Outpatient treatment of severe acute malnutrition: response to treatment with a reduced schedule of therapeutic food distribution ,

Abstract

Background: Community-based management of severe acute malnutrition (SAM) has been shown to be safe and cost-effective, but program coverage remains low. Treatment models that maintain high levels of clinical effectiveness but allow for increased coverage are still needed. A reduced schedule of follow-up, in which children receive clinical follow-up and therapeutic foods on a monthly rather than weekly basis, may be one alternative. Objective: We aimed to describe the safety and feasibility of a monthly distribution of ready-to-use therapeutic food (RUTF) in the treatment of uncomplicated SAM, in terms of clinical response to treatment and household RUTF use. Design: We conducted a nonrandomized pilot intervention study in which 115 children eligible for outpatient treatment of SAM were provided a monthly ration of RUTF. Anthropometric measurements were taken weekly for 4 wk to monitor treatment response. Unannounced household spot checks were conducted over 4 wk to assess household use of RUTF and storage practices. Results: Adequate weight and midupper arm circumference (MUAC) gain were found throughout the 4-wk follow-up period. Observed mean 6 SD weight gain from admission was 9.8 6 6.8 g $ kg 21 $ d 21 in week 1 and 4.2 6 2.1 g $ kg 21 $ d 21 by week 4. Unplanned household spot checks found an average surplus of RUTF sachets compared with the number expected based on the date of distribution and recommended dosing throughout the 4 wk of follow-up. The frequency at which more than the recommended dose was used (i.e., deviance of .2 sachets between available and expected stocks) was 4% and 22% of households visited in week 1 and week 4, respectively. Conclusion: Adequate treatment response and RUTF use in the outpatient treatment of SAM was maintained over 4 wk of follow-up with a monthly schedule of RUTF distribution. This study was registered at clinicaltrials.gov as NCT02994212. Am J Clin Nutr 2017;105:1191-7.

Are innovative ready to use therapeutic foods more effective, accessible and cost-efficient than conventional formulations? A review

“…This is where alternative RUTF formulations that can source more cost-effective ingredients locally could facilitate longer courses of treatment for those who need it. Isanaka et al’s (2017) study of outpatient treatment schedules of SAM in Niger finds similar results regarding individualization of treatment responses. They argue that a reduction in the monthly schedule of RUTF distribution could be a way to reduce costs without reducing effectiveness of RUTFs at treating SAM in children.…”

Effectiveness of a monthly schedule of follow-up for the treatment of uncomplicated severe acute malnutrition in Sokoto, Nigeria: A cluster randomized crossover trial

“…There was no statistical difference in weight velocity between groups at 4 and 8 weeks, but time to recovery was longer with monthly follow-up, and relapse at 3 months postdischarge was less likely to occur in the monthly group. While there has been limited evaluation of reduced schedules of follow-up, including from a pilot study in Niger [ 12 , 13 ], this study represents the first rigorous evaluation of the effectiveness of such a model conducted for outcomes of clinical and programmatic interest at larger scale.…”

“…The tools covered the key topics of (a) home-based MUAC measurement; (b) clinical surveillance of key danger signs or symptoms; and (c) appropriate storage and use of the monthly therapeutic ration. The feasibility and acceptability of these tools were tested in a pilot study in Madarounfa, Niger [ 12 , 13 ]. Caregiver understanding of clinical danger signs increased following training and agreement between MUAC measurements was high between nurses and caregivers.…”

“…To assess the early safety of the program at the 2-week home visit, morbidities and change in MUAC (mm/day) from the admission visit to the home visit were recorded. In addition, the RUTF deviance was calculated as the difference between the number of used RUTF sachets observed at home compared to the number expected based on the time since admission and the child’s prescribed dose, as described previously [ 12 ]. At 3 months postdischarge, longer-term outcomes assessed were all-cause hospitalization, all-cause cumulative mortality, and relapse after treatment recovery (defined as a maternal report of admission to any therapeutic feeding program within 3 months of discharge from the index admission or MUAC <115 mm or edema observed at the time of the postdischarge visit).…”

Penalized regression models to select biomarkers of environmental enteric dysfunction associated with linear growth acquisition in a Peruvian birth cohort

“…Exposure values were lagged by two months so that the analysis assessed the association between the subjects’ LAZ-score at month of age j and the exposures measured at age j -2 months. A 2-month lag was chosen because it is a length of time at which the impacts on a child’s growth of interventions such as steroids [27], chemotherapy [28] or treatment for severe acute malnutrition [29] become manifest, and therefore offers a feasible time window for clinical intervention and in which to reproducibly detect meaningful changes in ponderal growth associated with important physiologic determinants. Two months has also been demonstrated to be optimal for predicting future growth trajectory using fecal biomarkers [11].…”