Energy needs in the treatment of uncomplicated severe acute malnutrition: Secondary analysis to optimize delivery of ready‐to‐use therapeutic foods

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.     

Cost analysis of the treatment of severe acute malnutrition in West Africa

We present an updated cost analysis to provide new estimates of the cost of providing community‐based treatment for severe acute malnutrition, including expenditure shares for major cost categories. We calculated total and per child costs from a provider perspective. We categorized costs into three main activities (outpatient treatment, inpatient treatment, and management/administration) and four cost categories within each activity (personnel; therapeutic food; medical supplies; and infrastructure and logistical support). For each category, total costs were calculated by multiplying input quantities expended in the Médecins Sans Frontières nutrition program in Niger during a 12‐month study period by 2015 input prices. All children received outpatient treatment, with 43% also receiving inpatient treatment. In this large, well‐established program, the average cost per child treated was €148.86, with outpatient and inpatient treatment costs of €75.50 and €134.57 per child, respectively. Therapeutic food (44%, €32.98 per child) and personnel (35%, €26.70 per child) dominated outpatient costs, while personnel (56%, €75.47 per child) dominated in the cost of inpatient care. Sensitivity analyses suggested lowering prices of medical treatments, and therapeutic food had limited effect on total costs per child, while increasing program size and decreasing use of expatriate staff support reduced total costs per child substantially. Updated estimates of severe acute malnutrition treatment cost are substantially lower than previously published values, and important cost savings may be possible with increases in coverage/program size and integration into national health programs. These updated estimates can be used to suggest approaches to improve efficiency and inform national‐level resource allocation.     

Burden and risk factors for relapse following successful treatment of uncomplicated severe acute malnutrition in young children: Secondary analysis from a randomised trial in Niger

This study aimed to quantify the burden of relapse following successful treatment for uncomplicated severe acute malnutrition (SAM) and to identify associated risk factors in rural Niger. We used data from 1490 children aged 6−59 months discharged as recovered from an outpatient nutritional programme for SAM and followed for up to 12 weeks after admission. Postdischarge SAM relapse was defined as weight‐for‐height Z‐score <−3, mid‐upper arm circumference (MUAC) <115 mm or bipedal oedema after having been discharged as recovered. Postdischarge hospitalisation was defined as admission to inpatient SAM treatment or hospitalisation for any cause after having been discharged as recovered. We used multivariate log‐binomial models to identify independent risk factors. After programmatic discharge, 114 (8%) children relapsed to SAM and 89 (6%) were hospitalised. Factors associated with SAM relapse were discharge during the lean season (relative risk [RR] = 1.80 [95% confidence interval [CI] = 1.22−2.67]) and larger household size (RR = 1.56 [95% CI = 1.01−2.41]), whereas older child age (RR = 0.94 [95% CI = 0.88−1.00]), higher child MUAC at discharge (RR = 0.93 [95% CI = 0.87−1.00]) and maternal literacy (RR = 0.54 [95% CI = 0.29−0.98]) were protective factors. Discharge during the lean season (RR = 2.27 [95% CI = 1.46−3.51]) was independently associated with postdischarge hospitalisation. Future nutritional programmes in the context of Niger may consider modification of anthropometric discharge criteria or the provision of additional home support or follow‐up during the lean season as potential interventions to prevent relapse. More research including postdischarge follow‐up is needed to better understand the sustainability of treatment outcomes after discharge and the type of intervention that may best sustain recovery over time. Clinical Trial Registration: ClinicalTrials.gov number, {"type":"clinical-trial","attrs":{"text":"NCT01613547","term_id":"NCT01613547"}}NCT01613547.     

Performance of low‐literate community health workers treating severe acute malnutrition in South Sudan

Previous studies have described barriers to access of childhood severe acute malnutrition (SAM) treatment, including long travel distances and high opportunity costs. To increase access in remote communities, the International Rescue Committee developed a simplified SAM treatment protocol and low‐literacy‐adapted tools for community‐based distributors (CBD, the community health worker cadre in South Sudan) to deliver treatment in the community. A mixed‐methods pilot study was conducted to assess whether low‐literate CBDs can adhere to a simplified SAM treatment protocol and to examine the community acceptability of CBDs providing treatment. Fifty‐seven CBDs were randomly selected to receive training. CBD performance was assessed immediately after training, and 44 CBDs whose performance score met a predetermined standard were deployed to test the delivery of SAM treatment in their communities. CBDs were observed and scored on their performance on a biweekly basis through the study. Immediately after training, 91% of the CBDs passed the predetermined 80% performance score cut‐off, and 49% of the CBDs had perfect scores. During the study, 141 case management observations by supervisory staff were conducted, resulting in a mean score of 89.9% (95% CI: 86.4%–96.0%). For each performance supervision completed, the final performance score of the CBD rose by 2.0% (95% CI: 0.3%–3.7%), but no other CBD characteristic was associated with the final performance score. This study shows that low‐literate CBDs in South Sudan were able to follow a simplified treatment protocol for uncomplicated SAM with high accuracy using low‐literacy‐adapted tools, showing promise for increasing access to acute malnutrition treatment in remote communities.     

MUAC as the sole discharge criterion from community‐based management of severe acute malnutrition in Burkina Faso

The use of mid upper arm circumference (MUAC) measurement to screen and determine eligibility for admission to therapeutic feeding programs has been established, but evidence and programmatic experience to inform guidance on the use of MUAC as a discharge criterion is limited. We present results from a large‐scale nutritional program using MUAC for admission and discharge and compare program outcomes and response to treatment when determining eligibility for discharge by proportional weight gain versus discharge by MUAC. The study population included all children admitted to the Ministry of Health therapeutic feeding program supported by Médecins Sans Frontières in northern Burkina Faso from September 2007 to December 2011 (n = 50,841). Recovery was high overall using both discharge criteria, with low risks of death, nonresponse, and transfer to inpatient care and high daily gains in weight, MUAC, weight‐for‐height Z score, and height. When discharge was made by MUAC only, recovery increased, while all adverse program outcomes and length of stay decreased, with increasing MUAC on admission. MUAC‐based programming, where MUAC is integrated into program screening, admission, and discharge, is one of several new approaches that can be used to target resources to the most at‐risk malnourished children and improve program efficiency and coherency. This analysis provides additional programmatic experience on the use of MUAC‐based discharge criterion, but more work may be needed to inform optimal discharge thresholds across settings.     

Quality of care for severe acute malnutrition delivered by community health workers in southern Bangladesh

This study assessed the quality of care provided by community health workers (CHWs) in managing cases of severe acute malnutrition (SAM) according to a treatment algorithm. A mixed methods approach was employed to provide perspectives on different aspects of quality of care, including technical competence and acceptability to caretakers. CHWs screened children at community level using a mid‐upper arm circumference measurement, and treated cases without medical complications. Fifty‐five case management observations were conducted using a quality of care checklist, with 89.1% (95% confidence interval: 77.8–95.9%) of CHWs achieving 90% error‐free case management or higher. Caretakers perceived CHWs' services as acceptable and valuable, with doorstep delivery of services promoting early presentation in this remote area of Bangladesh. Integration of the treatment of SAM into community‐based health and nutrition programs appears to be feasible and effective. In this setting, well‐trained and supervised CHWs were able to effectively manage cases of SAM. These findings suggest the feasibility of further decentralization of treatment from current delivery models for community‐based management of acute malnutrition.     

Quality of care for treatment of uncomplicated severe acute malnutrition delivered by community health workers in a rural area of Mali

An alternative Community‐based Management of Acute Malnutrition model with community health workers (CHWs) delivering treatment for uncomplicated severe acute malnutrition (SAM) was piloted in Mali. The capacity of the CHWs to evaluate, classify, and treat cases of uncomplicated SAM, to provide nutritional counselling to caretakers of children receiving treatment for SAM, malaria, pneumonia or diarrhoea and to correctly refer cases of complicated SAM, was assessed. This was done using direct observation by trained enumerators of the management of SAM cases using checklists, re‐diagnosing the cases admitted for treatment and reviewing admissions cards and registers. One hundred twenty‐five cases, assessed and treated by the CHWs, were observed. The majority of children were correctly assessed for the presence of major clinical signs (cough, diarrhoea, fever, and vomiting; 97.6%), and similarly most children were checked for the presence of danger signs (95.2%). Mid‐upper arm circumference was correctly assessed in 96.8% of children and oedema was correctly assessed in 78.4% (The composite indicator, which includes all essential tasks to provide high‐quality treatment, was achieved in 79.5% of cases. This paper concludes that well‐trained and supervised CHWs are capable of managing cases of uncomplicated SAM. This suggests that such a strategy is an opportunity to increase access to quality treatment in Mali for SAM cases. However, further evidence is required to ensure that this level of care can be achieved at scale.     

Relapse after severe acute malnutrition: A systematic literature review and secondary data analysis

The objectives of most treatment programs for severe acute malnutrition (SAM) in children focus on initial recovery only, leaving post‐discharge outcomes, such as relapse, poorly understood and undefined. This study aimed to systematically review current literature and conduct secondary data analyses of studies that captured relapse rates, up to 18‐month post‐discharge, in children following recovery from SAM treatment. The literature search (including PubMed and Google Scholar) built upon two recent reviews to identify a variety of up‐to‐date published studies and grey literature. This search yielded 26 articles and programme reports that provided information on relapse. The proportion of children who relapsed after SAM treatment varied greatly from 0% to 37% across varying lengths of time following discharge. The lack of a standard definition of relapse limited comparability even among the few studies that have quantified post‐discharge relapse. Inconsistent treatment protocols and poor adherence to protocols likely add to the wide range of relapse reported. Secondary analysis of a database from Malawi found no significant association between potential individual risk factors at admission and discharge, except being an orphan, which resulted in five times greater odds of relapse at 6 months post‐discharge (95% CI [1.7, 12.4], P = 0.003). The development of a standard definition of relapse is needed for programme implementers and researchers. This will allow for assessment of programme quality regarding sustained recovery and better understanding of the contribution of relapse to local and global burden of SAM.     

Relapses from acute malnutrition and related factors in a community‐based management programme in Burkina Faso

Community‐based management of acute malnutrition (CMAM) is effective in treating acute malnutrition. However, post‐discharge follow‐up often lacks. We aimed at assessing the relapse rate and the associated factors in a CMAM programme in Burkina Faso. Discharged children from the community nutrition centre were requested to return at least every 3 months for follow‐up. The data of recovered children (weight‐for‐height z‐score ≥−2) who were discharged between July 2010 and June 2011 were collected in 45 villages, randomly selected out of 210 in January 2012. Sociodemographic data, economic variables, information on household food availability and the child's food consumption in the last 24 h were collected from the parents. A multivariate Cox proportional hazards regression was used to identify the factors associated to relapse. Of the 637 children, 14 (2.2%) died and 218 (34.2%) were lost to follow‐up. The relapse rate [95% confidence interval] among the children who returned for follow‐up was 15.4 [11.8–19.0] per 100 children‐years. The associated factors to relapses in multivariate Cox regression model were mid‐upper arm circumference (MUAC) at discharge below 125 mm, no oil/fat consumption during the last 24 h and incomplete vaccination. To limit relapses, CMAM programmes should avoid premature discharge before a MUAC of at least 125 mm. Nutrition education should emphasize fat/oil as inexpensive energy source for children. Promoting immunization is essential to promote child growth. Periodic monitoring of discharged children should be organized to detect earlier those who are at risk of relapse. The relapse rate should be a CMAM effectiveness indicator.     

Stigma as a barrier to treatment for child acute malnutrition in Marsabit County,Kenya

Acute malnutrition affects millions of children each year, yet global coverage of life‐saving treatment through the community‐based management of acute malnutrition (CMAM) is estimated to be below 15%. We investigated the potential role of stigma as a barrier to accessing CMAM. We surveyed caregivers bringing children to rural health facilities in Marsabit County, Kenya, divided into three strata based on the mid‐upper arm circumference of the child: normal status (n = 327), moderate acute malnutrition (MAM, n = 241) and severe acute malnutrition (SAM, n = 143). We used multilevel mixed effects logistic regression to estimate the odds of reporting shame as a barrier to accessing health care. We found that the most common barriers to accessing child health care were those known to be universally problematic: women's time and labour constraints. These constituted the top five most frequently reported barriers regardless of child acute malnutrition status. In contrast, the odds of reporting shame as a barrier were 3.64 (confidence interval: 1.66–8.03, P < 0.05) times higher in caregivers of MAM and SAM children relative to those of normal children. We conclude that stigma is an under‐recognized barrier to accessing CMAM and may constrain programme coverage. In light of the large gap in coverage of CMAM, there is an urgent need to understand the sources of acute malnutrition‐associated stigma and adopt effective means of de‐stigmatization.     

Predicted implications of using percentage weight gain as single discharge criterion in management of acute malnutrition in rural southern Ethiopia

Mid‐upper arm circumference (MUAC) is increasingly used in identifying and admitting children with acute malnutrition for treatment. It is easy to use because it does not involve height assessment, but its use calls for alternative discharge criteria. This study examined how use of percentage weight gain as discharge criterion would affect the nutritional status of children admitted into a community‐based management programme for acute malnutrition in rural southern Ethiopia. Non‐oedematous children (n = 631) aged 6–59 months and having a MUAC of <125 mm were studied. By simulation, 10%, 15% and 20% weight was added to admission weight and their nutritional status by weight‐for‐height z‐score (WHZ) was determined at each target. Moderate and severe wasting according to World Health Organization WHZ definitions was used as outcome. Applying the most commonly recommended target of 15% weight gain resulted in 9% of children with admission MUAC <115 mm still being moderately or severely wasted at theoretical discharge. In children with admission MUAC 115–124 mm, 10% of weight gain was sufficient to generate a similar result. Children failing to recover were the ones with the poorest nutritional status at admission. Increasing the percentage weight gain targets in the two groups to 20% and 15%, respectively, would largely resolve wasting but likely lead to increased programme costs by keeping already recovered children in the programme. Further research is needed on appropriate discharge procedures in programmes using MUAC for screening and admission.     

Factors associated with acute malnutrition among children 6‐59 months in rural Mozambique

Factors associated with acute malnutrition are complex and wide‐ranging particularly in developing countries. In Mozambique, contextual factors associated to children acute malnutrition are yet to be fully investigated and the evidences used to better inform prevention programme. The objective of this study is to identify key factors associated with acute malnutrition among 6‐ to 59‐month‐old children living in nine districts in rural Mozambique assessed in the 2018 seasonal nutrition assessment. We analysed Standardized Monitoring and Assessment for Relief and Transition (SMART) nutrition survey data of 1,116 children from three districts and rapid nutrition assessment (RNA) data of 3,884 children from six districts of Mozambique. We used a multiple logistic regression analysis to respond to the research question. Experiencing diarrhoea [odds ratio (OR) = 4.54; P = 0.001] was the only variable associated with acute malnutrition from the SMART survey dataset, whereas in the RNA, fever (OR = 3.0; P = 0.000) access to sanitation (OR = 0.118; P = 0.037), experiencing shock in the household (OR = 0.5; P = 0.020), diarrhoea (OR = 2.41; P = 0.001) and cough (OR = 1.75; P = 0.030) were the variables with significant association to acute malnutrition. We believe that the findings were influenced by the proportion of acute malnutrition in each survey type. Study findings confirm the association between acute malnutrition and child's health outcomes that are generally linked to poor living conditions and independent effects of shocks. This highlights the need for policy and programme to implement integrated, cross‐sectoral approaches to tackling child acute malnutrition, particularly addressing community level conditions such as water and sanitation.     

Severe acute malnutrition in children aged under 5 years can be successfully managed in a non‐emergency routine community healthcare setting in Ghana

This study investigated the performance of community‐based management of severe acute malnutrition (CMAM) within routine healthcare services in Ghana. This was a retrospective cohort study of n = 488 children (6–59 months) who had received CMAM. Data for recovery, default, and mortality rates were obtained from enrolment cards in 56 outpatient centres in Upper East region, Ghana. Satisfactory rates of recovery of 71.8% were reported. Children who were enrolled with higher mid‐upper arm circumference (MUAC) ≥11.5 cm had seven times greater chance of recovery compared with children who were enrolled with lower MUAC <11.5 cm, OR = 7.35, 95% CI [2.56, 21.15], p < .001. Children who were diagnosed without malaria at baseline were 30 times, OR = 30.39, 95% CI [10.02, 92.13], p < .001, more likely to recover compared with those with malaria (p < .001). The average weight gain was 4.7 g^?1·kg^?1·day^?1, which was influenced by MUAC status at baseline, β = .78, 95% CI [0.46, 1.00], p < .001, presence of malaria, β = ?1.25, 95% CI [?1.58, 0.92], p < .001, and length of stay, β = 0.13, 95% CI [0.08, 0.18], p < .001. The default rate (28.5%) was higher than international standards recommendations by Sphere. Mortality rate (1.6%) was lower than international standards. Our findings suggest that community‐based management of SAM can achieve similar success when delivered in routine non‐emergency settings. However, this success can be diluted by a high default rate, and the factors contributing to this need to be explored to improve programme effectiveness within communities.     

The impact of rickets on growth and morbidity during recovery among children with complicated severe acute malnutrition in Kenya: A cohort study

The effects of rickets on children recovery from severe acute malnutrition (SAM) are unknown. Rickets may affect both growth and susceptibility to infectious diseases. We investigated the associations of clinically diagnosed rickets with life‐threatening events and anthropometric recovery during 1 year following inpatient treatment for complicated SAM. This was a secondary analysis of clinical trial data among non‐human immunodeficiency virus‐infected Kenyan children with complicated SAM (2–59 months) followed for 1 year posthospital discharge ( ClinicalTrials.gov ID NCT00934492). The outcomes were mortality, hospital readmissions, and growth during 12 months. The main exposure was clinically diagnosed rickets at baseline. Of 1,778 children recruited, 230 (12.9%, 95% CI [11.4, 14 .6]) had clinical signs of rickets at baseline. Enrolment at an urban site, height‐for‐age and head circumference‐for‐age z scores were associated with rickets. Rickets at study enrolment was associated with increased mortality (adjusted Hazard Ratio [aHR] 1.61, 95% CI [1.14, 2.27]), any readmission (aHR 1.37, 95% CI [1.09, 1.72]), readmission for severe pneumonia (aHR 1.37, 95% CI [1.05, 1.79]), but not readmission with diarrhoea (aHR 1.05, 95% CI [0.73, 1.51]). Rickets was associated with increased height gain (centimetres), adjusted regression coefficient 0.19 (95% CI [0.10, 0.28]), but not changes in head circumference, mid‐upper arm circumference, or weight. Rickets was common among children with SAM at urban sites and associated with increased risks of severe pneumonia and death. Increased height gain may have resulted from vitamin D and calcium treatment. Future work should explore possibility of other concurrent micronutrient deficiencies and optimal treatment of rickets in this high‐risk population.     

Day-care management of children with severe malnutrition in an urban health clinic in Dhaka, Bangladesh

Management of severely malnourished children with associated complications relies on hospital-based treatment. Implementation of a standardized protocol at the Dhaka Hospital, ICDDR,B reduced case fatality approximately 50%. We developed and prospectively evaluated a day-care clinic approach that provided antibiotics, micronutrients and feeding during the day with continued care by parents at home at night as an alternative to hospitalization. Severely malnourished children aged 6-23 months denied admission to hospital were enrolled at Radda Clinic, Dhaka and received protocolized management with antibiotics, micronutrients and milk-based diet from 8:00 am to 5:00 pm each day, while mothers were educated on continuation of care at home. They were transitioned to the day-care nutrition rehabilitation (NR) unit of Radda Clinic following resolution of acute illness, received NR diet (Khichuri, halwa and milk-based) daily until children attained 80% weight-for-length. From February 2001 to November 2003, 264 children were enrolled; 52% were boys and 78%, 21% and 1% had marasmus, marasmus-kwashiorkor and kwashiorkor, respectively. Only 13% had severe malnutrition alone while 35% had pneumonia, 35% had diarrhea and 17% had both pneumonia and diarrhea. The mean (SD) duration of acute and NR phases were 8 (4) and 14 (13) days, respectively. Children gained weight [mean (SD) g/kg day] more rapidly during acute 10 (7) than NR phase 6 (5). Successful management was possible in 82% (95% CI 77-86%) children, 12% discontinued treatment and 6% referred to hospitals. Only one child died during NR phase. Severely malnourished children can be successfully managed at existing day-care clinics using a protocolized approach.     

Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic

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.     

Effectiveness of milk whey protein‐based ready‐to‐use therapeutic food in treatment of severe acute malnutrition in Malawian under‐5 children: a randomised,double‐blind,controlled non‐inferiority clinical trial

The cost of ready‐to‐use therapeutic food (RUTF) used in community‐based management of acute malnutrition has been a major obstacle to the scale up of this important child survival strategy. The current standard recipe for RUTF [peanut‐based RUTF (P‐RUTF)] is made from peanut paste, milk powder, oil, sugar, and minerals and vitamins. Milk powder forms about 30% of the ingredients and may represent over half the cost of the final product. The quality of whey protein concentrates 34% (WPC34) is similar to that of dried skimmed milk (DSM) used in the standard recipe and can be 25–33% cheaper. This blinded, parallel group, randomised, controlled non‐inferiority clinical trial tested the effectiveness in treating severe acute malnutrition (SAM) of a new RUTF formulation WPC‐RUTF in which WPC34 was used to replace DSM. Average weight gain (non‐inferiority margin Δ = ?1.2 g kg^?1 day^?1) and recovery rate (Δ = ?10%) were the primary outcomes, and length of stay (LOS) was the secondary outcome (Δ = +14 days). Both per‐protocol (PP) and intention‐to‐treat (ITT) analyses showed that WPC‐RUTF was not inferior to P‐RUTF for recovery rate [difference and its 95% confidence interval (CI) of 0.5% (95% CI –2.7, 3.7) in PP analysis and 0.6% (95% CI –5.2, 6.3) in ITT analysis] for average weight gain [0.2 (?0.5; 0.9) for both analyses] and LOS [?1.6 days (95% CI, ?4.6, 1.4 days) in PP analysis and ?1.9 days (95% CI, ?4.6, 0.8 days) for ITT analysis]. In conclusion, whey protein‐based RUTF is an effective cheaper alternative to the standard milk‐based RUTF for the treatment of SAM.     

Incidence of severe acute malnutrition after treatment: A prospective matched cohort study in Sokoto,Nigeria

Severe acute malnutrition (SAM) among children in Nigeria is tackled through the outpatient therapeutic programme (OTP) of the Community‐based Management of Acute Malnutrition (CMAM) programme. CMAM is evidently effective in resolving SAM, but little evidence exists on the remaining risk of SAM relapse for children discharged as cured from the OTP. We aimed to measure and compare the 6‐month incidence of SAM among OTP‐cured and community control children and identify factors associated with SAM relapse. We conducted a prospective matched cohort study that tracked 553 OTP‐cured and 526 control children in Sokoto State, Northern Nigeria. Outcomes and covariates were measured fortnightly in up to 12 home visits. We used multivariate Cox and accelerated failure time models to identify significant risk correlates, where the covariates to be tested for correlation with relapse were selected using domain knowledge and automatic feature selection methods. SAM incidence rates were 52 times higher in the OTP‐cured cohort (0.204/100 child‐days) than in the community control cohort (0.004/100 child‐days). Children with lower mid‐upper arm circumference at OTP admission, with lower height/length‐for‐age z‐scores, whose household head did not work over the full year, who lived in an area previously affected by environmental shocks, who were female and who had diarrhoea before the visit had a significantly higher relapse risk. Our study shows that OTP‐cured children remain at a significantly excess risk of SAM. To improve long‐term health outcomes of these children, programmes adopting a CMAM approach should strengthen follow‐up care and be integrated with other preventive services.     

Low‐dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar

The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready‐to‐use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low‐dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight‐for‐Height z‐score of ≥?3 and mid‐upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low‐dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non‐responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg^–1 day^–1 [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non‐response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67–7.42). Our results indicate that a low‐dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here.     

Identifying patient‐ and family‐centered outcomes relevant to inpatient versus at‐home management of neutropenia in children with acute myeloid leukemia

Efficacy of therapeutic strategies relative to patient‐ and family‐centered outcomes in pediatric oncology must be assessed. We sought to identify outcomes important to children with acute myeloid leukemia and their families related to inpatient versus at‐home management of neutropenia. We conducted qualitative interviews with 32 children ≥8 years old and 54 parents. Analysis revealed the impact of neutropenia management strategy on siblings, parent anxiety, and child sleep quality as being outcomes of concern across respondents. These themes were used to inform the design of a questionnaire that is currently being used in a prospective, multiinstitutional comparative effectiveness trial.