Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali

Abstract

Background Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. Methods and findings A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6–23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers’ participation and supplement children’s diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. Conclusions Incorporating SQ-LNSs into monthly community-level AM screenings and BC...

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials

“…We identified 15 trials that met our inclusion criteria, 14 of which provided individual participant data and are included in this analysis (Figure 1, Table 1) (34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48). Investigators for one trial were unable to participate (49).…”

Impact on child acute malnutrition of integrating a preventive nutrition package into facility-based screening for acute malnutrition during well-baby consultation: A cluster-randomized controlled trial in Burkina Faso

“…Taken together, the findings from our study and its companion study in Mali [8] highlight the trade-offs of using community- versus health center–based services for the delivery of AM services. Choosing the CNS as the intervention platform for strengthening AM screening offered several advantages.…”

“…However, impact studies using SQ-LNS in similar populations of similar age in Burkina Faso showed mixed effects of SQ-LNS on AM indicators; one study (included in the meta-analysis cited above) found a 4.8 pp (36%) reduction of wasting when SQ-LNS was combined with treatment of diarrhea and malaria [34]; and a second study found no impact of SQ-LNS on AM prevalence or WLZ [35]. In the Mali companion study to our Burkina Faso evaluation, SQ-LNS was responsible for a 29% reduction in AM incidence, mostly during the peak of AM observed between 6 and 12 months of age, with an SQ-LNS coverage of 60%–70% at that age [8]. In our study, fewer than half of the caregivers of children older than 6 months reported receiving SQ-LNS in the past month (47%, cross-sectional study; 37%, longitudinal study), and thus, it is possible that for the majority of children, the SQ-LNS did not make a large enough contribution to the nutrient adequacy of their diet to prevent AM.…”

“…This paper presents findings from the study in Burkina Faso, which used a health facility platform to integrate the preventive intervention package into the CMAM program. Results from the study in Mali, where the preventive intervention was integrated into a community-based screening platform, are presented in the companion paper [8].…”

Nutrition for women and children—Are we doing the right things in the right way?

“…There are, however, numerous difficulties in achieving satisfactory program effectiveness in community-based management of uncomplicated severe acute malnutrition. In the accompanying Special Issue, a number of the reported research studies illustrate some of these practical problems [15,16].…”