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.     

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.     

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.     

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.     

Critical appraisal of the management of severe malnutrition: 2. Dietary management

In the dietary management of severe acute malnutrition in children, there is evidence to support the WHO Manual's protocol of cautious feeding of a low energy and protein formula with small frequent feeds in the initial phase of treatment, particularly in kwashiorkor. However, this initial milk diet (WHO F-75) might benefit from increasing the sulphur amino acid, phosphorus and potassium content and reducing the lactose content, but further studies are needed. Careful tube-feeding results in faster initial recovery and weight gain, but has a significant risk of aspiration in poorly supervised settings. Ready-to-use therapeutic food is an important recent advance in the dietary management of malnutrition in ambulatory settings, allowing more effective prevention programmes and earlier discharge from hospital where community follow-up is available. It should be included in future protocols. There is very good evidence on the use of micronutrients such as zinc, and preliminary evidence suggests that smaller doses of daily vitamin A are preferable to a single large dose on admission for severe malnutrition.     

Home-based therapy for oedematous malnutrition with ready-to-use therapeutic food

BACKGROUND: Standard recommendations are that children with oedematous malnutrition receive inpatient therapy with a graduated feeding regimen. Aim: To investigate exclusive home-based therapy for children with oedematous malnutrition. METHODS: Children with oedematous malnutrition, good appetite and no complications were treated at home with ready-to-use therapeutic food (RUTF) and followed up fortnightly for up to 8 wk. Setting and participants: 219 children aged 1-5 y with oedema enrolled in one of two therapeutic nutritional studies in Malawi in 2003-2004. RESULTS: The overall recovery rate was 83% (182/219), and the case-fatality rate was 5% (11/219). For children with wasting and oedematous malnutrition, 65% (55/85) recovered and 7% (6/85) died. The average weight gain was 2.8+/-3.2 g/kg/d (mean+/-SD). CONCLUSION: This preliminary observation suggests that children with oedematous malnutrition and good appetite may be successfully treated with home-based therapy; a randomized, controlled trial to evaluate this is warranted.     

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.     

Admission profile and discharge outcomes for infants aged less than 6 months admitted to inpatient therapeutic care in 10 countries. A secondary data analysis

Evidence on the management of acute malnutrition in infants aged less than 6 months (infants <6mo) is scarce. To understand outcomes using current protocols, we analysed a sample of 24 045 children aged 0–60 months from 21 datasets of inpatient therapeutic care programmes in 10 countries. We compared the proportion of admissions, the anthropometric profile at admission and the discharge outcomes between infants <6mo and children aged 6–60 months (older children). Infants <6mo accounted for 12% of admissions. The quality of anthropometric data at admission was more problematic in infants <6mo than in older children with a greater proportion of missing data (a 6.9 percentage point difference for length values, 95% CI: 6.0; 7.9, P < 0.01), anthropometric measures that could not be converted to indices (a 15.6 percentage point difference for weight‐for‐length z‐score values, 95% CI: 14.3; 16.9, P < 0.01) and anthropometric indices that were flagged as outliers (a 2.7 percentage point difference for any anthropometric index being flagged as an outlier, 95% CI: 1.7; 3.8, P < 0.01). A high proportion of both infants <6mo and older children were discharged as recovered. Infants <6mo showed a greater risk of death during treatment (risk ratio 1.30, 95% CI: 1.09; 1.56, P < 0.01). Infants <6mo represent an important proportion of admissions to therapeutic feeding programmes, and there are crucial challenges associated with their care. Systematic compilation and analysis of routine data for infants <6mo is necessary for monitoring programme performance and should be promoted as a tool to monitor the impact of new guidelines on care.     

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.     

The health of HIV‐exposed children after early weaning

There are potential health risks associated with the use of early weaning to prevent mother‐to‐child transmission of human immunodeficiency virus (HIV) in resource‐poor settings. Our objective was to examine growth and nutrient inadequacies among a cohort of children weaned early. Children participating in the Breastfeeding Antiretrovirals and Nutrition (BAN) Study in Lilongwe, Malawi, had HIV‐infected mothers, were weaned at 6 months and fed LNS until 12 months. 40 HIV‐negative, BAN‐exited children were compared with 40 HIV‐negative, community children matched on age, gender and local health clinic. Nutrient intake was calculated from 24‐h dietary recalls collected from BAN‐exited children. Anthropometric measurements were collected from BAN‐exited and matched community children at 15–16 months, and 2 months later. Longitudinal random effects sex‐stratified models were used to evaluate anthropometric differences between the two groups. BAN‐exited children consumed adequate energy, protein and carbohydrates but inadequate amounts of fat. The prevalence of inadequate micronutrient intakes were: 46% for vitamin A; 20% for vitamin B6; 69% for folate; 13% for vitamin C; 19% for iron; 23% for zinc. Regarding growth, BAN‐exited girls gained weight at a significantly lower rate {0.02 g kg^?1 per day [95% confidence interval (CI): 0.01, 0.03]} than their matched comparison [0.05 g kg^?1 per day (95% CI: 0.03, 0.07)]; BAN girls grew significantly slower [0.73 cm month^?1 (95% CI: 0.40,1.06)] than their matched comparison (1.55 cm month^?1[95% CI: 0.98, 2.12]). Among this sample of BAN‐exited children, early weaning was associated with dietary deficiencies and girls experienced reduced growth velocity. In resource‐poor settings, HIV prevention programmes must ensure that breastfeeding stop only once a nutritionally adequate and safe diet without breast milk can be provided.     

The Treatment of Persistent Diarrhoea and Malnutrition: Long-term Effects of In-patient Rehabilitation

ABSTRACT. This study aimed to characterise the clinical condition of Gambian children presenting with persistent diarrhoea and severe protein energy malnutrition and to evaluate the effects of short term in-patient treatment in terms of long-term outcome. Twenty-two children (aged 6 to 36 months) with persistent diarrhoea (≥ four loose stools/day for more than two weeks) and severe malnutrition (weight-for-height <75% of the National Center for Health Statistics median value) were assessed prior to in-patient treatment for three weeks with antibiotics and high nutrient-density milk. Initial assessment included biochemical and immunological status together with stool microbiology. Criteria for discharge—cessation of diarrhoea for five consecutive days and steady weight gain—were met in all subjects within four weeks. Progress was assessed clinically and anthropometrically at weekly intervals and 6 and 12 months following discharge. Results showed a steady improvement in growth during the period of in-patient treatment. Continuing improvement in weight-for-age and mid-upper arm circumference was observed after 6 and 12 months and weight-for-height continued to improve up to 6 months but fell back by 12 months. This study has demonstrated that, in the treatment of persistent diarrhoea in the tropics, relatively short periods of in-patient rehabilitation, whilst leading to a resolution of diarrhoea1 symptoms and weight gain in the short term, do not lead to complete recovery. Persistent diarrhoea and malnutrition are likely to recur when the child returns to his village. It is necessary to establish in a prospective study the minimum period of supervised feeding required to ensure the 'critical level' of weight gain necessary for linear growth to return to normal.     

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 low- and middle-income countries

Low- and middle-income countries bear the greatest burden of malnutrition, especially those in sub-Saharan Africa and Asia. Children are particularly vulnerable. This article provides an overview for healthcare professionals working with children, giving definitions and practical advice for intervention and management. Severe acute malnutrition (SAM) is diagnosed in under 5s with severe wasting (“marasmus”) and/or nutritional oedema (“kwashiorkor”). Wasting is identified using weight-for-height and comparing the child's value with WHO reference data or by measurement of mid-upper arm circumference. SAM is thought to result from a complex interaction between infections and poor diet or feeding practices occurring in the context of multiple adverse social-economic factors, with poor sanitation and hygiene increasing exposure to infection. The clinical management of SAM depends on whether there are complications such as anorexia and infections. Children with uncomplicated SAM are best managed in community programmes using ready-to-use therapeutic food and with close monitoring. The management of complicated SAM requires in-patient care and presents a huge challenge especially in health facilities with limited resources. Management guided by the WHO “Ten Steps”, which account for the reductive adaptation that occurs in malnutrition reduces case-fatality but this often remains high. Prevention of SAM requires addressing the multifactorial underlying causes associated with poverty and food insecurity. Addressing malnutrition in children is essential to achieving many of the UN Sustainable Development Goals.     

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.     

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

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

Severe malnutrition in infants aged <6 months—Outcomes and risk factors in Bangladesh: A prospective cohort study

Severe acute malnutrition (SAM) affects ~4 million infants under 6 months (u6m) worldwide, but evidence underpinning their care is “very low” quality. To inform future research and policy, the objectives of our study were to identify risk factors for infant u6m SAM and describe the clinical and anthropometric outcomes of treatment with current management strategies. We conducted a prospective cohort study in infants u6m in Barisal district, Bangladesh. One group of 77 infants had SAM (weight‐for‐length Z‐score [WLZ] <?3 and/or bipedal oedema); 77 others were “non‐SAM” (WLZ ≥?2 to <+2, no oedema, mid‐upper‐arm circumference ≥125 mm). All were enrolled at 4–8 weeks of age and followed up at 6 months. Maternal education and satisfaction with breastfeeding were among factors associated with SAM. Duration of exclusive breastfeeding was shorter at enrolment (3·9 ± 2.1 vs. 5.7 ± 2.2 weeks, P < 0.0001) and at age 6 months (13.2 ± 8.9 vs. 17.4 ± 7.9 weeks; P = 0.003) among SAM infants. Despite referral, only 13 (17%) reported for inpatient care, and at 6 months, 18 (23%) infants with SAM still had SAM, and 3 (3.9%) died. In the non‐SAM group, one child developed SAM, and none died. We conclude that current treatment strategies have limited practical effectiveness: poor uptake of inpatient referral being the main reason. World Health Organization recommendations and other intervention strategies of outpatient‐focused care for malnourished but clinically stable infants u6m need to be tested. Breastfeeding support is likely central to future treatment strategies but may be insufficient alone. Better case definitions of nutritionally at‐risk infants are also needed.     

Fruits and vegetables are incorporated into home cuisine in different ways that are relevant to promoting increased consumption

Fruits and vegetables are essential for healthy life. We examined the fruits and vegetables consumption by 240 caregivers and their children aged 1–17 years in peri‐urban Lima, and the ways that they were incorporated into local cuisine. A randomized cross‐sectional household survey collected information on the weight of all foods eaten the previous day (24 h) including fruits and vegetables, their preparation and serving sizes. Fruit and vegetable consumption was low and very variable: fruit intake was mean 185.2 ± 171.5 g day^?1, median 138 g day^?1 for caregivers and 203.6 ± 190.6 g day^?1 and 159 g day^?1 for children, vegetable intake was mean 116.9 ± 94.0 g day^?1 median 92 g day^?1 for caregivers, mean 89.3 ± 84.7 g day^?1 median 60 g day^?1 for children. Only 23.8% of children and 26.2% of caregivers met the recommended ≥400 g of fruit or vegetable/day. Vegetables were mainly eaten either as ingredients of the main course recipe, eaten by about 80% of caregivers and children, or as salads eaten by 47% of caregivers and 42% of children. Fruits were most commonly eaten as whole fresh fruits eaten by 68% of caregivers and 75% of children. In multivariate analysis of the extent to which different presentations contributed to daily fruit and vegetable consumption, main courses contributed most to determining vegetable intake for caregivers, and for children, main course and salads had similar contributions. For fruit intake, the amount eaten as whole fruit determined total fruit and total fruit plus vegetable intake for both caregivers and children. Local cuisine should be considered in interventions to promote fruit and vegetable consumption. © 2016 John Wiley & Sons Ltd     

An integrated community‐based outpatient therapeutic feeding programme for severe acute malnutrition in rural Southern Ethiopia: Recovery,fatality, and nutritional status after discharge

A scaled up and integrated outpatient therapeutic feeding programme (OTP) brings the treatment of severely malnourished children closer to the community. This study assessed recovery from severe acute malnutrition (SAM), fatality, and acute malnutrition up to 14 weeks after admission to a programme integrated in the primary health care system. In this cohort study, 1,048 children admitted to 94 OTPs in Southern Ethiopia were followed for 14 weeks. Independent anthropometric measurements and information on treatment outcome were collected at four home visits. Only 32.7% (248/759) of children with SAM on admission fulfilled the programme recovery criteria at the time of discharge (i.e., gained 15% in weight, or oedema, if present at admission, was resolved at discharge). Of all children admitted to the programme for whom nutritional assessment was done 14 weeks later, 34.6% (321/928) were severely malnourished, and 37.5% (348/928) were moderately malnourished; thus, 72.1% were acutely malnourished. Of the children, 27/982 (2.7%) had died by 14 weeks, of whom all but one had SAM on admission. Children with severe oedema on admission had the highest fatality rate (12.0%, 9/75). The median length of admission to the programme was 6.6 weeks (interquartile range: 5.3, 8.4 weeks). Despite children participating for the recommended duration of the programme, many children with SAM were discharged still acutely malnourished and without reaching programme criteria for recovery. For better outcome of OTP, constraints in service provision by the health system as well as challenges of service utilization by the beneficiaries should be identified and addressed.     

Maternal risk factors in intrauterine malnutrition

Maternal risk factors in intrauterine malnutrition (IUM) were evaluated for their sensitivity and cut-off points for IUM were assessed for functional status. It was observed that the maternal weight and weight/height² were the most sensitive indicators of IUM, while during pregnancy poor weight gain (<6·0 kg) contributed to almost 60% of IUM. Assessment of biochemical parameters like maternal blood glucose improved the sensitivity of identification of IUM. Based on morbidity, immune response and leucocyte metabolites, it was observed that cut-off point of 2·5 kg for term infants or 10 percentile of expected weight at any time of pregnancy is a fairly good indicator of IUM.     

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.