Randomized Clinical Trial Comparing Hospital to Ambulatory Rehabilitation of Malnourished Children in Niger

Abstract

This study compared hospital to ambulatory nutritional rehabilitation outcomes and costs. Following a hospital stay to resolve initial acute medical conditions, 100 malnourished children (54 per cent male, ages 5 to 28 months) in Niger were randomly assigned to either hospital or ambulatory nutritional rehabilitation. Anthropometric measures were assessed at 15, 30, 60, 90 and 180 days post-randomization. Following randomization, the hospital group received a mean of 12.9 days of hospital rehabilitation and 5.6 days of ambulatory rehabilitation, while the ambulatory group received 2.2 days of hospital rehabilitation and 11.9 days of ambulatory rehabilitation. No significant differences between the two study groups in mortality rates or weight gain were found. The mean cost for hospital rehabilitation was 120 per cent higher (P < 0.001) than ambulatory rehabilitation. This study was the first randomized clinical trial directly comparing hospital to ambulatory nutritional rehabilitation and suggests that ambulatory rehabilitation is more cost-effective.

Long term mortality after community and facility based treatment of severe acute malnutrition: Analysis of data from Bangladesh, Kenya, Malawi and Niger

“…A literature search in Medline and Google scholar without period restriction was conducted using the term "protein energy malnutrition", "protein caloric malnutrition", "severe malnutrition", "marasmus", "kwashiorkor", "mortality" and "after recovery", "postdischarge" or "long term" Eight studies examining post-discharge mortality were retrieved (Chapko et al, 1994;Pecoul et al, 1992;Reneman and Derwig, 1997;Roosmalen-Wiebenga et al, 1987;Khanum et al, 1998;Kerac, 2010, Hennart et al, 1987Keet et al, 1971) but five studies were excluded either because the definition of SAM was different from what is currently used (n = 2) or because of incomplete data for the calculation of the incidence of deaths (n = 3) (Chapko et al, 1994;Roosmalen-Wiebenga et al, 1987;Kerac, 2010;Hennart et al, 1987;Keet et al, 1971). Among those included in this paper, the first study was carried out in Tahoua, a region of Niger.…”

“…A commonly cited reason behind this resistance is the supposed persistence of a high risk of mortality after recovery from SAM once the patient has exited the treatment programme (Ashworth, 2006). Data on the longer term mortality associated with discharge from inpatient therapeutic feeding centres is variable; some studies have reported a cumulative mortality rate of 1 to 1.5 years after discharge of up to 41% (Ashworth, 2006;Chapko et al, 1994;Pecoul et al, 1992;Reneman and Derwig, 1997;Roosmalen-Wiebenga et al, 1987), whilst others have reported lower figures of 2.3% after 12 months of follow up, and 4.1% after 1.5 years of follow up (Bahwere et al, 2008;Khanum et al, 1998). An earlier study reported a mortality of 1.5%, 12 months after discharge among children treated using the domiciliary approach (Khanum et al, 1998).…”

The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review.

“…62 were partially funded by a US governmental education fellowship, Khanum and colleagues 65 were supported by a UK charity and the UK government and Ciliberto and colleagues 63 received funding from the United Nations, a US charity and hospital foundation, a UK humanitarian organisation and the US government. Chapko and colleagues 62 compared inpatient with daily ambulatory rehabilitation, and two of the trials 63,64 investigated hospital-and home-based rehabilitation (differing, however, in the level of support provided).…”

“…Chapko and colleagues 62 compared inpatient with daily ambulatory rehabilitation, and two of the trials 63,64 investigated hospital-and home-based rehabilitation (differing, however, in the level of support provided). These three trials [62][63][64] evaluated alternative settings for the rehabilitation phase of treatment for malnourished children, after an initial phase of hospital care common to both treatment arms. In contrast, the fourth trial, by Khanum and colleagues, 65 had three trial arms to compare inpatient care with daily ambulatory care for both the initial and the rehabilitation phases of treatment for children with SAM, and with home rehabilitation (after daily ambulatory care during the initial phase of treatment).…”

“…Two studies 62,63 included both moderately and severely malnourished children using similar criteria. Chapko and colleagues 62 included children with a W/H z-score < −2 SD or kwashiorkor (not further defined) and Ciliberto and colleagues 63 included children with a W/H z-score < −2 SD or mild oedema (< 0.5 cm of pitting oedema on the dorsum of the foot).…”