Aim: Globally more than 19 million under-five children suffer from severe acute malnutrition (SAM). Data on efficacy of World Health Organization's (WHO's) guideline in reducing SAM mortality are limited. We aimed to assess the efficacy of WHO's facility-based guideline for the reduction of under-five SAM children mortality from low and middle income countries (LMICs). Methods: A systematic search of literature published in 1980-2015 was conducted using electronic databases. Additional articles were identified from the reference lists and grey literature. Studies from LMICs where SAM children (0-59 months) were managed in facilities according to WHO's guideline were included. Outcome was reduction in SAM mortality measured by case fatality rate (CFR). The review was reported following the Grading of Recommendations Assessment Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and meta-analyses done using RevMan 5.3 ® .Results: This review identified nine studies, which demonstrated reductions in SAM mortality. CFR ranged from 8 to 16% where WHO guideline applied. High rates of poverty, malnutrition, severe co-morbid condition, lack of resources and differences in treatment practices played a key role in large CFR variation. Most death occurred within 48 h of admission in Asia, between 4 days and 4 weeks in Africa and in Latin America. CFR was reduced by 41% (odds ratio: 0.59; 95% confidence interval: 0.46-0.76) when WHO guideline were applied. A 45% reduction in CFR was achieved after excluding human immunodeficiency virus positive cases. Dietary management also differed among WHO and conventional management. Conclusion: Children receiving SAM inpatient care as per WHO guideline have reduced CFR compared to conventional treatment.

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.

Background: Anemia is pervasive among children under the age of two years in Bangladesh. This study aimed to assess the effect of daily supplementation of multiple micronutrient powder (MNP) for 2 months and 4 months primarily on hemoglobin status of children aged 6-23 months living in a slum of Dhaka, Bangladesh. Methods: It was a community-based observational study where a total of 402 children and 578 children were enrolled for 2 months and 4 months MNP supplementation respectively. Venous blood was collected at enrollment and 5 months later. Hemoglobin level was measured and morbidity episodes recorded from twice weekly home visits. Results: At enrollment, hemoglobin levels were 10.57 ± 1.28 g/dl and 10.78 ± 1.35 g/dl across 2 months and 4 months MNP supplementation groups respectively, compared to 10.65 ± 1.36 g/dl and 11.14 ± 1.11 g/dl at the end-line after MNP supplementation. Plasma hemoglobin increased only after 4 months supplementation in difference-in-difference analysis and this was significantly more in younger children after adjusting the confounding variables (p = 0.03). Prevalence of anemia had improved for both at 2 months (p = 0.015) and 4 months (p = 0.004) of MNP supplementation. Incidence rate ratios (IRR) for diarrhea, cough and fever were comparable across the groups during the supplementation periods and IRR for acute lower respiratory tract infection was significantly lower in 4 months supplementation group with a IRR of 0.30 (95 % CI; 0.22, 0.42). Conclusion: Four months MNP supplementation was relatively more effective in improving hemoglobin level in children 6-24 months.

Aim This study assessed weight and height changes among underweight children who received a locally produced, cereal-based, ready-to-use supplementary food. Methods We recruited 500 underweight Bangladeshi children aged 6–23 months from a Dhaka slum and individually matched them by sex and neighbourhood with 480 well-nourished controls. The intervention group received the daily food supplement for five months and both groups received daily micronutrient supplements. Their weight, height, mid-upper-arm circumference and head circumference were measured monthly. Results The children’s mean daily weight gain decreased from 1.27 to 0.66 grams per kilogram per day (g/kg/day) in the intervention group and 0.77 to 0.49 g/kg/day in the controls after adjusting for age differences between the two groups from baseline to five months of follow up. The mean monthly height gain decreased from 1.13 to 1.03 millimeters per metre per month in the intervention children and 1.26 to 1.01 in the controls. The weight gain was highest in the intervention children who were most wasted at baseline and the controls who were least stunted. Conclusion The children showed suboptimal growth despite food supplements, highlighting the need for ongoing research to develop inexpensive, locally-sourced food supplements to improve the nutrition of underweight children in Bangladesh.

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