systematic evidence on the impact of CHW models in preventing, identifying, and managing child undernutrition in CAFS. We conducted this review to systematically evaluate evidence of CHW models in preventing, identifying, and managing undernutrition in children under the age of five in CAFS. METHODOLOGY This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. The search strategy was developed using the Population-Intervention-Comparisons-Outcomes-Setting framework as a guide. Searches were performed using Ovid online database search platform, searching the databases of Ovid MEDLINE(R), COCHRANE, Embase Classic, Embase, Econlit, Global Health, SCOPUS, and Social Policy and Practice. Peer-reviewed publications were eligible for inclusion if they evaluated an intervention using a CHW model that aims to prevent, identify, or manage some form of undernutrition in children under five in a CAFS. RESULTS We identified 25 studies-spanning 10 countries-that were included in the systematic review. CHW models were implemented alongside a variety of interventions, including behaviour change communication, supplementary foods, nutrition counselling, and integrated community health programmes. Key barriers in implementing successful CHW models include disruption of programmes due to active conflict, states of emergency, militancy, or political unrest; weak links between the community-based interventions and public health system; weak health system capacity that impeded referral and follow-ups; and cost of care and care-seeking. Key facilitators include CHWs' connection to the community, close proximity of programmes to the community, supervision, and investment in high quality training and tools. CONCLUSIONS The findings suggest that CHW models may be effective, cost-effective, acceptable, feasible, and scalable in the prevention, identification, and management child undernutrition in CAFS. The study findings also confirmed a need for greater evidence in the field. These findings may inform policymaking, programme implementation, and design to strengthen best practices for CHW models addressing child undernutrition in CAFS.
Collapse
Affiliation(s)
| | - Tracy Kuo Lin
- Institute for Health and Aging, Department of Social and Behavioral Sciences, University of California, San Francisco, 490 Illinois St, 123K, San Francisco, CA, 94158, USA.
- Middle East Centre, London School of Economics and Political Science, London, UK.
| |
Collapse
|
5
|
López-Ejeda N, Charle-Cuéllar P, Samake S, Dougnon AO, Sánchez-Martínez LJ, Samake MN, Bagayoko A, Bunkembo M, Touré F, Vargas A, Guerrero S. Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali. Front Public Health 2024; 12:1283148. [PMID: 38450139 PMCID: PMC10915236 DOI: 10.3389/fpubh.2024.1283148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/12/2024] [Indexed: 03/08/2024] Open
Abstract
Background Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs). Methods A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units. Results The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%). Implications Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.
Collapse
Affiliation(s)
- Noemí López-Ejeda
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | - Salimata Samake
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Mahamadou N’tji Samake
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Aliou Bagayoko
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Magloire Bunkembo
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | - Fanta Touré
- West and Central Africa Regional Office, Action Against Hunger, Dakar, Senegal
| | - Antonio Vargas
- Nutrition and Health Department, Action Against Hunger, Madrid, Spain
| | - Saul Guerrero
- Child Nutrition and Development Office, UNICEF, New York, NY, United States
| |
Collapse
|
6
|
Kangas ST, Ouédraogo CT, Tounkara M, Ouoluoguem B, Coulibaly IN, Haidara A, Diarra NH, Diassana K, Tausanovitch Z, Ritz C, Wells JC, Briend A, Myatt M, Radin E, Bailey J. Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm randomized controlled trial. Trials 2024; 25:30. [PMID: 38191436 PMCID: PMC10773065 DOI: 10.1186/s13063-023-07890-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol. METHODS This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ. DISCUSSION This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.
Collapse
Affiliation(s)
| | | | - Moctar Tounkara
- Department of Education and Research in Public Health and Specialties, Faculty of Medicine and Dentistry, University of Sciences, Technics and Technologies of Bamako, Bamako, Mali
| | | | | | | | | | | | | | - Christian Ritz
- National Institute of Public Health, Copenhagen, Denmark
| | - Jonathan C Wells
- Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - André Briend
- Department of International Health, University of Tampere School of Medicine, Tampere, Finland
- Department of Nutrition, Exercise and Sports, Faculty of Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mark Myatt
- Brixton Health, Brixton, UK
- Emergency Nutrition Network, Kidlington, Oxforshire, UK
| | | | | |
Collapse
|
7
|
Sánchez-Martínez LJ, Charle-Cuéllar P, Gado AA, Dougnon AO, Sanoussi A, Ousmane N, Lazoumar RH, Toure F, Vargas A, Hernández CL, López-Ejeda N. Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger. Front Nutr 2023; 10:1253545. [PMID: 38099186 PMCID: PMC10719846 DOI: 10.3389/fnut.2023.1253545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Of the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers. Methods This study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers. Results The recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff. Conclusion The outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.
Collapse
Affiliation(s)
- Luis Javier Sánchez-Martínez
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey, Niger
| | | | | | - Fanta Toure
- Action Against Hunger, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Candela Lucía Hernández
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Noemí López-Ejeda
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
- EPINUT Research Group (Ref. 920325), Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| |
Collapse
|
8
|
Papadopoulou E, Lim YC, Chin WY, Dwan K, Munabi-Babigumira S, Lewin S. Lay health workers in primary and community health care for maternal and child health: identification and treatment of wasting in children. Cochrane Database Syst Rev 2023; 8:CD015311. [PMID: 37646367 PMCID: PMC10467022 DOI: 10.1002/14651858.cd015311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Since the early 2010s, there has been a push to enhance the capacity to effectively treat wasting in children through community-based service delivery models and thus reduce morbidity and mortality. OBJECTIVES To assess the effectiveness of identification and treatment of moderate and severe wasting in children aged five years or under by lay health workers working in the community compared with health providers working in health facilities. SEARCH METHODS We searched MEDLINE, CENTRAL, two other databases, and two ongoing trials registers to 24 September 2021. We also screened the reference lists of related systematic reviews and all included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies in children aged five years or under with moderate wasting (defined as weight-for-height Z-score (WHZ) below -2 but no lower than ≥ -3, or mid-upper-arm circumference (MUAC) below 125 mm but no lower than 115 mm, and no nutritional oedema) or severe wasting (WHZ below -3 or MUAC below 115 mm or nutritional oedema). Eligible interventions were: • identification by lay health workers (LHWs) of children with wasting (intervention 1); • identification by LHWs of children with wasting and medical complications needing referral (intervention 2); and • identification by LHWs of children with wasting without medical complications needing referral (intervention 3). Eligible comparators were: • identification and treatment of wasting by health professionals such as nurses or doctors (at health facilities); and • identification and treatment of wasting by health facility-based teams, including health professionals and LHWs. DATA COLLECTION AND ANALYSIS Two review authors independently screened trials, extracted data and assessed risk of bias using the Cochrane risk of bias tool (RoB 2) and Cochrane Effective Practice and Organisation of Care (EPOC) guidelines. We used a random-effects model to meta-analyse data, producing risk ratios (RRs) for dichotomous outcomes in trials with individual allocation, adjusted RRs for dichotomous outcomes in trials with cluster allocation (using the generic inverse variance method in Review Manager 5), and mean differences (MDs) for continuous outcomes. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included two RCTs and five non-RCTs. Six studies were from African countries, and one was from Pakistan. Six studies included children with severe wasting, and one included children with moderate wasting. All studies offered home-based ready-to-use therapeutic food treatment and monitoring. Children received antibiotics in three studies, vitamins or micronutrients in three studies, and deworming treatment in two studies. In three studies, the comparison arm involved LHWs screening children for malnutrition and referring them to health facilities for diagnosis and treatment. All the non-randomised studies had a high overall risk of bias. Interventions 1 and 2 Identification and referral for treatment by LHWs, compared with treatment by health professionals following self-referral, may result in little or no difference in the percentage of children who recover from moderate or severe wasting (MD 1.00%, 95% confidence interval (CI) -2.53 to 4.53; 1 RCT, 29,475 households; low certainty). Intervention 3 Compared with treatment by health professionals following identification by LHWs, identification and treatment of severe wasting in children by LHWs: • may slightly reduce improvement from severe wasting (RR 0.93, 95% CI 0.86 to 0.99; 1 RCT, 789 participants; low certainty); • may slightly increase non-response to treatment (RR 1.44, 95% CI 1.04 to 2.01; 1 RCT, 789 participants; low certainty); • may result in little or no difference in the number of children with WHZ above -2 on discharge (RR 0.94, 95% CI 0.28 to 3.18; 1 RCT, 789 participants; low certainty); • probably results in little or no difference in the number of children with WHZ between -3 and -2 on discharge (RR 1.09, 95% CI 0.87 to 1.36; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with WHZ below -3 (severe wasting) on discharge (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with MUAC equal to or greater than 115 mm on discharge (RR 0.99, 95% CI 0.93 to 1.06; 1 RCT, 789 participants; moderate certainty); • results in little or no difference in weight gain per day (mean weight gain 0.50 g/kg/day higher, 95% CI 1.74 lower to 2.74 higher; 1 RCT, 571 participants; high certainty); • probably has little or no effect on relapse of severe wasting (RR 1.03, 95% CI 0.69 to 1.54; 1 RCT, 649 participants; moderate certainty); • may have little or no effect on mortality among children with severe wasting (RR 0.46, 95% CI 0.04 to 5.98; 1 RCT, 829 participants; low certainty); • probably has little or no effect on the transfer of children with severe wasting to inpatient care (RR 3.71, 95% CI 0.36 to 38.23; 1 RCT, 829 participants; moderate certainty); and • probably has little or no effect on the default of children with severe wasting (RR 1.48, 95% CI 0.65 to 3.40; 1 RCT, 829 participants; moderate certainty). The evidence was very uncertain for total MUAC gain, MUAC gain per day, total weight gain, treatment coverage, and transfer to another LHW site or health facility. No studies examined sustained recovery, deterioration to severe wasting, appropriate identification of children with wasting or oedema, appropriate referral of children with moderate or severe wasting, adherence, or adverse effects and other harms. AUTHORS' CONCLUSIONS Identification and treatment of severe wasting in children who do not require inpatient care by LHWs, compared with treatment by health professionals, may lead to similar or slightly poorer outcomes. We found only two RCTs, and the evidence from non-randomised studies was of very low certainty for all outcomes due to serious risks of bias and imprecision. No studies included children aged under 6 months. Future studies must address these methodological issues.
Collapse
Affiliation(s)
| | | | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kerry Dwan
- The Liverpool School of Tropical Medicine, Liverpool, UK
| | - Susan Munabi-Babigumira
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Ålesund, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| |
Collapse
|
9
|
Phelan K, Seri B, Daures M, Yao C, Alitanou R, Aly AAM, Maidadji O, Sanoussi A, Mahamadou A, Cazes C, Moh R, Becquet R, Shepherd S. Treatment outcomes and associated factors for hospitalization of children treated for acute malnutrition under the OptiMA simplified protocol: a prospective observational cohort in rural Niger. Front Public Health 2023; 11:1199036. [PMID: 37475774 PMCID: PMC10354363 DOI: 10.3389/fpubh.2023.1199036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/14/2023] [Indexed: 07/22/2023] Open
Abstract
Introduction Globally, access to treatment for severe and moderate acute malnutrition is very low, in part because different protocols and products are used in separate programs. New approaches, defining acute malnutrition (AM) as mid-upper arm circumference (MUAC) < 125 mm or oedema, are being investigated to compare effectiveness to current programs. Optimizing Malnutrition treatment (OptiMA) is one such strategy that treats AM with one product - ready-to-use therapeutic food, or RUTF - at reduced dosage as the child improves. Methods This study aimed to determine whether OptiMA achieved effectiveness benchmarks established in the Nigerien National Nutrition protocol. A prospective cohort study of children in the rural Mirriah district evaluated outcomes among children 6-59 months with uncomplicated AM treated under OptiMA. In a parallel, unconnected program in one of the two trial sites, all non-malnourished children 6-23 months of age were provided small quantity lipid-based nutritional supplements (SQ-LNS). A multivariate logistic regression identified factors associated with hospitalization. Results From July-December 2019, 1,105 children were included for analysis. Prior to treatment, 39.3% of children received SQ-LNS. Recovery, non-response, and mortality rates were 82.3%, 12.6%, and 0.7%, respectively, and the hospitalization rate was 15.1%. Children who received SQ-LNS before an episode of AM were 43% less likely to be hospitalized (ORa=0.57; 0.39-0.85, p = 0.004). Discussion OptiMA had acceptable recovery compared to the Nigerien reference but non-response was high. Children who received SQ-LNS before treatment under OptiMA were less likely to be hospitalized, showing potential health benefits of combining simplified treatment protocols with food-based prevention in an area with a high burden of malnutrition such as rural Niger.
Collapse
Affiliation(s)
- Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Benjamin Seri
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Cyrille Yao
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Niamey, Niger
| | | | | | - Atté Sanoussi
- Ministry of Health, Nutrition Division, Niamey, Niger
| | - Aboubacar Mahamadou
- High-Commission of the Nigériens Nourrissent les Nigériens (3N) Initiative, Niamey, Niger
| | - Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Raoul Moh
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
- Dermatology and Infectiology Pedagogical Unit, Training and Research Units in Medical Sciences, Abidjan, Côte d'Ivoire
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| |
Collapse
|
10
|
Briend A, Myatt M, Berkley JA, Black RE, Boyd E, Garenne M, Lelijveld N, Isanaka S, McDonald CM, Mwangwome M, O’Brien KS, Schwinger C, Stobaugh H, Taneja S, West KP, Khara T. Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children. Public Health Nutr 2023; 26:1210-1221. [PMID: 36722310 PMCID: PMC10346023 DOI: 10.1017/s1368980023000149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/18/2022] [Accepted: 12/26/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children. DESIGN Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations. SETTING Community-based, prospective studies from twelve countries in Africa and Asia. PARTICIPANTS Children aged 6-59 months living in the study areas. RESULTS For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone. CONCLUSIONS Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.
Collapse
Affiliation(s)
- André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 30, DK-1958, Frederiksberg, Denmark
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Arvo building, Arvo Ylpön katu 34, FIN-33014Tampere, Finland
| | - Mark Myatt
- Brixton Health, Cilfach Greigiog, Fford Celynin, Llwyngwril, Gwynedd, UK
- Emergency Nutrition Network, Kidlington, OX, UK
| | - James A Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, UK
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erin Boyd
- USAID, Bureau for Humanitarian Assistance, Washington, DC, USA
- Tufts University, Boston, MA, USA
| | - Michel Garenne
- IRD, UMI Résiliences, Paris, France
- FERDI, Université d’Auvergne, Clermont-Ferrand, France
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christine M McDonald
- Departments of Pediatrics, and Epidemiology and Biostatistics, University of California, San Francisco, Oakland, CA, USA
| | - Martha Mwangwome
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Kenya Medical Research Institute (KEMRI), Centre for Geographic Medicine Research-Coast (CGMRC), Kilifi, Kenya
| | - Kieran S O’Brien
- Department of Ophthalmology, University of California, Francis I. Proctor Foundation, San Francisco, CA, USA
| | - Catherine Schwinger
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Heather Stobaugh
- Tufts University, Boston, MA, USA
- Action Against Hunger USA, New York, NY, USA
| | - Sunita Taneja
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Keith P West
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tanya Khara
- Emergency Nutrition Network, Kidlington, OX, UK
| |
Collapse
|
11
|
Charle-Cuéllar P, Lopez-Ejeda N, Aziz Gado A, Dougnon AO, Sanoussi A, Ousmane N, Hamidou Lazoumar R, Sánchez-Martínez LJ, Toure F, Vargas A, Guerrero S. Effectiveness and Coverage of Severe Acute Malnutrition Treatment with a Simplified Protocol in a Humanitarian Context in Diffa, Niger. Nutrients 2023; 15:nu15081975. [PMID: 37111194 PMCID: PMC10146545 DOI: 10.3390/nu15081975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND the aim of this study is to evaluate the effectiveness and coverage of a simplified protocol that is implemented in health centers (HCs) and health posts (HPs) for children who are suffering from severe acute malnutrition (SAM) in the humanitarian context of Diffa. METHODS We conducted a non-randomized community-controlled trial. The control group received outpatient treatment for SAM, without medical complications, at HCs and HPs with the standard protocol of community management of acute malnutrition (CMAM). Meanwhile, with respect to the intervention group, the children with SAM received treatment at the HCs and HPs through a simplified protocol wherein the mid-upper arm circumference (MUAC) and the presence of edema were used as the admission criteria, and the children with SAM were administered doses of fixed ready-to-use therapeutic food (RUTF). RESULTS A total of 508 children, who were all under 5 years and had SAM, were admitted into the study. The cured proportion was 87.4% in the control group versus 96.6% in the intervention group (p value = 0.001). There was no difference between the groups in the length of stay, which was 35 days, but the intervention group used a lower quantity of RUTF-70 sachets versus 90 sachets, per child cured. Coverage increases were observed in both groups. DISCUSSION the simplified protocol used at the HCs and HPs did not result in worse recovery and resulted in fewer discharge errors compared to the standard protocol.
Collapse
Affiliation(s)
| | - Noemi Lopez-Ejeda
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology, Faculty of Biological Sciences, and Evolution, Complutense University of Madrid, 28040 Madrid, Spain
| | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey BP 623, Niger
| | - Nassirou Ousmane
- Centre de Recherche Médicale et Sanitaire (CERMES), Niamey BP 10887, Niger
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (Ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology, Faculty of Biological Sciences, and Evolution, Complutense University of Madrid, 28040 Madrid, Spain
| | - Fanta Toure
- Action against Hunger, West and Central Africa Regional, Dakar BP 29621, Senegal
| | - Antonio Vargas
- Action against Hunger, C/Duque de Sevilla no. 3, 28002 Madrid, Spain
| | - Saul Guerrero
- United Nations International Children's Emergency Fund-UNICEF, 3 United Nations Plaza, New York, NY 10017, USA
| |
Collapse
|
12
|
Likoswe BH, Chimera-Khombe B, Patson N, Selemani A, Potani I, Phuka J, Maleta K. A Systematic Review on the Optimal Dose and Duration of Ready-to-Use Therapeutic Food (RUTF) for 6-59-Month-Old Children with Severe Wasting or Oedema. Nutrients 2023; 15:nu15071750. [PMID: 37049590 PMCID: PMC10096907 DOI: 10.3390/nu15071750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
The World Health Organisation (WHO) recommends that severe wasting and/or oedema should be treated with ready-to-use therapeutic food (RUTF) at a dose of 150-220 kcal/kg/day for 6-8 weeks. Emerging evidence suggests that variations of RUTF dosing regimens from the WHO recommendation are not inferior. We aimed to assess the comparative efficacy and effectiveness of different RUTF doses and durations in comparison with the current WHO RUTF dose recommendation for treating severe wasting and/or oedema among 6-59-month-old children. A systematic literature search identified three studies for inclusion, and the outcomes of interest included anthropometric recovery, anthropometric measures and indices, non-response, time to recovery, readmission, sustained recovery, and mortality. The study was registered with PROSPERO, CRD 42021276757. Only three studies were eligible for analysis. There was an overall high risk of bias for two of the studies and some concerns for the third study. Overall, there were no differences between the reduced and standard RUTF dose groups in all outcomes of interest. Despite the finding of no differences between reduced and standard-dose RUTF, the studies are too few to conclusively declare that reduced RUTF dose was more efficacious than standard RUTF.
Collapse
Affiliation(s)
- Blessings H Likoswe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Bernadette Chimera-Khombe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Noel Patson
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Apatsa Selemani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Isabel Potani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - John Phuka
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Kenneth Maleta
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| |
Collapse
|
13
|
The effect of short-term preoperative nutritional intervention for cleft surgery eligibility. BMC Nutr 2023; 9:47. [PMID: 36918940 PMCID: PMC10012294 DOI: 10.1186/s40795-023-00704-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/06/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Children with orofacial clefts are highly susceptible to malnutrition, with severe malnutrition restricting their eligibility to receive safe surgery. Ready-to-use therapeutic foods (RUTF) are an effective treatment for malnutrition; however, the effectiveness has not been demonstrated in this patient population prior to surgery. We studied the effectiveness of short-term RUTF use in transitioning children with malnutrition, who were initially ineligible for surgery, into surgical candidates. METHODS A cohort of patients from Ghana, Honduras, Malawi, Madagascar, Nicaragua, and Venezuela enrolled in a nutrition program were followed by Operation Smile from June 2017 to January 2020. Age, weight, and length/height were tracked at each visit. Patients were included until they were sufficiently nourished (Z > = -1) with a secondary outcome of receiving surgery. The study was part of a collaborative program between Operation Smile (NGO), Birdsong Peanuts (peanut shellers and distributors), and MANA Nutrition (RUTF producer). RESULTS A total of 556 patients were recruited between June 2017 and January 2020. At baseline 28.2% (n = 157) of patients were diagnosed with severe, 21.0% (n = 117) moderate, and 50.7% (n = 282) mild malnutrition. 324 (58.3%) presented for at least one return visit. Of those, 207 (63.7%) reached optimal nutrition status. By visit two, the mean z-score increased from -2.5 (moderate) to -1.7 (mild) (p < 0·001). The mean time to attain optimal nutrition was 6 weeks. There was a significant difference in the proportion of patients who improved by country(p < 0.001). CONCLUSION Malnutrition prevents many children with orofacial clefts in low- and middle-income countries from receiving surgical care even when provided for free. This creates an even larger disparity in access to surgery. In an average of 6 weeks with an approximate cost of $25 USD per patient, RUTF transitioned over 60% of patients into nutritionally eligible surgical candidates, making it an effective, short-term preoperative nutritional intervention. Through unique partnerships, the expansion of cost-effective, large-scale nutrition programs can play a pivotal role in ensuring those at the highest risk of living with unrepaired orofacial clefts receive timely and safe surgical care.
Collapse
|
14
|
Semitala FC, Katwesigye R, Kalibbala D, Mbuliro M, Lalitha R, Owachi D, Atine E, Nassazi J, Turyahabwe S, Sekadde M. Integration of COVID-19 and TB screening in Kampala, Uganda: healthcare provider perspectives. Implement Sci Commun 2023; 4:8. [PMID: 36650596 PMCID: PMC9844180 DOI: 10.1186/s43058-023-00391-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 12/27/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Following the first wave of the COVID-19 outbreak, Uganda experienced a 40% drop in tuberculosis (TB) screening by June 2020. We sought to identify barriers to and facilitators of integrated COVID-19 and TB screening from the perspective of healthcare providers (HCPs) at a National Referral Hospital in Kampala, Uganda. DESIGN/METHODS We conducted a cross-sectional study using in-depth interviews with 12 HCPs involved in TB activities in the outpatient and emergency departments at Kiruddu National Referral Hospital, Kampala, Uganda. We explored the HCP experiences at work in the setting of COVID-19, HCP perceived effect of COVID-19 on TB screening activities at the hospital, and perceptions about social and contextual factors that might influence the willingness of HCP to integrate screening of COVID-19 and TB. We analyzed the data using an inductive thematic approach and we denoted the emergent themes as barriers to and facilitators of COVID-19/TB integrated screening. We then mapped the themes to the Capability, Opportunity, Motivation, and Behavior (COM-B) model. RESULTS The facilitators to integrated COVID-19 and TB screening included the availability of TB focal persons and already existing training forums at the hospital that could be utilized to strengthen the capacity of HCP to integrate COVID-19 and TB screening. The barriers included HCP's inadequate knowledge on how to integrate screening of COVID-19 and TB, the absence of simple easy-to-use standard operating procedures and data collection tools for integrated screening, inconsistent supply of personal protective equipment (PPE), understaffing, and fear of contracting COVID-19 infection. The identified intervention functions to address the facilitators or barriers included education, persuasion, enablement, and training. CONCLUSIONS These findings provided a basis for designing contextually appropriate interventions targeting factors that are likely to influence HCP decisions and willingness to conduct TB screening in the context of COVID-19. Future studies should evaluate the effect of addressing these barriers to the integration of COVID-19 and TB as well as the effect of this on TB case finding in high-burden TB settings.
Collapse
Affiliation(s)
- Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda ,grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Rodgers Katwesigye
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Dennis Kalibbala
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Mary Mbuliro
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Rejani Lalitha
- grid.11194.3c0000 0004 0620 0548Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Darius Owachi
- grid.513250.0Kiruddu National Referral Hospital, Kampala, Uganda
| | - Edgar Atine
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Josephine Nassazi
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Stavia Turyahabwe
- grid.415705.2Ministry of Health Uganda, National Tuberculosis and Leprosy Program, Kampala, Uganda
| | - Moorine Sekadde
- grid.415705.2Ministry of Health Uganda, National Tuberculosis and Leprosy Program, Kampala, Uganda
| |
Collapse
|
15
|
Effectiveness of Acute Malnutrition Treatment at Health Center and Community Levels with a Simplified, Combined Protocol in Mali: An Observational Cohort Study. Nutrients 2022; 14:nu14224923. [PMID: 36432609 PMCID: PMC9699530 DOI: 10.3390/nu14224923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022] Open
Abstract
A simplified, combined protocol was created that admits children with a mid-upper-arm circumference (MUAC) of <125 mm or edema to malnutrition treatment with ready-to-use therapeutic food (RUTF) that involves prescribing two daily RUTF sachets to children with MUAC < 115 mm or edema and one daily sachet to those with 115 mm ≤ MUAC < 125 mm. This treatment was previously shown to result in non-inferior programmatic outcomes compared with standard treatment. We aimed at observing its effectiveness in a routine setting at scale, including via delivery by community health workers (CHWs). A total of 27,800 children were admitted to the simplified, combined treatment. Treatment resulted in a 92% overall recovery, with a mean length of stay of 40 days and a mean RUTF consumption of 62 sachets per child treated. Among children admitted with MUAC < 115 mm or edema, 87% recovered with a mean length of stay of 55 days and consuming an average of 96 RUTF sachets. The recovery in all sub-groups studied exceeded 85%. Treatment by CHWs resulted in a similar (94%) recovery to treatment by formal healthcare workers (92%). The simplified, combined protocol resulted in high recovery and low RUTF consumption per child treated and can safely be adopted by CHWs to provide treatment at the community level.
Collapse
|
16
|
Wrabel M, Stokes‐Walters R, King S, Funnell G, Stobaugh H. Programmatic adaptations to acute malnutrition screening and treatment during the COVID-19 pandemic. MATERNAL & CHILD NUTRITION 2022; 18:e13406. [PMID: 35929509 PMCID: PMC9480950 DOI: 10.1111/mcn.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
The COVID-19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community-based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid-upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow-up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well-accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID-19 disruptions; however, challenges included long-term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme. Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi-year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences.
Collapse
Affiliation(s)
| | | | - Sarah King
- Action Against Hunger USAWashington, DCUSA
| | | | - Heather Stobaugh
- Action Against Hunger USAWashington, DCUSA
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| |
Collapse
|
17
|
Angeline J, Tushar L, Akbar JA, Raj GB. A Pilot Study to Assess and Compare Acceptability of an Energy-Dense Nutrient Supplement Among Moderate Underweight Children in Rural and Urban Settings of Pune, Maharashtra. JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITION 2022. [DOI: 10.1080/19320248.2022.2122764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Jeyakumar Angeline
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India
- School of Hospitality and Tourism, University of Johannesburg, South Africa
| | - Lokare Tushar
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India
| | - Janan Ali Akbar
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India
| | - Giri Bibek Raj
- Interdisciplinary School of Health Sciences, Savitribai Phule Pune University, Pune, India
| |
Collapse
|
18
|
Kangas ST, Salpéteur C, Nikièma V, Ritz C, Friis H, Briend A, Kaestel P. Predictors of time to recovery and non-response during outpatient treatment of severe acute malnutrition. PLoS One 2022; 17:e0267538. [PMID: 35639683 PMCID: PMC9154090 DOI: 10.1371/journal.pone.0267538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background Every year, over 4 million children are treated for severe acute malnutrition with varying program performance. This study sought to explore the predictors of time to recovery from and non-response to outpatient treatment of SAM. Methods Children with weight-for-height z-score (WHZ) <-3 and/or mid-upper arm circumference (MUAC) <115 mm, without medical complications were enrolled in a trial (called MANGO) from outpatient clinics in Burkina Faso. Treatment included a weekly ration of ready-to-use therapeutic foods. Recovery was declared with WHZ ≥-2 and/or MUAC ≥125 mm, for two weeks without illness. Children not recovered by 16 weeks were considered as non-response to treatment. Predictors studied included admission characteristics, morbidity and compliance during treatment and household characteristics. Cox proportional hazard models were fitted and restricted mean time to recovery calculated. Logistic regression was used to analyse non-response to treatment. Results Fifty-five percent of children recovered and mean time to recovery was eight weeks while 13% ended as non-response to treatment. Independent predictors of longer time to recovery or non-response included low age, being admitted with WHZ <-3, no illness nor anaemia at admission, illness episodes during treatment, skipped or missed visits, low maternal age and not practising open defecation. Eighty-four percent of children had at least one and 59% at least two illness episodes during treatment. This increased treatment duration by 1 to 4 weeks. Thirty-five percent of children missed at least one treatment visit. One missed visit predicted 3 weeks longer and two or more missed visits 5 weeks longer treatment duration. Conclusions Both longer time to recovery and higher non-response to treatment seem most strongly associated with illness episodes and missed visits during treatment. This indicates that prevention of illnesses would be key to shortening the treatment duration and that there is a need to seek ways to facilitate adherence.
Collapse
Affiliation(s)
- Suvi T. Kangas
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
- * E-mail:
| | - Cécile Salpéteur
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
| | - Victor Nikièma
- Nutrition and Health Department, Action Against Hunger (ACF) Mission in Burkina Faso, Paris, France
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Center for Child Health Research, University of Tampere School of Medicine, Tampere University, Tampere, Finland
| | - Pernille Kaestel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
19
|
Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trial. THE LANCET GLOBAL HEALTH 2022; 10:e510-e520. [DOI: 10.1016/s2214-109x(22)00041-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/22/2021] [Accepted: 01/24/2022] [Indexed: 12/20/2022] Open
|
20
|
Hitchings MDT, Berthé F, Aruna P, Shehu I, Hamza MA, Nanama S, Steve-Edemba C, Grais RF, Isanaka S. Effectiveness of a monthly schedule of follow-up for the treatment of uncomplicated severe acute malnutrition in Sokoto, Nigeria: A cluster randomized crossover trial. PLoS Med 2022; 19:e1003923. [PMID: 35231024 PMCID: PMC8887725 DOI: 10.1371/journal.pmed.1003923] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 01/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Community-based management of severe acute malnutrition (SAM) involves weekly or biweekly outpatient clinic visits for clinical surveillance and distribution of therapeutic foods. Distance to outpatient clinics and high opportunity costs for caregivers can represent major barriers to access. Reducing the frequency of outpatient visits while providing training to caregivers to recognize clinical danger signs at home between outpatient visits may increase acceptability, coverage, and public health impact of SAM treatment. We investigated the effectiveness of monthly clinic visits compared to the standard weekly follow-up in the outpatient treatment of uncomplicated SAM in northwestern Nigeria. METHODS AND FINDINGS We conducted a cluster randomized crossover trial to test the noninferiority of nutritional recovery in children with uncomplicated SAM receiving monthly follow-up compared to the standard weekly schedule. From January 2018 to November 2019, 3,945 children aged 6 to 59 months were enrolled at 10 health centers (5 assigned to monthly follow-up and 5 assigned to weekly follow-up) in Sokoto, Nigeria. In total, 96% of children (n = 1,976 in the monthly follow-up group and 1,802 in the weekly follow-up group) were followed until program discharge, and 91% (n = 1,873 in the monthly follow-up group and 1,721 in the weekly follow-up group) were followed to 3 months postdischarge. The mean age at admission was 15.8 months (standard deviation [SD] 7.1), 2,097/3,945 (53.2%) were girls, and the mean midupper arm circumference (MUAC) at admission was 105.8 mm (SD 6.0). In a modified intention-to-treat analysis, the primary outcome of nutritional recovery, defined as having MUAC ≥125 mm on 2 consecutive visits, was analyzed using generalized linear models, with generalized estimating equations to account for clustering. Nutritional recovery was lower in the monthly follow-up group compared to the weekly group (1,036/1,976, 52.4% versus 1,059/1,802, 58.8%; risk difference: -6.8%), and noninferiority was not demonstrated (lower bound of the confidence interval [CI] was -11.5%, lower than the noninferiority margin of 10%). The proportion of children defaulting was lower in the monthly group than in the weekly group (109/1,976, 5.5% versus 151/1,802, 8.4%, p = 0.03). Three months postdischarge, children in the monthly group were less likely to relapse compared to those in the weekly group (58/976, 5.9% versus 78/1,005, 7.8%, p = 0.03), but cumulative mortality at 3 months postdischarge was higher in the monthly group (159/1,873, 8.5% versus 106/1,721, 6.2%, p < 0.001). Study results may depend on context-specific factors including baseline level of care and the clinical status of children presenting to health centers, and, thus, generalizability of these results may be limited. CONCLUSIONS Where feasible, a weekly schedule of clinic visits should be preferred to maintain effectiveness of SAM treatment. Where geographic coverage of programs is low or frequent travel to outpatient clinics is difficult or impossible, a monthly schedule of visits may provide an alternative model to deliver treatment to those in need. Modifications to the outpatient follow-up schedule, for example, weekly clinic visits until initial weight gain has been achieved followed by monthly visits, could increase the effectiveness of the model and add flexibility for program delivery. TRIAL REGISTRATION ClinicalTrials.gov NCT03140904.
Collapse
Affiliation(s)
- Matt D. T. Hitchings
- Department of Biology, University of Florida, Gainesville, Florida, United States of America
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | | | - Philip Aruna
- Médecins Sans Frontières–Operational Center Amsterdam, Amsterdam, the Netherlands
| | | | | | - Siméon Nanama
- UNICEF West and Central Regional Office, Dakar, Senegal
| | | | | | - Sheila Isanaka
- Epicentre, Paris, France
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| |
Collapse
|
21
|
Daures M, Hien J, Phelan K, Boubacar H, Atté S, Aboubacar M, Aly AAGM, Mayoum B, Azani JC, Koffi JJ, Séri B, Beuscart A, Gabillard D, Hubert V, Cazes C, Kinda M, Anglaret X, Kangas S, Shepherd S, Becquet R. Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a 3 arms community-based individually randomised controlled trial in decentralised Niger. Trials 2022; 23:89. [PMID: 35090531 PMCID: PMC8796195 DOI: 10.1186/s13063-021-05955-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Simplified approaches of acute malnutrition (AM) treatment have been conducted over the past 5 years intending to unify processes and increase coverage among children aged 6 to 59 months without medical complication. The Optimsing treatment for Acute Malnutrition (OptiMA) and the Combined Protocol for Acute Malnutrition Study (ComPAS) are mid-upper arm circumference (MUAC)-based approaches treating children with MUAC < 125 mm or oedema with one sole product-ready-to-use therapeutic food-at a gradually tapered doses. This trial aims to compare the OptiMA and ComPAS strategies to the standard nutritional protocol of Niger assessed by a favourable outcome in the treatment of uncomplicated AM at 6 months post-randomisation and in terms of recovery rate after treatment of uncomplicated SAM (WHZ < - 3 or MUAC < 115mm or oedema) and among the most vulnerable children (MUAC < 115mm or oedema). METHODS A non-inferiority individually randomised controlled clinical trial was conducted at the primary health centres level and in the community in the Zinder region in Niger in March 2021. Participants are children aged 6-59 months attending outpatient health centres with MUAC < 125mm or oedema without medical complications. All participants are followed for 6 months. Simplified strategies propose a gradual reduction of RUTF according to MUAC and weight in OptiMA and MUAC only in ComPAS. Favourable outcome is compositely defined at 6 months post-inclusion as being alive, not acutely malnourished by the definition applied at inclusion and without any additional episode of AM throughout the 6-month observation period. Recovery is defined throughout the 6 months post-randomisation by a minimum of 4-week duration of treatment, an axillary temperature < 37.5°C, an absence of bipedal oedema and a MUAC ≥ 125 mm for two consecutive weeks. The sample size calculation required 567 children per arm for the main objective, 295 and 384 children per arm for the secondary objectives among SAM and MUAC < 115 mm children, respectively. Per-protocol and intention-to-treat analyses will be conducted for each outcome. DISCUSSION This trial is intending to generate much-needed evidence on various simplified and optimised AM treatment approaches and to participate in reaching a consensus on such nutrition protocols. TRIAL REGISTRATION ClinicalTrials.gov NCT04698070 . Registered on January 6, 2021.
Collapse
Affiliation(s)
- Maguy Daures
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France.
| | - Jérémie Hien
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Sanoussi Atté
- Nutrition Directorate, Ministry of Health, Niamey, Niger
| | - Mahamadou Aboubacar
- Commission for the Initiative "les Nigériens Nourrissent les Nigériens" (HC3N), Niamey, Niger
| | - Ahmad A G M Aly
- The Alliance for International Medical Action (ALIMA), Zinder, Niger
| | - Baweye Mayoum
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Jean-Claude Azani
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Jean-Jacques Koffi
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Benjamin Séri
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Aurélie Beuscart
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Delphine Gabillard
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Cécile Cazes
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal.
| | - Xavier Anglaret
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| | - Suvi Kangas
- International Rescue Committee (IRC), Dakar, Senegal
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), 15 rue des immeubles industriels, 75011, Dakar, Senegal
| | - Renaud Becquet
- Fench National Institute for Health and Medical Research (Inserm), French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, University of Bordeaux, 146 rue Léo Saignat, 33076, Bordeaux, France
| |
Collapse
|
22
|
Gluning I, Kerac M, Bailey J, Bander A, Opondo C. The management of moderate acute malnutrition in children aged 6-59 months in low- and middle-income countries: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2021; 115:1317-1329. [PMID: 34535798 DOI: 10.1093/trstmh/trab137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/11/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malnutrition is a leading cause of morbidity and mortality in children aged <5 y, especially in low- and middle-income countries (LMICs). Unlike severe acute malnutrition, moderate acute malnutrition (MAM) affects greater numbers globally, and guidelines lack a robust evidence base. This systematic review and meta-analysis assessed the evidence for lipid-based nutrient supplements (LNSs), fortified blended flours (FBFs) and nutrition counselling, in the treatment of MAM. METHODS Four databases were systematically searched for studies conducted in LMICs that compared the effectiveness of food-based products with any comparator group in promoting recovery from MAM in children aged 6-59 mo. Where appropriate, pooled estimates of effect were estimated using random-effects meta-analyses. RESULTS A total of 13 trials were identified for inclusion. All used active controls. There was evidence of increased probability of recovery (gaining normal weight-for-height and/or mid-upper arm circumference) among children treated with LNSs compared with children treated with FBFs (risk ratio 1.05, 95% CI 1.01 to 1.09, p=0·009). CONCLUSION Based on a relatively small number of studies mainly from Africa, LNSs are superior to FBFs in improving anthropometric recovery from MAM. Current evidence for the use of food supplements in MAM treatment is based on comparisons with active controls. Future studies should assess a wider range of comparator groups, such as nutrition education/counselling alone, and outcomes, including body composition, morbidity and development.
Collapse
Affiliation(s)
- Imara Gluning
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Brighton and Sussex University Hospitals Trust, Brighton, BN2 5BE, UK
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Centre for MARCH (Maternal, Reproductive, Adolescent & Child Health Centre), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Jeanette Bailey
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,International Rescue Committee, New York, NY, 10168-1289, USA
| | - Amela Bander
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, OX3 7LF, UK
| |
Collapse
|
23
|
Ickes SB, Craig C, Heidkamp R. Design Factors for Food Supplementation and Nutrition Education Interventions That Limit Conclusions about Effectiveness for Wasting Prevention: A Scoping Review of Peer-Reviewed Literature. Adv Nutr 2021; 13:328-341. [PMID: 34666351 PMCID: PMC8803494 DOI: 10.1093/advances/nmab107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/04/2021] [Accepted: 09/07/2021] [Indexed: 11/13/2022] Open
Abstract
We conducted a scoping review to characterize the evidence base for the effectiveness of food supplementation (FS), nutrition education (NE), or FS/NE interventions to prevent wasting among children aged 6 to 59 mo. We aimed to identify gaps in peer-reviewed literature and to develop recommendations for strengthening study designs. We identified 56 unique studies (FS = 21, NE = 19, FS/NE = 16) for which we assessed intervention design factors, implementation context, evaluation methods, and wasting impact. Compared with studies focused on stunting, fewer wasting-focused studies reported weight-for-height z score (WHZ). Midupper arm circumference (MUAC) was more commonly reported in wasting-focused studies (71.4%) than those focused on stunting (36.8%) or wasting and stunting (30.4%). FS studies measured anthropometry (mean, 95% CI) more frequently at every 11.3 (7.8, 14.8) wk than NE interventions at 36.3 (8.8, 62.1) wk (P = 0.036), but not FS/NE interventions at 25.8 (5.6, 49.1) wk (P = 0.138). NE interventions tended to be of longer duration than FS or FS/NE interventions. Only 6 studies followed and measured children after the intervention period ended. Across all studies, 45% reported a significant effect on wasting; these included FS, NE, and FS/NE interventions. The lack of comparability across studies limits conclusions about the effectiveness of specific types of interventions. To build a more unified evidence base for wasting prevention we recommend that future studies 1) report on a consistent set of metrics, including MUAC; 2) attempt to measure change in wasting incidence using more frequent measures; 3) measure wasting prevalence among the general population; 4) follow children postintervention to assess relapse; 5) measure food insecurity and diet quality; and 6) use harmonized protocols across multiple settings. Such efforts to improve study comparability will strengthen the evidence base, may help unite divergent professional communities, and ultimately accelerate progress toward eliminating child undernutrition.
Collapse
Affiliation(s)
| | | | - Rebecca Heidkamp
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
24
|
Kiguli S, Olopot-Olupot P, Alaroker F, Engoru C, Opoka RO, Tagoola A, Hamaluba M, Mnjalla H, Mpoya A, Mogaka C, Nalwanga D, Nabawanuka E, Nokes J, Nyaigoti C, Briend A, van Woensel JBM, Grieve R, Sadique Z, Williams TN, Thomas K, Harrison DA, Rowan K, Maitland K. Children's Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial. Wellcome Open Res 2021; 6:221. [PMID: 34734123 PMCID: PMC8529399 DOI: 10.12688/wellcomeopenres.17123.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 11/20/2022] Open
Abstract
Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies. Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).
Collapse
Affiliation(s)
- Sarah Kiguli
- Paediatrics, Makerere University, Kampala, Uganda
| | | | | | - Charles Engoru
- Paediatrics, Soroti Regional Referral Hospital, Soroti, Uganda
| | | | - Abner Tagoola
- Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Mainga Hamaluba
- Paediatrics, Kilifi County Hospital, Kilifi, Kilifi, POBox230, Kenya
| | - Hellen Mnjalla
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - Ayub Mpoya
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - Christabel Mogaka
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | | | | | - James Nokes
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - Charles Nyaigoti
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - André Briend
- School of Medicine, University of Tampere, Tampere, Finland
| | - Job B. M. van Woensel
- Paediatric Intensive Care Unit, Emma Children’s Hospital and Academic Medical Center, Amsterdam, The Netherlands
| | - Richard Grieve
- Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, UK
| | - Zia Sadique
- Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas N. Williams
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
| | - Karen Thomas
- Intensive Care National Audit, London, WC1V 6AZ, UK
| | | | | | - Kathryn Maitland
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
| |
Collapse
|
25
|
Kiguli S, Olopot-Olupot P, Alaroker F, Engoru C, Opoka RO, Tagoola A, Hamaluba M, Mnjalla H, Mpoya A, Mogaka C, Nalwanga D, Nabawanuka E, Nokes J, Nyaigoti C, Briend A, van Woensel JBM, Grieve R, Sadique Z, Williams TN, Thomas K, Harrison DA, Rowan K, Maitland K. Children's Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial. Wellcome Open Res 2021; 6:221. [PMID: 34734123 PMCID: PMC8529399 DOI: 10.12688/wellcomeopenres.17123.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 09/22/2023] Open
Abstract
Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies. Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).
Collapse
Affiliation(s)
- Sarah Kiguli
- Paediatrics, Makerere University, Kampala, Uganda
| | | | | | - Charles Engoru
- Paediatrics, Soroti Regional Referral Hospital, Soroti, Uganda
| | | | - Abner Tagoola
- Paediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Mainga Hamaluba
- Paediatrics, Kilifi County Hospital, Kilifi, Kilifi, POBox230, Kenya
| | - Hellen Mnjalla
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - Ayub Mpoya
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - Christabel Mogaka
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | | | | | - James Nokes
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - Charles Nyaigoti
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
| | - André Briend
- School of Medicine, University of Tampere, Tampere, Finland
| | - Job B. M. van Woensel
- Paediatric Intensive Care Unit, Emma Children’s Hospital and Academic Medical Center, Amsterdam, The Netherlands
| | - Richard Grieve
- Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, UK
| | - Zia Sadique
- Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas N. Williams
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
| | - Karen Thomas
- Intensive Care National Audit, London, WC1V 6AZ, UK
| | | | | | - Kathryn Maitland
- KEMRI Wellcome TRust Research Programme, Kilifi, Kilifi, POBox230, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
| |
Collapse
|
26
|
Lelijveld N, Godbout C, Krietemeyer D, Los A, Wegner D, Hendrixson DT, Bandsma R, Koroma A, Manary M. Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial. Am J Clin Nutr 2021; 114:955-964. [PMID: 33963734 PMCID: PMC8921644 DOI: 10.1093/ajcn/nqab137] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There is a lack of consensus on what is the most appropriate treatment of moderate acute malnutrition (MAM). OBJECTIVES We aimed to determine if provision of ready-to-use-therapeutic food (RUTF) and antibiotics to "high-risk" MAM (HR-MAM) children in addition to nutritional counseling would result in higher recovery and less deterioration than nutrition counseling alone. METHODS At the 11 intervention clinics, HR-MAM children were given RUTF and amoxicillin along with standard nutrition counseling, for 2-12 wk. All others received 6 wk of nutrition counseling alone. HR-MAM was defined as midupper arm circumference (MUAC) <11.9 cm, weight-for-age z score (WAZ) <-3.5, mother not the main caregiver, or a child <2 y old not being breastfed. Outcomes were compared using intention-to-treat analysis. RESULTS Analysis included 573 children at the intervention sites and 714 children at the control sites. Of the intervention group, 317 (55%) were classified as HR-MAM. Short-term recovery was greater at the intervention sites [48% compared with 39% at week 12; risk difference (rd): 0.08; 95% CI: 0.03, 0.13]. The intervention group had lower risk of deteriorating to severe acute malnutrition (SAM) (18% compared with 24%; rd: -0.07; 95% CI: -0.11, -0.04), lower risk of dying (1.8% compared with 3.1%; rd: -0.02; 95% CI: -0.03, -0.00), and greater gains in MUAC and weight than did children at the control sites. However, by 24 wk, the risk of SAM was similar between the 2 arms (31% compared with 34%; rd: -0.03; 95% CI: -0.09, 0.02). Control group data identified recent illness, MUAC <12.0 cm, WAZ <-3, dropping anthropometry, age <12 mo, being a twin, and a history of previous SAM as risk factors for deterioration. CONCLUSIONS Provision of RUTF and antibiotics to HR-MAM children improved short-term recovery and reduced short-term risk of deterioration. However, recovery rates were still suboptimal and differences were not sustained by 6 mo post enrollment.This trial was registered at clinicaltrials.gov as NCT03647150.
Collapse
Affiliation(s)
- Natasha Lelijveld
- Centre for Global Child Health, Hospital for Sick Kids,
Toronto, Ontario, Canada
- Emergency Nutrition Network, Oxford, United Kingdom
| | - Claire Godbout
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
| | - Destiny Krietemeyer
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
| | - Alyssa Los
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
| | - Donna Wegner
- Washington University School of Medicine, St. Louis, MO,
USA
| | | | - Robert Bandsma
- Centre for Global Child Health, Hospital for Sick Kids,
Toronto, Ontario, Canada
| | | | - Mark Manary
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
| |
Collapse
|
27
|
Heidkamp RA, Piwoz E, Gillespie S, Keats EC, D'Alimonte MR, Menon P, Das JK, Flory A, Clift JW, Ruel MT, Vosti S, Akuoku JK, Bhutta ZA. Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action. Lancet 2021; 397:1400-1418. [PMID: 33691095 DOI: 10.1016/s0140-6736(21)00568-7] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/28/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022]
Abstract
As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.
Collapse
Affiliation(s)
| | - Ellen Piwoz
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Stuart Gillespie
- International Food Policy Research Institute, Washington, DC, USA
| | - Emily C Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Purnima Menon
- International Food Policy Research Institute, Delhi, India
| | - Jai K Das
- Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan
| | | | | | - Marie T Ruel
- International Food Policy Research Institute, Washington, DC, USA
| | - Stephen Vosti
- Department of Agricultural and Resource Economics, and Institute for Global Nutrition, University of California, Davis, CA, USA
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada; Centre of Excellence in Women and Child Health and Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan.
| |
Collapse
|
28
|
Response to Malnutrition Treatment in Low Weight-for-Age Children: Secondary Analyses of Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial. Nutrients 2021; 13:nu13041054. [PMID: 33805040 PMCID: PMC8064102 DOI: 10.3390/nu13041054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5–12.5 cm) and a severely low WAZ (<−3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<−3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < −3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < −3.0.
Collapse
|
29
|
Nikièma V, Kangas ST, Salpéteur C, Ouédraogo A, Lachat C, Bassolé NHI, Fogny NF. Adequacy of Nutrient Intakes of Severely and Acutely Malnourished Children Treated with Different Doses of Ready-To-Use Therapeutic Food in Burkina Faso. J Nutr 2021; 151:1008-1017. [PMID: 33571369 PMCID: PMC8030704 DOI: 10.1093/jn/nxaa393] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/09/2020] [Accepted: 11/16/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Ready-to-use therapeutic foods (RUTF) are designed to cover the daily nutrient requirements of children with severe acute malnutrition (SAM). However, with the transfer of uncomplicated SAM care from the hospital environment to the community level, children will be able to consume complementary and family foods (CFF) in addition to RUTF, and this might decrease the quantity of RUTF needed for recovery. OBJECTIVES Using an individually randomized clinical trial, we investigated the effects of a reduced RUTF dose on the daily energy and macronutrient intakes, the proportion of energy coming from CFF, and the mean probability of adequacy (MPA) of intake in 11 micronutrients of 516 children aged 6-59 mo who were treated for SAM in Burkina Faso. METHODS The data were collected using a single 24-h multipass dietary recall, 1 mo after starting treatment, from December 2016 to August 2018, repeated on a subsample of 66 children. Differences between children receiving the reduced RUTF (intervention arm) and those receiving standard RUTF (control arm) were assessed by linear mixed models. RESULTS Daily energy intake was lower (P < 0.01) in the intervention arm (mean ± SD 1321 ± 339 kcal) than in the control arm (1467 ± 319 kcal). CFF contributed to 40% of the daily energy intake in the intervention and 35% in the control arm. The MPA for 11 micronutrients was 0.89 ± 0.1 in the intervention arm and 0.95 ± 0.07 in the control arm (P = 0.06). CONCLUSIONS Reducing the dose of RUTF during SAM treatment had a negative impact on daily energy intake of the children. Despite this, children covered their recommended energy intake. The energy intake coming from CFF was similar between arms, suggesting that children's feeding practices did not change due to the reduction in RUTF in this context. This trial was registered at the IRSCTN registry as ISRCTN50039021.
Collapse
Affiliation(s)
| | - Suvi T Kangas
- Expertise and Advocacy Department, Action contre la Faim, Paris, France
| | - Cécile Salpéteur
- Expertise and Advocacy Department, Action contre la Faim, Paris, France
| | - Abdoulaye Ouédraogo
- Food Security and Livelihoods Department, Action contre la Faim, Ouagadougou, Burkina Faso
| | - Carl Lachat
- Department of Food Technology, Safety, and Health, Faculty of Bioscience Engineering, Ghent University, Belgium
| | - Nestor H I Bassolé
- Department of Biochemistry and microbiology, Joseph KI-ZERBO University, Ouagadougou, Burkina Faso
| | - Nadia F Fogny
- School of Nutrition and Food Sciences and Technologies, Faculty of Agronomic Sciences, University of Abomey-Calavi, Benin
| |
Collapse
|
30
|
Lelijveld N, Musyoki E, Adongo SW, Mayberry A, Wells JC, Opondo C, Kerac M, Bailey J. Relapse and post-discharge body composition of children treated for acute malnutrition using a simplified, combined protocol: A nested cohort from the ComPAS RCT. PLoS One 2021; 16:e0245477. [PMID: 33534818 PMCID: PMC7857614 DOI: 10.1371/journal.pone.0245477] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/01/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Severe and moderate acute malnutrition (SAM and MAM) affect more than 50 million children worldwide yet 80% of these children do not access care. The Combined Protocol for Acute Malnutrition Study (ComPAS) trial assessed the effectiveness of a simplified, combined SAM/MAM protocol for children aged 6-59 months and found non-inferior recovery compared to standard care. To further inform policy, this study assessed post-discharge outcomes of children treated with this novel protocol in Kenya. METHODS Six 'combined' protocol clinics treated SAM and MAM children using an optimised mid-upper arm circumference (MUAC)-based dose of ready-to-use therapeutic food (RUTF). Six 'standard care' clinics treated SAM with weight-based RUTF rations; MAM with ready-to-use supplementary food (RUSF). Four months post-discharge, we assessed anthropometry, recent history of illness, and body composition by bioelectrical impedance analysis. Data was analysed using multivariable linear regression, adjusted for age, sex and allowing for clustering by clinic. RESULTS We sampled 850 children (median age 18 months, IQR 15-23); 44% of the original trial sample in Kenya. Children treated with the combined protocol had similar anthropometry, fat-free mass, fat mass, skinfold thickness z-scores, and frequency of common illnesses 4 months post-discharge compared the standard protocol. Mean subscapular skinfold z-scores were close to the global norm (standard care: 0.24; combined 0.27). There was no significant difference in odds of relapse between protocols (SAM, 3% vs 3%, OR = 1.0 p = 0.75; MAM, 10% vs 12%, OR = 0.90 p = 0.34). CONCLUSIONS Despite the lower dosage of RUTF for most SAM children in the combined protocol, their anthropometry and relapse rates at 4 months post-discharge were similar to standard care. MAM children treated with RUTF had similar body composition to those treated with RUSF and neither group exhibited excess adiposity. These results add further evidence that a combined protocol is as effective as standard care with no evidence of adverse effects post-discharge. A simplified, combined approach could treat more children, stretch existing resources further, and contribute to achieving Sustainable Development Goal Two.
Collapse
Affiliation(s)
- Natasha Lelijveld
- No Wasted Lives, Action Against Hunger, London, United Kingdom
- Emergency Nutrition Network, Oxford, United Kingdom
- * E-mail:
| | | | | | - Amy Mayberry
- No Wasted Lives, Action Against Hunger, London, United Kingdom
| | - Jonathan C. Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street, Institute of Child Health, University College London, London, United Kingdom
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marko Kerac
- Department of Population Health, Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeanette Bailey
- Department of Population Health, Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, United Kingdom
- International Rescue Committee, New York City, New York, United States of America
| |
Collapse
|
31
|
Guesdon B, Couture A, Lesieur E, Bilukha O. "No weight for height" case detection strategies for therapeutic feeding programs: sensitivity to acute malnutrition and target composition based on representative surveys in humanitarian settings. BMC Nutr 2021; 7:3. [PMID: 33526090 PMCID: PMC7850713 DOI: 10.1186/s40795-021-00406-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 01/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background One newly proposed approach to determining eligibility of children aged 6–59 months for therapeutic feeding programs (TFPs) is to use mid-upper arm circumference (MUAC) < 115 mm, bilateral oedema or Weight-for-Age Z-score (WAZ) < − 3 as admission criteria (MUAC+SWAZ). We explored potential consequences of this approach on the eligibility for treatment, as compared with the existing WHO normative guidance. We also compared sensitivity and specificity parameters of this approach for detecting wasted children to the previously described “Expanded MUAC” approach. Methods We analyzed data from 558 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and those who are both wasted and stunted (WA + ST), and calculated proportions of previously eligible children who would now be excluded from treatment, as well as proportions of non-malnourished children among those who would become eligible. We also analyzed the expected changes in the number and demographics (sex, age) of the selected populations of children according to the different admission approaches. Results Both MUAC+SWAZ and Expanded MUAC case detection approaches substantially increase the sensitivity in detecting SAM, as compared to an approach which restricts detection of SAM cases to MUAC< 115 mm and oedema. Improved sensitivity however is attained at the expense of specificity and would require a very large increase of the size of TFPs, while still missing a non-negligible proportion (20–25%) of the SAM caseload. While our results confirm the sensitivity of the MUAC+SWAZ case detection approach in detecting WA + ST (over 80%), they show, on the other hand, that about half of the additional target detected by using SWAZ criterion will be neither SAM nor WA + ST. Conclusions These results suggest that recently promoted approaches to case detection inflate TFPs’ targets through the allocation of treatment to large numbers of children who have not been shown to require this type of support, including a significant proportion of non-acutely malnourished children in the MUAC+SWAZ approach. Considering the scarcity of resources for the implementation of TFPs, the rationale of abandoning the use of WHZ and of these alternative case detection strategies need to be critically reviewed.
Collapse
Affiliation(s)
- Benjamin Guesdon
- Action Contre La Faim - France, 14-16 Boulevard Douaumont, 75854, Paris, France.
| | - Alexia Couture
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - Elise Lesieur
- Action Contre La Faim - France, 14-16 Boulevard Douaumont, 75854, Paris, France
| | - Oleg Bilukha
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control, 1600 Clifton Road, Atlanta, GA, 30329, USA
| |
Collapse
|
32
|
Stephenson KB, Agapova SE, Hendrixson DT, Koroma AS, Manary MJ. An Optimized Dose of Therapeutic Feeding Results in Noninferior Growth in Midupper Arm Circumference Compared with a Standard Dose in Children in Sierra Leone Recovering from Acute Malnutrition. Curr Dev Nutr 2021; 5:nzab007. [PMID: 33659773 PMCID: PMC7904386 DOI: 10.1093/cdn/nzab007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ready-to-use therapeutic food (RUTF) given at 175 kcal/kg per day throughout severe acute malnutrition (SAM) treatment is recommended. Some treatment programs have diverged from this paradigm in 2 ways: reducing the supplemental food dose to 75 kcal/kg per day when midupper arm circumference (MUAC) is >11.4 cm or simplifying to a fixed-dose regimen. OBJECTIVE The objective was to determine if transitioning to an optimized, fixed-dose supplementary feeding regimen during SAM treatment when MUAC is >11.4 cm would result in noninferior gain in MUAC compared with standard treatment. METHODS Using data from 2 clinical trials conducted in Sierra Leone, a retrospective dual-cohort study was performed. The 2 cohorts included children with SAM who had improved to meet criteria for moderate acute malnutrition (MAM). The standard dose cohort continued to receive weight-based RUTF at 175 kcal/kg per day, while the optimized dose cohort received fixed-dose, 500 kcal/d of supplementary feeding. The primary outcome was a noninferiority margin of 1 mm of MUAC after 4 wk of treatment, while secondary outcomes included rate of anthropometric changes as well as time-to-relapse to SAM or death. RESULTS MUAC after 4 wk was noninferior (Δ: -0.1 mm; 95% CI: -0.05, 0.03; inferiority rejected P = 0.008). Rates of weight gain and MUAC gain were the same in the optimized-dose and standard-dose groups, whereas the rate of length gain was slower in the optimized-dose cohort. Time-to-relapse to SAM or death was not different (HR: 1.05; P = 0.71). CONCLUSIONS This study supports the practice of treating children with SAM who have recovered to meet criteria for MAM with a reduced and fixed-dose regimen of RUTF. The results also raise the question of whether this strategy might adversely impact linear growth during SAM treatment.
Collapse
Affiliation(s)
| | - Sophia E Agapova
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| | | | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J Manary
- Department of Pediatrics, Washington University, St. Louis, MO, USA
| |
Collapse
|
33
|
Cazes C, Phelan K, Hubert V, Alitanou R, Boubacar H, Izie Bozama L, Tshibangu Sakubu G, Beuscart A, Yao C, Gabillard D, Kinda M, Augier A, Anglaret X, Shepherd S, Becquet R. Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a community-based individually randomised controlled trial in Kasaï, Democratic Republic of Congo. BMJ Open 2020; 10:e041213. [PMID: 33268424 PMCID: PMC7713214 DOI: 10.1136/bmjopen-2020-041213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Acute malnutrition (AM) is a continuum condition, arbitrarily divided into moderate and severe AM (SAM) categories, funded and managed in separate programmes under different protocols. Optimising acute MAlnutrition (OptiMA) treatment aims to simplify and optimise AM management by treating children with mid-upper arm circumference (MUAC) <125 mm or oedema with one product-ready-to-use therapeutic food-at a gradually tapered dose. Our main objective was to compare the OptiMA strategy with the standard nutritional protocol in children 6-59 months presenting with MUAC <125 mm or oedema without additional complications, as well as in children classified as uncomplicated SAM (ie, MUAC <115 mm or weight-for-height Z-score (WHZ) <-3 or with oedema). METHODS AND ANALYSIS This study was a non-inferiority, individually randomised controlled clinical trial conducted at community level in the Democratic Republic of Congo. Children 6-59 months presenting with MUAC <125 mm or WHZ <-3 or with bipedal oedema and without medical complication were included after signed informed consent in outpatient health facilities. All participants were followed for 6 months. Success in both arms was defined at 6 months post inclusion as being alive, not acutely malnourished per the definition applied at inclusion and without an additional episode of AM throughout the 6-month observation period. Recovery among children with uncomplicated SAM was the main secondary outcome. For the primary objective, 890 participants were needed, and 480 children with SAM were needed for the main secondary objective. We will perform non-inferiority analyses in per-protocol and intention-to-treat basis for both outcomes. ETHICS AND DISSEMINATION Ethics approvals were obtained from the National Health Ethics Committee of the Democratic Republic of Congo and from the Ethics Evaluation Committee of Inserm, the French National Institute for Health and Medical Research (Paris, France). We will submit results for publication to a peer-reviewed journal and disseminate findings in international and national conferences and meetings. TRIAL REGISTRATION NUMBER NCT03751475. Registered 19 September 2018, https://clinicaltrials.gov/ct2/show/NCT03751475.
Collapse
Affiliation(s)
- Cécile Cazes
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Liévin Izie Bozama
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of Congo
| | - Gilbert Tshibangu Sakubu
- Kamuesha Health Zone in the Kasaï Province, Ministry of Health, Kamuesha, Democratic Republic of Congo
| | - Aurélie Beuscart
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Cyrille Yao
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Augustin Augier
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Xavier Anglaret
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| |
Collapse
|
34
|
Fabiansen C, Cichon B, Yaméogo CW, Iuel-Brockdorf AS, Phelan KPQ, Wells JC, Ritz C, Filteau S, Briend A, Christensen VB, Ashorn P, Michaelsen KF, Shepherd S, Friis H. Association between admission criteria and body composition among young children with moderate acute malnutrition, a cross-sectional study from Burkina Faso. Sci Rep 2020; 10:13266. [PMID: 32764545 PMCID: PMC7413376 DOI: 10.1038/s41598-020-69987-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 07/20/2020] [Indexed: 12/03/2022] Open
Abstract
Children with moderate acute malnutrition (MAM) are treated based on low weight-for-length z-score (WLZ), low mid-upper arm circumference (MUAC) or both. This study aimed to assess associations of admission criteria and body composition (BC), to improve treatment of MAM. We undertook a cross-sectional study among 6–23 months old Burkinabe children with MAM. Fat-free (FFM) and fat mass (FM) were determined by deuterium dilution and expressed as FFM (FFMI) and FM index (FMI). Of 1,489 children, 439 (29.5%) were recruited by low MUAC only (MUAC-O), 734 (49.3%) by low WLZ and low MUAC (WLZ-MUAC) and 316 (21.2%) by low WLZ only (WLZ-O). Thus, 1,173 (78.8%) were recruited by low MUAC, with or without low WLZ (ALL-MUAC). After adjustments, WLZ-O had 89 g (95% confidence interval (CI) 5; 172) lower FFM compared to MUAC-O. Similarly, WLZ-O had 0.89 kg/m2 (95% CI 0.77; 1.01) lower FFMI compared to MUAC-O, whereas there was no difference for FMI. However, boys included by WLZ-O compared to MUAC-O had 0.21 kg/m2 (95% CI 0.05; 0.38) higher FMI. In contrast, girls included by WLZ-O had 0.17 (95% CI 0.01; 0.33) kg/m2 lower FMI compared to MUAC-O (interaction, p = 0.002). We found that different criteria for admission into MAM treatment programmes select children with differences in BC, especially FFMI. Trial registration: ISRCTN42569496.
Collapse
Affiliation(s)
- Christian Fabiansen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark. .,Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark.
| | - Bernardette Cichon
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark
| | - Charles W Yaméogo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Département Biomédical et Santé Publique, Institut de Recherche en Sciences de la Santé, Ouagadougou 03, BP 7047, Bobo-Dioulasso, Burkina Faso
| | - Ann-Sophie Iuel-Brockdorf
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark
| | | | - Jonathan C Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark
| | - Suzanne Filteau
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, Keppel Street, London, WC1E 7HT, UK
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark.,Center for Child Health Research, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Lääkärinkatu 1, 33014, Tampere, Finland
| | - Vibeke B Christensen
- Médecins Sans Frontières-Denmark, Dronningensgade 68, 3, 1420, Copenhagen, Denmark.,Department of Paediatrics and Adolenscent Medicine, Blegdamsvej 9, 2100, RighospitaletCopenhagen, Denmark
| | - Per Ashorn
- Center for Child Health Research, Tampere University, Faculty of Medicine and Health Technology and Tampere University Hospital, Lääkärinkatu 1, 33014, Tampere, Finland
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark
| | - Susan Shepherd
- ALIMA, Route de l'Aéroport, Rue NG 96, BP 15530, Dakar, Sénégal
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 25, 1958, Frederiksberg, Denmark
| |
Collapse
|
35
|
Kozuki N, Seni M, Sirat A, Abdullahi O, Adalbert MFE, Biotteau M, Goldsmith A, Dalglish SL. Adapting acute malnutrition treatment protocols in emergency contexts: a qualitative study of national decision-making. Confl Health 2020; 14:47. [PMID: 32695220 PMCID: PMC7364598 DOI: 10.1186/s13031-020-00293-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 07/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Each year, an estimated 17 million children suffer from severe acute malnutrition (SAM) and 33 million from moderate acute malnutrition (MAM), with many of the most severe cases found in extremely food insecure contexts or conflict situations. Current global outpatient treatment protocols for uncomplicated SAM and MAM, adapted by most countries for use at national level, call for SAM and MAM to be managed separately, however global-level stakeholders have recently begun evaluating simplified and/or combined protocols managing acute malnutrition. Methods This study analyzes national policy discussions and decision-making around outpatient acute malnutrition treatment for uncomplicated cases in emergency situations in Niger, Nigeria, Somalia, and South Sudan. Data collection (March–July 2018) included semi-structured in-depth interviews with 50 respondents (N = 11–15 per country) from government, funding agencies, and implementing partners, as well as 11 global and regional stakeholders. We also conducted a document analysis (N = 10–15 per country and at global level) to situate debates and evaluate current policy. Data were analyzed iteratively using thematic content analysis. Results We find that while combined/simplified protocols for outpatient management of uncomplicated cases of acute malnutrition are being used in emergency situations in all four countries, there is widespread confusion about protocol terminology and content, stemming from a lack of coherence at the global level. As a result, national-level stakeholders express diverse, if overlapping, rationales for modifying current protocols, which vary given the intensity and scope of the emergency. Without specific global-level guidance, combined/simplified protocols are often used on an ad hoc basis, although the processes for triggering them were at least nominally controlled at the national level. Decisions about when and where to enact “exceptional” modifications to country protocols were often based on inconsistent determinations of what constitutes an “emergency.” Respondents said more evidence is needed on both clinical and operational aspects of these protocols, and they awaited clear guidance from global norm-setting agencies. Conclusions Based on these findings, global-level stakeholders should urgently improve coordination and communication around existing protocols. Standardized guidance based on the available evidence is required to clarify best practices for combined management of SAM and MAM, particularly in emergency contexts (which should be defined) and in situations of limited resources. Given the complexity of governance arrangements in conflict situations, both guidance and updates on research must be disseminated in a rational, systematic, and digestible way to the multiplicity of field actors.
Collapse
Affiliation(s)
- Naoko Kozuki
- International Rescue Committee, 1730 M St. NW, Washington, DC 20036 USA
| | | | - Amin Sirat
- International Rescue Committee, Maiduguri, Nigeria
| | | | | | | | - Amelia Goldsmith
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Sarah L Dalglish
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| |
Collapse
|
36
|
Bailey J, Opondo C, Lelijveld N, Marron B, Onyo P, Musyoki EN, Adongo SW, Manary M, Briend A, Kerac M. A simplified, combined protocol versus standard treatment for acute malnutrition in children 6-59 months (ComPAS trial): A cluster-randomized controlled non-inferiority trial in Kenya and South Sudan. PLoS Med 2020; 17:e1003192. [PMID: 32645109 PMCID: PMC7347103 DOI: 10.1371/journal.pmed.1003192] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 06/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Malnutrition underlies 3 million child deaths worldwide. Current treatments differentiate severe acute malnutrition (SAM) from moderate acute malnutrition (MAM) with different products and programs. This differentiation is complex and costly. The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6-59 months. Eliminating the need for separate products and protocols could improve the impact of programs by treating children more easily and cost-effectively, reaching more children globally. METHODS AND FINDINGS A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm. Standard care clinics treated SAM with weight-based RUTF rations, and MAM with ready-to-use supplementary food (RUSF). The primary outcome was nutritional recovery. Secondary outcomes included cost-effectiveness, coverage, defaulting, death, length of stay, and average daily weight and MUAC gains. Main analyses were per-protocol, with intention-to-treat analyses also conducted. The non-inferiority margin was 10%. From 8 May 2017 to 31 March 2018, 2,071 children were enrolled in 12 combined protocol clinics (mean age 17.4 months, 41% male), and 2,039 in 12 standard care clinics (mean age 16.7 months, 41% male). In total, 1,286 (62.1%) and 1,202 (59.0%), respectively, completed treatment; 981 (76.3%) on the combined protocol and 884 (73.5%) on the standard protocol recovered, yielding a risk difference of 0.03 (95% CI -0.05 to 0.10, p = 0.52; per-protocol analysis, adjusted for country, age, and sex). The amount of ready-to-use food (RUTF or RUSF) required for a child with SAM to reach full recovery was less in the combined protocol (122 versus 193 sachets), and the combined protocol cost US$123 less per child recovered (US$918 versus US$1,041). There were 23 (1.8%) deaths in the combined protocol arm and 21 (1.8%) deaths in the standard protocol arm (adjusted risk difference 95% CI -0.01 to 0.01, p = 0.87). There was no evidence of a difference between the protocols for any of the other secondary outcomes. Study limitations included contextual factors leading to defaulting, a combined multi-country power estimate, and operational constraints. CONCLUSIONS Combined treatment for SAM and MAM is non-inferior to standard care. Further research should focus on operational implications, cost-effectiveness, and context (Asia versus Africa; emergency versus food-secure settings). This trial is complete and registered at ISRCTN (ISRCTN30393230). TRIAL REGISTRATION The trial is registered at ISRCTN, trial number ISRCTN30393230.
Collapse
Affiliation(s)
- Jeanette Bailey
- International Rescue Committee, New York, New York, United States of America
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Bethany Marron
- International Rescue Committee, New York, New York, United States of America
| | | | | | | | - Mark Manary
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - André Briend
- Department of International Health, University of Tampere, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Maternal, Adolescent, Reproductive, & Child Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
37
|
Chase RP, Kerac M, Grant A, Manary M, Briend A, Opondo C, Bailey J. 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. PLoS One 2020; 15:e0230452. [PMID: 32492023 PMCID: PMC7269364 DOI: 10.1371/journal.pone.0230452] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/01/2020] [Indexed: 01/31/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Rachel P. Chase
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Marko Kerac
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Angeline Grant
- Action Against Hunger-USA, New York, New York, United States of America
| | - Mark Manary
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States of America
| | - André Briend
- University of Tampere, University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Jeanette Bailey
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
- International Rescue Committee, New York, New York, United States of America
| |
Collapse
|
38
|
Zuzarte A, Mui M, Ordiz MI, Weber J, Ryan K, Manary MJ. Reducing Oil Separation in Ready-to-Use Therapeutic Food. Foods 2020; 9:foods9060706. [PMID: 32492836 PMCID: PMC7353625 DOI: 10.3390/foods9060706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Ready-to-use therapeutic food (RUTF) is a shelf-stable, low moisture, energy dense medicinal food composed of peanut butter, vegetable oils, milk powder, a multiple micronutrient premix and sugar. RUTF is used by millions of children annually to treat malnutrition. After mixing, RUTF is a semisolid covered with oil. To produce a homogenous RUTF, hydrogenated vegetable oils are incorporated in small quantities. This study utilized a benchtop methodology to test the effect of RUTF ingredients on oil separation. An acceptable oil separation was <4%. This method compared 15 different vegetable oil stabilizers with respect to oil separation. The dynamic progression of oil separation followed a Michaelis–Menten pattern, reaching a maximum after 60 days when stored at 30 °C. Hydrogenated vegetable oils with triglyceride or 50% monoglycerides reduced the oil separation to acceptable levels. The additive showing the largest reduction in oil separation was used in an industrial trial, where it also performed acceptably. In conclusion, fully hydrogenated soybean and rapeseed oil added as 1.5% controlled oil separation in RUTF.
Collapse
|
39
|
Das JK, Salam RA, Saeed M, Kazmi FA, Bhutta ZA. Effectiveness of interventions to manage acute malnutrition in children under 5 years of age in low- and middle-income countries: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2020; 16:e1082. [PMID: 37131422 PMCID: PMC8356333 DOI: 10.1002/cl2.1082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Childhood malnutrition is a major public health concern as it is associated with significant short- and long-term morbidity and mortality. Objectives To comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization protocol using facility- and community-based approaches as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use and vitamin A supplementation. Search methods We searched relevant electronic databases till 11 February 2019. No date or language restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and quasi-experimental studies including controlled before-after (CBA) studies and interrupted time series (ITS) studies. Data collection and analysis Two review authors independently screened studies for relevance, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software and set out the main findings of the review in "Summary of findings" tables. Main results This review summarises findings from a total of 42 studies (48 papers) including 35,017 children. Thirty-three of the included studies were RCTs; six studies were quasi-experimental and three studies were cost studies. Majority of the studies were judged to be at high risk of bias for blinding of the participants, personnel and outcome assessment. Majority of the outcomes were rated as either moderate or low quality. Outcomes were downgraded mainly due to study limitations, high heterogeneity, imprecision and small sample size. Community-based strategies to screen and manage SAM/MAM versus no community-based strategies (two studies): Integrated community-based management probably improves recovery rate by 4% [risk ratio (RR): 1.04; 95% confidence interval (CI): 1.00 to 1.09; one study; 1,957 participants; moderate-quality outcome], and reduces weight gain by 0.8 g·kg-1·day-1 [mean difference (MD): -0.80 g·kg-1·day-1; 95% CI: -0.82 to -0.78; one study; 1,957 participants; moderate-quality outcome] compared with no community-based strategies, while mortality was similar between the two groups (RR: 0.93; 95% CI: 0.60 to 1.45; one study; 1,957 participants; moderate-quality outcome). Facility-based strategies to screen and manage uncomplicated SAM versus other standard of care (four studies): There was no evidence of effect on recovery (RR: 1.00; 95% CI: 0.80, 1.25; one study; 60 participants; very-low-quality evidence) and mortality (RR: 1.21; 95% CI: 0.75 to 1.94; two studies; 473 participants; low-quality outcome). Facility-based management with RUTF versus F100 ("catch-up" formula to rebuild wasted tissues containing 100 kcal and 2.9 g protein per 100 ml) for SAM (three studies): There was no evidence of effect on weight gain (MD: 2 g·kg-1·day-1; 95% CI: -0.23 to 4.23; three studies; 266 participants; very-low-quality outcome) and mortality (RR: 1.20; 95% CI: 0.34 to 4.22; two studies; 168 participants; low-quality outcome). Community-based management of SAM with standard RUTF compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUTF was compared to non-milk/peanut butter-based RUTF (RR: 1.03; 95% CI: 0.99 to 1.08; five studies; 5743 participants; I2 50%; moderate quality outcome), energy-dense, home-prepared food (RR: 1.14; 95% CI 0.95 to 1.36; four studies; 959 participants; I2 75%; low quality outcome), or high oleic RUTF (RR: 1.06; 95% CI: 0.85 to 1.31; one study; 141 participants; moderate quality outcome). Standard RUTF may improve weight gain by 0.5 g·kg-1·day-1 (MD: 0.5 g·kg-1·day-1; 95% CI: 0.02 to 0.99; three studies; 3,069 participants; low-quality outcome) when compared with non-milk/peanut butter-based RUTF and by 5.5 g·kg-1·day-1 when compared with F100 (MD: 5.50 g·kg-1·day-1; 95% CI: 2.92 to 8.08; one study; 70 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUTF was compared with other foods (RR: 0.99; 95% CI: 0.69 to 1.41; nine studies; 7,667 participants; low-quality outcome). RUSF for MAM compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUSF was compared with local/home made food (RR: 0.92; 95% CI: 0.64 to 1.33; three studies; 435 participants; low-quality outcome) and whey RUSF (RR: 0.96; 95% CI: 0.92 to 1.00; one study; 2230 participants; high-quality outcome); while standard RUSF may improve recovery by 7% when compared with corn-soy blend (CSB) (RR: 1.07; 95% CI: 1.02 to 1.13; six studies; 5,744 participants; low-quality outcome). There was no evidence of effect on weight gain when standard RUSF was compared with local home made food (MD: -0.75 g·kg-1·day-1; 95% CI: -2.03 to 0.43; one study; 73 participants; low-quality outcome) and whey RUSF (MD: -0.16 g·kg-1·day-1; 95% CI: -0.33 to 0.01; one study; 2,230 participants; high-quality outcome); while standard RUSF may improve weight gain by 0.49 g·kg-1·day-1 when compared with CSB (MD: 0.49 g·kg-1·day-1; 95% CI: 0.10 to 0.87; five studies; 4,354 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUSF was compared with other foods (RR: 0.98; 95% CI: 0.57 to 1.68; eight studies; 8,310 participants; moderate-quality outcome). Prophylactic antibiotic versus no antibiotic (three studies): Prophylactic antibiotic therapy for uncomplicated SAM improves recovery rate by 6% (RR: 1.06; 95% CI: 1.03 to 1.08; two studies; 5,166 participants; high-quality outcome), probably improves weight gain by 0.67 g·kg-1·day-1 (MD: 0.67 g·kg-1·day-1; 95% CI: 0.28, 1.06; two studies; 5,052 participants; moderate-quality outcome) and probably reduces mortality by 26% (RR: 0.74; 95% CI: 0.55, 0.98; three studies; 6944 participants; moderate quality outcome) compared to no antibiotics group. High-dose vitamin A versus low-dose vitamin A (two studies): There was no evidence of effect on weight gain (MD: 0.05 g·kg-1·day-1; 95% CI: -0.08 to 0.18; one study; 207 participants; moderate-quality outcome) and mortality (RR: 7.07; 95% CI: 0.37 to 135.13; one study; 207 participants; moderate-quality outcome). Authors’ conclusions Limited data show some benefit of integrated community-based screening, identification and management of SAM and MAM on improving recovery. Facility-based screening and management of uncomplicated SAM has no benefit on recovery and mortality, while the effect of F100 for SAM is similar to RUTF for weight gain and mortality. Local food and whey RUSF have similar effects as standard RUSF on recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate, weight gain and reduces mortality, while limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.
Collapse
Affiliation(s)
- Jai K. Das
- Division of Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Rehana A. Salam
- Division of Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Marwah Saeed
- Division of Women and Child Health, Aga Khan UniversityKarachiPakistan
| | - Faheem Ali Kazmi
- Division of Women and Child Health, Aga Khan UniversityKarachiPakistan
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick ChildrenTorontoOntarioCanada
| |
Collapse
|
40
|
Abitew DB, Yalew AW, Bezabih AM, Bazzano AN. Predictors of relapse of acute malnutrition following exit from community-based management program in Amhara region, Northwest Ethiopia: An unmatched case-control study. PLoS One 2020; 15:e0231524. [PMID: 32320426 PMCID: PMC7176369 DOI: 10.1371/journal.pone.0231524] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 03/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Community-based management of acute malnutrition (CMAM) is an effective program to manage children with acute malnutrition, including both severe and moderate acute malnutrition. However, little is known about continued child nutritional status after discharge from community based management of acute malnutrition programs in Ethiopia. OBJECTIVE The study aimed to identify factors associated with relapse of acute malnutrition among children 6-59 months after been discharged recovered from community based management program in South Gondar Zone, Northwest Ethiopia. METHODS A case-control study was conducted in three districts of South Gondar Zone by tracing children age 6-59 months who were reported as recovered from the community based management program. Sample size calculated for the first objective of assessing prevalence of severe acute malnutrition among children following discharge as recovery using Epi- Info version 7.1.3.3 StatCalc taking 95% CL, 17.8% post discharge relapse (Ashraf H, et al. (2012), 3% margin of error, design effect of 2 and adding 5% non-response rate was the largest sample size and used to this study. Children with Mid Upper Arm Circumference (MUAC) <12.5cm constituted cases and children with > = 12.5cm served as controls. Data were collected from 10 November 2017 to 30 January 2018 using a survey questionnaire and families were asked to bring children to a health facility for anthropometric measurements, following which data were entered and analyzed. Bivariate and multivariable logistic regression models were utilized to measure association between the risk factors and acute malnutrition. RESULTS Overall, 1,273 participants were interviewed. The mean age in months of children was 23.1 (±9.1 SD) for cases and 23.1 (±8.9 SD) for controls. About 40% of the cases and 50% of the controls were female children. The factors associated with acute malnutrition were: male children (AOR = 1.84, 95% CI: 1.42-2.39), living in a food insecure household (AOR = 1.67, 95% CI:1.15-2.44), non-receipt of Vitamin A supplement (AOR = 1.76, 95% CI: 1.28-2.41), prelacteal feeding (AOR = 2.81 (95%CI, 1.57-5.05), distance to water source more than 15 walk (AOR = 1.88, 95% CI:1.32-2.71), less frequent self-reported hand washing (AOR = 1.35, 95% CI:1.05-1.75), mother not having consumed extra food during this pregnancy/lactation (AOR = 1.36, 95% CI: 1.03-1.78), and respondent age above 30 years (AOR = 1.43, 95% CI:1.10-1.87). CONCLUSION The key factors contributing to relapse of acute malnutrition were related to childcare and feeding practices. Social and behavior change communication strategies targeting families at risk of undernutrition, along with improved food security and integrated programming are recommended to prevent relapse of acute malnutrition.
Collapse
Affiliation(s)
| | | | | | - Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States of America
| |
Collapse
|
41
|
Isanaka S, Andersen CT, Hanson KE, Berthé F, Grais RF, Briend A. Energy needs in the treatment of uncomplicated severe acute malnutrition: Secondary analysis to optimize delivery of ready-to-use therapeutic foods. MATERNAL AND CHILD NUTRITION 2020; 16:e12989. [PMID: 32144946 PMCID: PMC7507348 DOI: 10.1111/mcn.12989] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/24/2020] [Accepted: 02/18/2020] [Indexed: 11/28/2022]
Abstract
Outpatient therapeutic feeding protocols for the treatment of uncomplicated severe acute malnutrition in children were initially based on weight gain data from inpatient settings and expert knowledge of the physiological requirements during recovery. However, weight gain and energy requirements from historic inpatient settings may differ from modern outpatient settings and therefore may not be appropriate to guide current therapeutic feeding protocols. We calculated the weight gain and average estimated total daily energy requirement of children successfully treated for uncomplicated severe acute malnutrition as outpatients in Niger (n = 790). Mean energy provided by six therapeutic feeding protocols was calculated and compared with average estimated energy requirements in the study population. Overall weight gain was 5.5 g·kg-1 ·day-1 among recovered children. Average energy requirements ranged from 92 to 110 kcal·kg-1 ·day-1 depending on the estimation approach. Two current therapeutic feeding protocols were found to provide an excess of energy after the first week of treatment in our study population, whereas four research protocols tended to provide less energy than the estimated requirement after the first week of treatment. Alternative feeding protocols have the potential to simplify and lead to important savings for programmes but should be evaluated to show adequacy to meet the energy needs of children under treatment, as well as feasibility and cost efficiency. Our findings rely on theoretical calculations based on several assumptions and should be confirmed in field studies.
Collapse
Affiliation(s)
- Sheila Isanaka
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Epicentre, Paris, France
| | - Christopher T Andersen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Kerstin E Hanson
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | | | | | - André Briend
- Center for Child Health Research, University of Tampere School of Medicine, Tampere, Finland.,Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
42
|
Potential consequences of expanded MUAC-only programs on targeting of acutely malnourished children and ready-to-use-therapeutic-food allocation: lessons from cross-sectional surveys. BMC Nutr 2020; 6:5. [PMID: 32153978 PMCID: PMC7050718 DOI: 10.1186/s40795-019-0328-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/10/2019] [Indexed: 01/08/2023] Open
Abstract
Background Some of the recently piloted innovative approaches for the management of acute malnutrition in children use the “expanded MUAC-only” approach, with Mid Upper Arm Circumference (MUAC) < 125 mm as the sole anthropometric criterion for screening and admission, classification of cases as severe using the 115 mm cut-off, and use Ready-to-Use-Therapeutic-Food (RUTF) for the management of both moderate (MAM) and severe (SAM) cases of acute malnutrition. Our study aimed at exploring the potential consequences of this “expanded MUAC-only” program scenario on the eligibility for treatment and RUTF allocation, as compared with the existing WHO normative guidance. Methods We analyzed data from 550 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as SAM and MAM according to currently used case definitions, and calculated the proportions of SAM children who would be excluded from treatment, misclassified as MAM, or whose specific risks (because of having both MUAC and weight-for height deficits) would be ignored. We also analyzed the expected changes in the number and demographics (sex, age) of children meant to receive RUTF according to the new approach. Results We found that approximately one quarter of SAM children would not be detected and eligible for treatment under the “expanded MUAC-only” scenario, and another 20% would be classified as MAM. A further 17% of the total SAM children would be admitted and followed only according to their MUAC or oedema status, while they also present with a severe weight-for height deficit on admission. Considering MAM targeting, about half of the MAM children would be left undetected. This scenario also shows a 2.5 time increase in the number of children targeted with RUTF, with approximately 70% of MAM and 30% of SAM cases among this new RUTF target. Conclusions This empirical evidence suggests that adoption of “expanded MUAC-only” programs would likely lead to a priori exclusion from treatment or misclassifying as MAM a large proportion of SAM cases, while redirecting programmatic costs in favor of those less in need. It underscores the need to explore other options for improving the impact of programs addressing the needs of acutely malnourished children.
Collapse
|
43
|
Abitew DB, Worku A, Mulugeta A, Bazzano AN. Rural children remain more at risk of acute malnutrition following exit from community based management of acute malnutrition program in South Gondar Zone, Amhara Region, Ethiopia: a comparative cross-sectional study. PeerJ 2020; 8:e8419. [PMID: 32071802 PMCID: PMC7008819 DOI: 10.7717/peerj.8419] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/17/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Community-based management of acute malnutrition has been reported effective in terms of recovery rate, but recovered children may be at increased risk of developing acute malnutrition after returning to the same household (HH) environment. OBJECTIVE Compare the magnitude and factors associated with acute malnutrition among recovered and never treated children in South Gondar Zone, Amhara Region, Ethiopia. METHOD A comparative cross-sectional study was conducted in three districts of South Gondar Zone by tracing 720 recovered and an equal number of age matched children who were never treated for acute malnutrition. Parents were asked to bring children to health post for survey data collection, anthropometric measurements, and edema assessment. Data were collected using a survey questionnaire, entered in to EpiData and analyzed using SPSS v20. Anthropometric indices were generated according to the WHO's 2006 Child Growth Standards using WHO Anthro software version 3.2.2. Bivariate and multivariable logistic regression was utilized. Values with P < 0.05 were considered statistically significant and Odds Ratio with 95% CI was used to measure strength of association. RESULT A total of 1,440 parents were invited, of which 1,414 participated (98.2% response rate). Mean age in months of children (±SD) was 23.7 (±10.4) for recovered and 23.3 (±10.8) for comparison group. About 49% of recovered and 46% of comparison children were females. A significant difference was observed on magnitude of acute malnutrition between recovered (34.2% (95% CI [30.9-38.0]) and comparison groups (26.7% (95% CI [23.5-30.2]), P = 0.002. Factors associated with acute malnutrition among recovered were district of Ebnat (AOR = 3.7; 95% CI [1.9-7.2]), Tach-Gayint (AOR = 2.4; 95% CI [1.2-4.7]); male child (AOR = 1.4; 95% CI [1.0-2.0]); prelactal feeding (AOR = 2.6; 95% CI [1.3 -5.1]); not feeding colostrum (AOR = 1.5; 95% CI [1.1-2.3]); not consuming additional food during pregnancy/lactation (AOR = 1.6; 95% CI [1.1-2.3]); not given Vitamin A supplement (AOR = 2.1; 95% CI [1.4-3.2]); and safe child feces disposal practice (AOR = 1.7; 95% CI [1.2-2.5]) while district of Tach-Gayint (AOR = 2.5; 95% CI [1.3-4.8]); male child (AOR = 1.5; 95% CI [1.1-2.1]), not feeding colostrum (AOR = 1.7; 95% CI [1.2-2.5]), poor hand washing practice (AOR = 1.6; 95% CI [1.1-2.2]); food insecure HH (AOR = 1.6; 95% CI [1.1-2.4]), birth interval <24 months (AOR = 1.9; 95% CI [1.2-3.2]), and poor access to health facility (AOR = 1.7; 95% CI [1.2-2.4]) were factors associated with acute malnutrition among comparison group. CONCLUSION Recovered children were more at risk of acute malnutrition than the comparison group. Nutrition programs should invest in improving nutrition counseling and education; as well as the hygienic practices to protect children against post-discharge relapse of acute malnutrition.
Collapse
Affiliation(s)
- Dereje B. Abitew
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| |
Collapse
|
44
|
Das JK, Salam RA, Saeed M, Kazmi FA, Bhutta ZA. Effectiveness of Interventions for Managing Acute Malnutrition in Children under Five Years of Age in Low-Income and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients 2020; 12:nu12010116. [PMID: 31906272 PMCID: PMC7019612 DOI: 10.3390/nu12010116] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/15/2019] [Accepted: 12/22/2019] [Indexed: 11/17/2022] Open
Abstract
Childhood malnutrition is a major public health concern, as it is associated with significant short- and long-term morbidity and mortality. The objective of this review was to comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization (WHO) protocol using facility- and community-based approaches, as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use, and vitamin A supplementation. We searched relevant electronic databases until 11 February 2019, and performed a meta-analysis. This review summarizes findings from a total of 42 studies (48 papers), including 35,017 children. Limited data show some benefit of integrated community-based screening, identification, and management of SAM and MAM on improving recovery rate. Facility-based screening and management of uncomplicated SAM has no effect on recovery and mortality, while the effect of therapeutic milk F100 for SAM is comparable to RUTF for weight gain and mortality. Local food and whey RUSF are comparable to standard RUSF for recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate and probably improves weight gain and reduces mortality. Limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.
Collapse
Affiliation(s)
- Jai K. Das
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (J.K.D.); (R.A.S.); (F.A.K.)
| | - Rehana A. Salam
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (J.K.D.); (R.A.S.); (F.A.K.)
| | - Marwah Saeed
- Medical Student, Aga Khan University, Karachi 74800, Pakistan;
| | - Faheem Ali Kazmi
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (J.K.D.); (R.A.S.); (F.A.K.)
| | - Zulfiqar A. Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
- Centre for Global Child Health, the Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Correspondence:
| |
Collapse
|
45
|
New approach to simplifying and optimising acute malnutrition treatment in children aged 6-59 months: the OptiMA single-arm proof-of-concept trial in Burkina Faso. Br J Nutr 2019; 123:756-767. [PMID: 31818335 PMCID: PMC7054246 DOI: 10.1017/s0007114519003258] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The Optimising treatment for acute MAlnutrition (OptiMA) strategy trains mothers to use mid upper arm circumference (MUAC) bracelets for screening and targets treatment to children with MUAC < 125 mm or oedema with one therapeutic food at a gradually reduced dose. This study seeks to determine whether OptiMA conforms to SPHERE standards (recovery rate > 75 %). A single-arm proof-of-concept trial was conducted in 2017 in Yako district, Burkina Faso including children aged 6–59 months in outpatient health centres with MUAC < 125 mm or oedema. Outcomes were stratified by MUAC category at admission. Multivariate survival analysis was carried out to identify variables predictive of recovery. Among 4958 children included, 824 (16·6 %) were admitted with MUAC < 115 mm or oedema, 1070 (21·6 %) with MUAC 115–119 mm and 3064 (61·8 %) with MUAC 120–124 mm. The new dosage was correctly implemented at all visits for 75·9 % of children. Global recovery was 86·3 (95 % CI 85·4, 87·2) % and 70·5 (95 % CI 67·5, 73·5) % for children admitted with MUAC < 115 mm or oedema. Average therapeutic food consumption was 60·8 sachets per child treated. Recovery was positively associated with mothers trained to use MUAC prior to child’s admission (adjusted hazard ratio 1·09; 95 % CI 1·01, 1·19). OptiMA was successfully implemented at the scale of an entire district under ‘real-life’ conditions. Programme outcomes exceeded SPHERE standards, but further study is needed to determine if increasing therapeutic food dosages for the most severely malnourished will improve recovery.
Collapse
|
46
|
Dalglish SL, Seni Badou M, Sirat A, Abdullahi O, Adalbert MFE, Biotteau M, Goldsmith A, Kozuki N. Combined protocol for severe and moderate acute malnutrition in emergencies: Stakeholders perspectives in four countries. MATERNAL AND CHILD NUTRITION 2019; 16:e12920. [PMID: 31773867 PMCID: PMC7083443 DOI: 10.1111/mcn.12920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/07/2019] [Accepted: 11/11/2019] [Indexed: 12/29/2022]
Abstract
Each year, acute malnutrition affects an estimated 52 million children under 5 years of age. Current global treatment protocols divide treatment of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) despite malnutrition being a spectrum disease. A proposed Combined Protocol provides for (a) treatment of MAM and SAM at the same location; (b) diagnosis using middle‐upper‐arm circumference (MUAC) and oedema only; (c) treatment using a single product, ready‐to‐use‐therapeutic food (RUTF), and (d) a simplified dosage schedule for RUTF. This study examines stakeholders' knowledge of and opinions on the Combined Protocol in Niger, Nigeria, Somalia, and South Sudan. Data collection included a document review followed by in‐depth interviews with 50 respondents from government, implementing partners, and multilateral agencies, plus 11 global and regional stakeholders. Data were analysed iteratively using thematic content analysis. We find that acute malnutrition protocols in these countries have not been substantially modified to include components of the Combined Protocol, although aspects were accepted for use in emergencies. Respondents generally agreed that MAM and SAM treatment should be provided in the same location, however they said MUAC and oedema‐only diagnosis, although more field‐ready than other diagnostic measures, did not necessarily catch all malnourished children and may not be appropriate for “tall and slim” morphologies. Similarly, using only RUTF presented inherent logistical advantages, but respondents worried about pipeline issues. Respondents did not express strong opinions about simplified dosage schedules. Stakeholders interviewed indicated more evidence is needed on the operational implications and effectiveness of the Combined Protocol in different contexts.
Collapse
Affiliation(s)
- Sarah L Dalglish
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Amin Sirat
- Nutrition Department, International Rescue Committee, Maiduguri, Nigeria
| | - Omar Abdullahi
- Nutrition Department, International Rescue Committee, Mogadishu, Somalia
| | | | - Marie Biotteau
- Nutrition Department, International Rescue Committee, Bamako, Mali
| | - Amelia Goldsmith
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Naoko Kozuki
- Nutrition Department, International Rescue Committee, Washington, DC, USA
| |
Collapse
|
47
|
Lelijveld N, Beedle A, Farhikhtah A, Elrayah EE, Bourdaire J, Aburto N. Systematic review of the treatment of moderate acute malnutrition using food products. MATERNAL AND CHILD NUTRITION 2019; 16:e12898. [PMID: 31667981 PMCID: PMC7038867 DOI: 10.1111/mcn.12898] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/02/2019] [Accepted: 09/25/2019] [Indexed: 01/05/2023]
Abstract
There is currently a lack of international guidance on the most appropriate treatment for moderate acute malnutrition (MAM), and discrepancies in national treatment guidelines exist. We aimed to explore whether food interventions are effective for MAM children 6–59 months old and whether they result in better outcomes compared with no treatment or management with nutrition counselling. A systematic literature search was conducted in October 2018, identifying studies that compared treating MAM children with food products versus management with counselling or no intervention. A total of 673 abstracts were screened, 101 full texts were read, and one study was identified that met our inclusion criteria. After broadening the criteria to include micronutrients in the control group and enrolment based on out‐dated anthropometric criteria, 11 studies were identified for inclusion. Seven of these found food products to be superior for anthropometric outcomes compared with counselling and/or micronutrient supplementation; two of the studies found no significant benefit of a food product intervention; and two studies were inconclusive. Hence, the majority of studies in this review found that food products resulted in greater anthropometric gains than counselling or micronutrient interventions. This was especially true if the supplementary food provided was of suitable quality and provided for an adequate duration. Improving quality of and adherence to counselling may improve its effectiveness, particularly in food secure contexts. There is currently a paucity of comparable studies on this topic as well as a lack of studies that include important functional outcomes beyond anthropometric proxies.
Collapse
Affiliation(s)
- Natasha Lelijveld
- School of Human Development and Health, University of Southampton, Southampton, UK
| | - Alexandra Beedle
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Nancy Aburto
- United National World Food Programme, Rome, Italy
| |
Collapse
|
48
|
Wagnew F, Dessie G, Takele WW, Tadesse A, Islam SMS, Mulugeta H, Haile D, Negesse A, Abajobir AA. A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia. BMC Public Health 2019; 19:1175. [PMID: 31455292 PMCID: PMC6712890 DOI: 10.1186/s12889-019-7466-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/11/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Severe forms of malnutrition have drastic effects on childhood morbidity and mortality in sub-Saharan countries, including Ethiopia. Although few studies have previously estimated treatment outcomes of severe acute malnutrition (SAM) in Ethiopia, the findings were widely varied and inconsistent. This study thus aimed to pool estimates of treatment outcomes and identify predictors of mortality among children with SAM in Ethiopia. METHODS A systematic review was carried out to select 21 eligible articles from identified 1013 studies (dating from 2000 to 2018) that estimated treatment outcomes and predictors of mortality among SAM children. Databases including PubMed, CINHAL, Web of Sciences; Cochrane, Psych INFO and Google Scholar were comprehensively reviewed using medical subject headings (MESH) and a priori set criteria PRISMA guideline was used to systematically review and meta-analyze eligible studies. Details of sample size, magnitude of effect sizes, including Hazard Ratio (HRs) and standard errors were extracted. Random-effects model was used to calculate pooled estimates in Stata/se version-14. Cochran's Q, I2, and meta-bias statistics were assessed for heterogeneity and Egger's test for publication bias. RESULT Twenty-one studies were included in the final analysis, which comprised 8057 under-five children with SAM in Ethiopia. The pooled estimates of treatment outcomes, in terms of death, recovery, defaulter and transfer out and non-response rates were 10.3% (95% CI: 8.3, 12.3), 70.5% (95% CI: 65.7, 72.2), 13.8% (95% CI: 10.8, 16.9) and 5.1% (95% CI: 3.3, 6.9), respectively. Diarrhea (HR: 1.5, 95% CI: 1.1, 2.2), dehydration (HR: 3.1, 95% CI: 2.3, 4.2) and anemia (HR: 2.2, 95% CI: 1.5, 3.3) were statistically significant predictors of mortality among these children. No publication bias was detected. CONCLUSION Treatment outcomes in under-five children with SAM are lower than the World Health Organization (WHO) standard, where mortality is being predicted by comorbidities at admission. Children with SAM need to be treated for diarrhea, dehydration and anemia at the primary point of care to reduce mortality.
Collapse
Affiliation(s)
- Fasil Wagnew
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Getenet Dessie
- College of Health Sciences, Bahirdar University, Bahirdar, Ethiopia
| | | | - Aster Tadesse
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | | | - Henok Mulugeta
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Dessalegn Haile
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Ayenew Negesse
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Amanuel Alemu Abajobir
- Faculty of Medicine/school of Public Health, The University of Queensland, Brisbane, Australia
- African Population and Health Research Center, Maternal and Child Wellbeing Unit, Nairobi, Kenya
| |
Collapse
|
49
|
Kangas ST, Salpéteur C, Nikièma V, Talley L, Ritz C, Friis H, Briend A, Kaestel P. Impact of reduced dose of ready-to-use therapeutic foods in children with uncomplicated severe acute malnutrition: A randomised non-inferiority trial in Burkina Faso. PLoS Med 2019; 16:e1002887. [PMID: 31454351 PMCID: PMC6711495 DOI: 10.1371/journal.pmed.1002887] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/23/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children with uncomplicated severe acute malnutrition (SAM) are treated at home with ready-to-use therapeutic foods (RUTFs). The current RUTF dose is prescribed according to the weight of the child to fulfil 100% of their nutritional needs until discharge. However, there is doubt concerning the dose, as it seems to be shared, resulting in suboptimal cost-efficiency of SAM treatment. We investigated the efficacy of a reduced RUTF dose in community-based treatment of uncomplicated SAM. METHODS AND FINDINGS We undertook a randomised trial testing the non-inferiority of weight gain velocity of children with SAM receiving (a) a standard RUTF dose for two weeks, followed by a reduced dose thereafter (reduced), compared with (b) a standard RUTF dose throughout the treatment (standard). A mean difference of 0.0 g/kg/day was expected, with a non-inferiority margin fixed at -0.5 g/kg/day. Linear and logistic mixed regression analyses were performed, with study site and team as random effects. Between October 2016 and July 2018, 801 children with uncomplicated SAM aged 6-59 months were enrolled from 10 community health centres in Burkina Faso. At admission, the mean age (± standard deviation [SD]) was 13.4 months (±8.7), 49% were male, and the mean weight was 6.2 kg (±1.3). The mean weight gain velocity from admission to discharge was 3.4 g/kg/day and did not differ between study arms (Δ 0.0 g/kg/day; 95% CI -0.4 to 0.4; p = 0.92) confirming non-inferiority (p = 0.013). However, after two weeks, the weight gain velocity was significantly lower in the reduced dose with a mean of 2.3 g/kg/day compared with 2.7 g/kg/day in the standard dose (Δ -0.4 g/kg/day; 95% CI -0.8 to -0.02; p = 0.041). The length of stay (LoS) was not different (p = 0.73) between groups with a median of 56 days (interquartile range [IQR] 35-91) in both arms. No differences were found between reduced and standard arm in recovery (52.7% and 55.4%; p = 0.45), referral (19.2% and 20.1%; p = 0.80), defaulter (12.2% and 8.5%; p = 0.088), non-response (12.7% and 12.5%; p = 0.95), and relapse (2.4% and 1.8%; p = 0.69) rates, respectively. However, the reduced RUTF dose had a small 0.2 mm/week (95% CI 0.04 to 0.4; p = 0.015) negative effect on height gain velocity with a mean height gain of 2.6 mm/week with reduced and 2.8 mm/week with standard RUTF dose. The impact was more pronounced in children under 12 months of age (interaction, p = 0.019) who gained 2.8 mm/week with reduced and 3.1 mm/week with standard dose (Δ -0.4 mm/week; 95% CI -0.6 to -0.2; p < 0.001). Limitations include not blinding participants to the RUTF dose received and excluding all children with negative appetite test. The results are generalisable for relatively food secure contexts with a young SAM population. CONCLUSIONS Reducing the RUTF dose provided to children with SAM after two weeks of treatment did not reduce overall weight or mid-upper arm circumference (MUAC) gain velocity nor affect recovery or lengthen treatment time. However, it led to a small but significant negative effect on linear growth, especially among the youngest. The potential effect of reducing the RUTF dose in a routine program on treatment outcomes should be evaluated before scaling up. TRIAL REGISTRATION ISRCTN registry ISRCTN50039021.
Collapse
Affiliation(s)
- Suvi T. Kangas
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
- * E-mail:
| | - Cécile Salpéteur
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
| | - Victor Nikièma
- Nutrition and Health Department, Action Against Hunger (ACF) mission, Ouagadougou, Burkina Faso
| | - Leisel Talley
- Centers for Disease Control and Prevention, Atlanta, United States of America
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Center for Child Health Research, University of Tampere School of Medicine, Tampere University, Tampere, Finland
| | - Pernille Kaestel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
50
|
Stephens K, Orlick M, Beattie S, Snell A, Munsterman K, Oladitan L, Abdel-Rahman S. Examining Mid-Upper Arm Circumference Malnutrition z-Score Thresholds. Nutr Clin Pract 2019; 35:344-352. [PMID: 31175704 DOI: 10.1002/ncp.10324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Anthropometric z-scores used commonly for diagnosis and determining degree of malnutrition, specifically body mass index (BMIz), weight-for-length (WLz), and mid-upper arm circumference (MUACz), are not wholly concordant, yet the proposed thresholds for classification are identical. This study was designed to critically examine MUACz thresholds and their ability to correctly classify nutrition status. METHODS This was a 2-year, prospective single-center study of children ≤18 years seen by registered dietitians within a large pediatric institution. The sensitivity, specificity, and predictive performance of the malnutrition classification thresholds were estimated against clinician-based classification. RESULTS Sixty-one dietitians enrolled 10,401 patients with distributions of z-scores for weight (-0.5 ± 1.9), length (-0.8 ± 1.6), BMI or WL (-0.1 ± 1.8), and MUAC (-0.4 ± 1.5), suggesting participants were smaller and shorter than the reference U.S. POPULATION Distributions of MUACz were broad and overlapped between nutrition classification groups, an observation that extended to BMIz and WLz as well. Consequently, existing thresholds do not accurately classify 100% of children. Misclassification rates increase, with increasing severity ranging from 8% in children with no malnutrition to 71% in children with severe malnutrition. Algorithm- and manually-based refinement of thresholds result in mixed improvements and can be explored by the reader with the associated supplement. CONCLUSION The sensitivity of proposed MUACz thresholds systematically decreases with increasing severity of malnutrition and will require optimization if we aim to limit the number of children at risk of misclassification. Indicators for overnutrition remain to be addressed but are explored herein.
Collapse
Affiliation(s)
- Karen Stephens
- Nutrition Services, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Meike Orlick
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Audrey Snell
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Leah Oladitan
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Susan Abdel-Rahman
- UMKC School of Medicine, Kansas City, Missouri, USA.,Innovation in Health Care Delivery, Children's Research Institute, Kansas City, Missouri, USA.,Section of Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Missouri, USA
| |
Collapse
|