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International audience; BACKGROUND: Global access to acute malnutrition treatment is low. Different programmes using different nutritional products manage cases of severe acute malnutrition and moderate acute malnutrition separately. We aimed to assess whether integrating severe acute malnutrition and moderate acute malnutrition treatment into one programme, using a single nutritional product and reducing the dose as the child improves, could achieve similar or higher individual efficacy, increase coverage, and minimise costs compared with the current programmes.METHODS: We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Acutely malnourished children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 125 mm or oedema were randomly assigned (1:1), using specially developed software and random blocks (size was kept confidential), to either the current standard strategy (one programme for severe acute malnutrition using ready-to-use therapeutic food [RUTF] at an increasing dose as weight increased, another for moderate acute malnutrition using a fixed dose of ready-to-use supplementary food [RUSF]) or the OptiMA strategy (a single programme for both severe acute malnutrition and moderate acute malnutrition using RUTF at a decreasing dose as MUAC and weight increased). The primary endpoint was a favourable outcome at 6 months, defined as being alive, not acutely malnourished as per the definition applied at inclusion, and with no further episodes of acute malnutrition throughout the 6-month observation period; the endpoint was analysed in the intention-to-treat (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, or were prescribed RUSF rations for a minimum of 4 weeks [ie, minimum of 28 RUSF sachets], and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority analysis (margin 10%) was to be followed by a superiority analysis (margin 0%) if non-inferiority was concluded. This trial is registered at ClinicalTrials.gov, NCT03751475, and is now closedFINDINGS: Between July 22 and Dec 6, 2019, 912 children were randomly assigned; after 16 were excluded, 896 were analysed (446 in the standard group and 450 in the OptiMA group). In the intention-to-treat analysis, 282 (63%) of 446 children in the standard group and 325 (72%) of 450 children in the OptiMA group had a favourable outcome (difference -9.0%, 95% CI -15.9 to -2.0). In the per protocol analysis, 161 (61%) of 264 children in the standard group and 291 (74%) of 392 children in the OptiMA group had a favourable outcome (-13.2%, -21.6 to -4.9).INTERPRETATION: In this non-inferiority trial treating children with MUAC of less than 125 mm or oedema, decreasing RUTF dose according to MUAC and weight increase proved to be a superior strategy to the standard protocol in the Democratic Republic of the Congo. These results demonstrate the safety and benefits of an approach that could substantially increase access to treatment for millions of children with acute malnutrition in sub-Saharan Africa.FUNDING: Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Access to treatment for acute malnutrition remains a challenge, in part due to the fragmentation of treatment programmes based on case severity. This paper evaluates utilization patterns, outcomes and associated costs for treating acute malnutrition cases among a cohort of children in Burkina Faso. This study is a secondary analysis of a proof-of-concept trial, called Optimizing treatment for acute Malnutrition (OptiMA), conducted in Burkina Faso in 2016. A total of 4958 eligible children whose mid-upper arm circumference (MUAC) was less than 125 mm or with oedema were followed weekly and given ready-to-use therapeutic foods (RUTF). We evaluated the service utilization and outcomes among patients and estimated resource use and variable cost per patient, and examined factors driving variation in resource use. Children with lower initial MUAC level grew faster but required more time to recover than those with higher initial MUAC level. They also had higher rates of death, default and nonresponse. The simplified OptiMA approach for treating acute malnutrition achieved high rates of recovery overall (84%), especially among less severe cases, with modest quantities of RUTF. The average overall variable cost per child admitted was US$38.0 (SD: 20.5) half of which was accounted for by the cost of RUTF. Cost per recovered case was correlated with case severity, ranging from US$35.1 to US$132.8. If simplified integrated programmes using severity-based RUTF dosing can increase access to treatment at earlier, less severe stages of acute malnutrition, they can help avoid more serious and costlier cases.

Background: Global access to acute malnutrition treatment is low and underfunded. Different programmes using different nutritional products with a sub-optimal dosage manage severe and moderate acute malnutrition separately. We aimed to assess whether integrating severe and moderate acute malnutrition treatment into one programme, using a single nutritional product and reducing the dose as the child improves, could achieve similar or higher individual efficacy, increase access to treatment and minimise costs compared with the current programmes. Methods: We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Acutely malnourished children aged 6-59 months with a mid-upper-arm circumference {MUAC) of less than 125 mm or with oedema were randomly assigned (1:1), to either the current standard strategy (one programme for severe acute malnutrition using ready-to-use therapeutic food [RUTF] at an increasing dose as weight increased, another for moderate acute malnutrition using a fixed dose of ready-to-use supplementary food [RUSFI) or to the OptiMA strategy (a single programme for both severe and moderate acute malnutrition usin g RUTF at a decreasing dose as MUAC and weight increased). The primary endpoint was a favourable outcome at 6 months, defined as being alive, not acutely malnourished as per the definition applied at inclusion, and with no further episodes of acute malnutrition throu ghout the 6- month observation period. Randomisation was stratified on the severity criteria of the disease for the main secondary end point. Recovery was defined as a combination of the following criteria for two consecutive weeks after a minimum of 4 weeks' treatment: axill ary temperature less than 37.5°C, absence of bipedal oedema and anthropometric improvement {MUAC of 125 mm or larger or WHZ of-1·5 or higher); measured over 6 months among children with a MUAC of less than 115 mm or a weight-for-height z-score (WHZ) of less than -3 or bipedal oedema. These two endpoints were analysed in the intention-to-treat (ITT) (all children) and per-protocol (PP) populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total a mou nt of RUTF they were su pposed to receive as per the protocol, or were prescribed RUSF rations for a minimum of 4 weeks [ie, minimum of 28 RUSF sachets], and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority analysis (margin 10%) was to be followed by a superiority analysis (margin 0%) if non-inferiority was concluded., Justification : L'accès au traitement de la malnutrition aiguë reste faible dans le monde. Les programmes nutritionnels actuels, sous financés, prennent en charge les cas de malnutrition aiguë sévère et de malnutrition aiguë modérée, séparément, en utilisant différents traitements avec un dosage non optimal. Nous avons évalué une stratégie simplifiée basée sur un programme unique, utilisant un seul traitement pour tous les enfants pris en charge. Méthodologie: Nous avons mené un essai contrôlé randomisé ouvert, de non-infériorité, en République démocratique du Congo. Des enfants âgés de 6 à 59 mois souffrant de malnutrition aiguë présentant un périmètre brachial {PB)< 125mm ou des œdèmes nutritionnels, ont été randomisés (1:1), soit vers le protocole standard (un programme pour la malnutrition aiguë sévère utilisant des aliments thérapeutiques prêts à l'emploi [ATPE] avec une dose croissante en fonction du poids et d'autre aliments supplémentaires prêts à l'emploi [ASPE] à dose fixe pour la malnutrition aiguë modérée), soit vers le protocole OptiMA (un seul programme pour la malnutrition aiguë sévère et modérée utilisant les ATPE à une dose décroissante en fonction du PB et du poids). Le critère de jugement principal était une issue favorable à 6 mois, définie par les critères suivants : le fait d'être en vie, de ne pas souffrir de malnutrition aiguë et sans rechute pendant la période d'observation de 6 mois. La randomisation était stratifiée sur les critères de sévérité de la maladie pour le critère de jugement secondaire prioritaire. La guérison était définie par la combinaison des critères suivants: un minimum de 4 semaines de traitement, une température axillaire< 37,5°C, absence d'œdèmes nutritionnel et amélioration anthropométrique {PB ≥ à 125 mm ou un indice poids pour taille (P/T)≥ -1-5 zscore); et mesurée au cours des 6 mois de suivi parmi les enfants avec un PB

Background Nutritional care is not optimally integrated into pediatric HIV care in sub-Saharan Africa. We assessed the 6-month effect of a nutritional support provided to children living with HIV, followed in a multicentric cohort in West Africa. Methods In 2014-2016, a nutritional intervention was carried out for children living with HIV, aged under 10 years, receiving antiretroviral therapy (ART) or not, in five HIV pediatric cohorts, in Benin, Togo and Côte d’Ivoire. Weight deficiency was assessed using two definitions: wasting (Weight for Height Z-score [WHZ] for children Results Overall, 326 children were included, 48% were girls. At baseline, 66% were aged 5-10 years, 91% were on ART, and 17% were severely immunodeficient (CD4 p=0.907), nor by intervention groups (p-value=0.767). Conclusions This intervention had a limited effect on nutritional recovery and dietary diversity improvement. Questions remain on determining appropriate nutritional products, in terms of adherence, proper use for families and adequate energy needs coverage for children living with HIV. Trial registration PACTR202001816232398, June 01, 2020, retrospectively registered.