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Background: Middle childhood and adolescence are critical times for the growth, development, and establishment of healthy eating habits. The Europe and Central Asia (ECA) region has been through economic and nutrition transitions over the past 20 years, which are likely to have affected the nutritional status of this group. Objective: This review aimed to collate data on the nutritional status and dietary patterns of school-aged children (SAC) and adolescents (5-19 years) across the ECA region in order to inform policy and programming decisions. Methods: A systematic search of the literature in Pubmed, Cochrane, and ScienceDirect databases was conducted (April 2019), complemented by a systematic review of nationally representative surveys. Inclusion criteria were any data on micronutrient deficiencies, overweight, stunting, wasting, thinness, or dietary patterns in SAC and adolescents in the 21 UNICEF-defined countries of ECA, published since the year 2000. Results: Results included 134 published papers and 6 sources of survey data. The majority of studies were conducted in Turkey (56%), with all other countries having fewer than 10 studies each; 8 countries in the region having no studies on this age group at all. The most significant nutrition issue was overweight and obesity. Micronutrient deficiencies, particularly anemia, emerge as a further challenge. Dietary patterns were worse in urban areas and boys. Conclusions: The findings of this review suggest that there are 3 critical areas that need immediate attention: the promotion of healthy diets and physical activity to address high levels of overweight/obesity, anemia prevention efforts, and addressing the considerable data gaps for SAC and adolescent nutrition.

Recognizing the multiple interacting layers of pedagogical content knowledge, in this article, we present the findings from a study that examined the extent to which participation in case-based instruction about self-generated visual representations (VRs) supported special education pre-service teachers ( N = 25) in enhancing their (a) knowledge of VRs, specifically what and how to teach, as a strategy for solving mathematics problems, and (b) applied instructional practices, specifically analysis of student knowledge and instructional planning, about VRs for students with disabilities (SWDs) to solve mathematics problems. The data revealed that case-based instruction about VRs in a special education mathematics methods course enriched pre-service teachers personal understanding about VRs and their ability to target SWDs learning needs regarding VRs. Implications for pre-service teacher preparation and research are provided.

Childhood wasting and stunting affect large numbers of children globally. Both are important risk factors for illness and death yet, despite the fact that these conditions can share common risk factors and are often seen in the same child, they are commonly portrayed as relatively distinct manifestations of undernutrition. In 2014, the Wasting and Stunting project was launched by the Emergency Nutrition Network. Its aim was to better understand the complex relationship and associations between wasting and stunting and examine whether current separations that were apparent in approaches to policy, financing, and programs were justified or useful. Based on the project's work, this article aims to bring a wasting and stunting lens to how research is designed and financed in order for the nutrition community to better understand, prevent, and treat child undernutrition. Discussion of lessons learnt focuses on the synergy and temporal relationships between children's weight loss and linear growth faltering, the proximal and distal factors that drive diverse forms of undernutrition, and identifying and targeting people most at risk. Supporting progress in all these areas requires research collaborations across interest groups that highlight the value of research that moves beyond a focus on single forms of undernutrition, and ensures that there is equal attention given to wasting as to other forms of malnutrition, wherever it is present. publishedVersion

In 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low‐ and middle‐income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near‐term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid‐upper‐arm circumference combined with weight‐for‐age Z score might effectively identify children at most risk of near‐term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.

Pain is the most disabling characteristic of musculoskeletal disorders, and while exercise is promoted as an important treatment modality for chronic musculoskeletal conditions, the relative contribution of the specific effects of exercise training, placebo effects and non-specific effects such as natural history are not clear. The aim of this systematic review and meta-analysis was to determine the relative contribution of these factors to better understand the true effect of exercise training for reducing pain in chronic primary musculoskeletal pain conditions.Systematic review with meta-analysis DATA SOURCES: MEDLINE, CINAHL, SPORTDiscus, EMBASE and CENTRAL from inception to February 2021. Reference lists of prior systematic reviews.Randomised controlled trials of interventions that used exercise training compared to placebo, true control or usual care in adults with chronic primary musculoskeletal pain. The review was registered prospectively with PROSPERO (CRD42019141096).We identified 79 eligible trials for quantitative analysis. Pairwise meta-analysis showed very low-quality evidence (GRADE criteria) that exercise training was not more effective than placebo (g [95% CI]: 0.94 [- 0.17, 2.06], P = 0.098, IThere is very low-quality evidence that exercise training is not more effective than non-exercise placebo treatments in chronic pain. Exercise training and the associated clinical encounter are more effective than true control or standard medical care for reductions in pain for adults with chronic musculoskeletal pain, with very low quality of evidence based on GRADE criteria.

Ready-to-use therapeutic food (RUTF) with adequate quality protein is used to treat children with oedematous and non-oedematous severe acute malnutrition (SAM). The plasma amino acid (AA) profile reflects the protein nutritional status; hence, its assessment during SAM treatment is useful in evaluating AA delivery from RUTFs. The objective was to evaluate the plasma AAs during the treatment of oedematous and non-oedematous SAM in community-based management of acute malnutrition (CMAM) using amino acid-enriched plant-based RUTFs with 10% milk (MSMS-RUTF) or without milk (FSMS-RUTF) compared to peanut milk RUTF (PM-RUTF). Plasma AA was measured in a non-blinded, 3-arm, parallel-group, simple randomized controlled trial conducted in Malawi. The RUTFs used for SAM were FSMS-RUTF, MSMS-RUTF or PM-RUTF. A non-inferiority hypothesis was tested to compare plasma AA levels from patients treated with FSMS-RUTF or MSMS-RUTF with those from patients treated with PM-RUTF at discharge. For both types of SAM, FSMS-RUTF and MSMS-RUTF treatments were non-inferior to the PM-RUTF treatment in restoration of the EAA and cystine except that for FSMS-RUTF, methionine and tryptophan partially satisfied the non-inferiority criteria in the oedematous group. Amino-acid-enriched milk-free plant-source-protein RUTF has the potential to restore all the EAA, but it is possible that enrichment with amino acids may require more methionine and tryptophan for oedematous children., SCOPUS: ar.j, info:eu-repo/semantics/published

Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5–12.5 cm) and a severely low WAZ (&lt, −3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (&lt, 11.5 cm), with/without a severely low WAZ (&lt, −3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ &lt, −3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC &lt, 11.5 and/or WAZ &lt, −3.0.

Objective: To compare levels of immunity in children recovering from severe acute malnutrition (cases) against those of community controls (controls). Results: At baseline children recovering from severe acute malnutrition had lower, mid upper arm circumference (122 mm for cases and 135 mm for controls; p < 0.001), weight-for-height Z-score (- 1.0 for cases and - 0.5 for controls; p < 0.001), weight-for-age Z-score (- 2.8 for cases and - 1.1 for controls; p < 0.001) and height/length-for-age Z-score (- 3.6 for cases and - 1.4 for controls; p < 0.001), than controls. Age and gender matched community controls. At baseline, prevalence of a positive tuberculin skin test, assessed by cutaneous delayed-type hypersensitivity reaction skin test, was very low in both cases (3/93 = 3.2%) and controls (2/94 = 2.1%) and did not significantly increase at 6 months follow up (6/86 = 7.0% in cases and 3/84 = 3.4% in controls). The incidences of common childhood morbidities, namely fever, diarrhoea and cough, were 1.7-1.8 times higher among cases than controls. In conclusion, these results show that tuberculin skin test does not enable any conclusive statements regarding the immune status of patients following treatment for severe acute malnutrition. The increased incidence of infection in cases compared to controls suggests persistence of lower resistance to infection even after anthropometric recovery is achieved., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: The prevalence of anaemia and iron deficiency (ID) among children with severe acute malnutrition (SAM) and their correction during nutritional rehabilitation are not well documented. This study assessed anaemia and ID prevalence and their predictors at start of SAM treatment, and the efficacy of their treatment and effect on gut health of two novel Ready-To-Use Therapeutic foods (RUTF) prepared from soybean, maize and sorghum (SMS) with (MSMS-RUTF) or without added milk (FSMS-RUTF) compared to those of the standard formulation prepared from peanut and milk (PM-RUTF). Methods: This was a 3-arms parallel groups, simple randomised, controlled non-inferiority trial in 6-59 months old Central Malawian children with SAM. Anaemia was defined using altitude- and ethnicity-adjusted haemoglobin. Iron status was defined using soluble transferrin receptor (sTfR) and body iron stores (BIS). We used Pearson's chi-square test, t-test for paired or unpaired data, Kruskal-Wallis test for between-arm differences as appropriate and logistic regression to identify independent predictors of anaemia or iron deficiency anaemia (IDA). Results: The sample size was 389. At admission, the prevalence [%(95%CI)] of anaemia was 48.9(41.4-56.5)% while that of ID and IDA were 55.7(48.6-62.5)% and 34.3(28.2-41.0)% when using sTfR criterion and 29.1(24.4-34.4)% and 28.9(23.7-34.9)% when using BIS criterion, respectively. At discharge, nutrition rehabilitation with SMS-RUTF was associated with the lowest prevalence of anaemia [12.0(6.9-20.3)% for FSMS-RUTF, 18.2(11.9-26.8)% for MSMS-RUTF and 24.5(15.8-35.9)% for PM-RUTF; p = 0.023] and IDA [7.9(3.4-17.3)% for FSMS-RUTF, 10.9(4.8-22.6)% for MSMS-RUTF and 20.5(10.7-35.5)% for PM-RUTF; p = 0.028]. SMS-RUTF was also associated with the highest increase in BIS [Change in BIS (95%CI)] among the iron deplete at admission [6.2 (3.7; 8.6), 3.2 (0.8; 5.6), 2.2 (0.2; 4.3) for the same study arms; Anova p = 0.045]. Compared to P-RUTF, FSMS-RUTF had the highest adjusted recovery rate [OR (95%CI = 0.3 (0.2-0.5) with p < 0.001 for FSMS-RUTF and 0.6 (0.3-1.0) with p = 0.068 for MSMS-RUTF]. No effect of iron content on risk of iron overload or gut inflammation was observed. Conclusions: Anaemia and ID are common among children with SAM. FSMS-RUTF is more efficacious in treating anaemia and correcting BIS among this group than PM-RUTF. Trial registration: This study was registered on 15 April 2015 (PACTR201505001101224)., SCOPUS: ar.j, info:eu-repo/semantics/published

Background Ready-to-use therapeutic food (RUTF) is used to treat children suffering from severe acute malnutrition (SAM). Standard RUTF uses milk as the primary protein source, which makes the product expensive, and given the high worldwide SAM burden, having a less expensive effective alternative is a public health priority. Objective The objective of this study was to evaluate whether newly developed amino acid-enriched milk-free RUTF (FSMS-RUTF) or amino acid-enriched low-milk RUTF (MSMS-RUTF) treatment could replenish plasma amino acids to levels comparable to those following standard peanut-milk RUTF (PM-RUTF) treatment and to improve understanding of the effects of treatment on anthropometric measurements. A secondary analysis was performed to test the noninferiority hypothesis of plasma essential amino acid (EAA) levels. Methods Plasma EAA levels were measured in a nonblinded, 3-arm, parallel-group simple randomized controlled trial conducted in Malawi to examine the efficacy of FSMS-RUTF, MSMSRUTF and PM-RUTF in the treatment of SAM in 2 groups of children aged 6-23 and 24-59 months (mo). Sample size calculations were performed based on the previous our study. A noninferiority margin was set at -25% of the PM-RUTF arm at discharge. Results The relative values of the differences (95% CI) in plasma EAA levels between PM-RUTF treatment and FSMS-RUTF and MSMS-RUTF treatments at discharge were -7.9% (-18.6, 2.8) and 9.8% (0.2, 19.5), respectively, in children aged 6-23 mo, while in those aged 24-59 mo, the difference values were 17.8% (1.6, 34.1) and 13.6% (-2.8, 29.9), respectively. Conclusion At discharge, the plasma EAA concentrations in 6-59-mo-old SAM children treated with FSMS-RUTF and MSMS-RUTF were not less than those of children treated with PM-RUTF. These findings indicate that treatment with either of the 3 RUTFs was associated with adequate protein synthesis and that all the formulations provided sufficient functional metabolites of plasma amino acids to support nutritional recovery from SAM., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: Development of more cost-effective ready-to-use therapeutic food (RUTF) is a global public health priority. To date, previous lower-cost recipes have been less effective than the standard peanut and milk (PM)-based RUTF, particularly in children aged

Community health workers (CHWs) have strong potential to extend health and nutrition services to underserved populations. However, CHWs face complex challenges when working within weak health systems and among communities with limited abilities to access and utilise CHW services. It is crucial to understand these challenges to improve programme support mechanisms. This study describes the results of qualitative investigations into CHW perceptions of barriers to quality of care among two groups of workers implementing community case management of acute respiratory infection, diarrhoea and severe acute malnutrition in southern Bangladesh. We explored systemic barriers to service delivery, pertaining to communities and health systems, which limited the usefulness and effectiveness of CHW services. Focus group discussions (n = 10) were conducted in March 2010. Discussions were analysed for themes related to CHWs' work challenges. Findings highlight several perceived barriers to effective service provision, including community poverty constraining uptake of recommended practices, irregular supplies of medicine from the health facility and poor quality of care for CHW referrals sent there. This study further documents interactions between demand-side and supply-side constraints including the influence of health system resource constraints on community trust in CHW services, and the influence of community resource constraints on the utilisation and effectiveness of CHW services. By documenting service delivery challenges from the perspective of the frontline workers themselves, this article contributes evidence to help identify appropriate support mechanisms for these workers, in order to develop scalable and sustainable CHW programmes in countries with under-resourced public health care infrastructure.

Background Children with moderate acute malnutrition (MAM) have an increased risk of mortality, infections and impaired physical and cognitive development compared to well-nourished children. In parts of Ethiopia not considered chronically food insecure there are no supplementary feeding programmes (SFPs) for treating MAM. The short-term outcomes of children who have MAM in such areas are not currently described, and there remains an urgent need for evidence-based policy recommendations. Methods We defined MAM as mid-upper arm circumference (MUAC) of ≥11.0cm and, SCOPUS: ar.j, info:eu-repo/semantics/published

Background Community health workers (CHWs) perform a range of important tasks; however, limited evidence is available regarding the association between their workload and the quality of care they provide. Objective To analyze the quality of preventive and curative care provided by two groups of CHWs with different workloads in southern Bangladesh. Methods One group of CHWs provided preventive care in addition to implementing community case management (CCM) of acute respiratory infection and diarrhea, and another group additionally treated severe acute malnutrition (SAM). Preventive care was measured by case management observation at a routine household visit. Curative care was measured by case scenarios. Qualitative methods were used to contextualize CHWs' performance by examining their perceptions of challenges related to their workload. A total of 338 CHWs were assessed. Results CHWs managing cases of SAM worked significantly more hours than the other group (16.7 ± 6.9 hours compared with 13.3 ± 4.6 hours weekly, p < .001) but maintained quality of care on curative and preventive work tasks. Effectively treating cases of SAM appeared to motivate CHWs. Conclusions This was one of the first trials adding the treatment of SAM to a CHW workload and suggests that adding SAM to a well-trained and supervised CHW's workload, including preventive and curative tasks, does not necessarily yield lower quality of care. However, increased workloads had consequences for CHWs' domestic life, and further increases in workload may not be possible without additional incentives.

The effectiveness of the community based therapeutic care (CTC) in treating severe acute malnutrition (SAM) has been demonstrated. However, there is still resistance from some policy makers and donors to invest into this cost-effective intervention. The mortality rate ratio (MRR) calculated by dividing the observed deaths after discharge by expected deaths was used to compare survival of 1,670 children discharged from the Dowa CTC from August 2002 to May 2005 and that of other cohorts reporting on long term survival of children after treatment of SAM retrieved from literature. A MMR of 1.1 (0.9 to 1.4) was observed for the Dowa CTC cohort while the MMR of 2.7 (1.3 to 4.9), 5.5 (3.9 to 7.6) and 20.0 (11.0 to 33.4) were observed for studies retrieved from the literature. Data showed that the survival of children who defaulted was worse than that of those who were discharged cured, and that of children treated at home after stabilisation or directly was better than those treated as inpatient until exit from the programme. The study outlines the need of using MMR when reporting on long term survival after SAM treatment and suggests that CTC should be included in the package of interventions with high potential for accelerating the progress towards reaching Millennium Developmental Goal four. Key words: Severe acute malnutrition, children, long term, survival, mortality ratio.

This study assessed the quality of care provided by community health workers (CHWs) in managing cases of severe acute malnutrition (SAM) according to a treatment algorithm. A mixed methods approach was employed to provide perspectives on different aspects of quality of care, including technical competence and acceptability to caretakers. CHWs screened children at community level using a mid-upper arm circumference measurement, and treated cases without medical complications. Fifty-five case management observations were conducted using a quality of care checklist, with 89.1% (95% confidence interval: 77.8-95.9%) of CHWs achieving 90% error-free case management or higher. Caretakers perceived CHWs' services as acceptable and valuable, with doorstep delivery of services promoting early presentation in this remote area of Bangladesh. Integration of the treatment of SAM into community-based health and nutrition programs appears to be feasible and effective. In this setting, well-trained and supervised CHWs were able to effectively manage cases of SAM. These findings suggest the feasibility of further decentralization of treatment from current delivery models for community-based management of acute malnutrition.

AIM: To assess the clinical outcomes of a combined approach to the treatment of severe acute malnutrition in an area of high HIV prevalence using: (i) an initial inpatient phase, based on WHO guidelines and (ii) an outpatient recovery phase using ready-to-use therapeutic food. METHODS: An operational prospective cohort study implemented in a referral hospital in Southern Malawi between May 2003 and 2004. Patient outcomes were compared with international standards and with audits carried out during the year preceding the study. RESULTS: Inpatient mortality was 18% compared to 29% the previous year. Programme recovery rate was 58.1% compared to 45% the previous year. The overall programme mortality rate was 25.7%. Of the total known HIV seropositive children, 49.5% died. CONCLUSIONS: Inpatient mortality and cure rates improved compared to pre-study data but the overall mortality rate did not meet international standards. Additional interventions will be needed if these standards are to be achieved.

ObjectiveTo compare therapeutic feeding programme coverage for severely malnourished children achieved by a community-based therapeutic care (CTC) programme and a therapeutic feeding centre (TFC) programme operating in neighbouring districts in Malawi.DesignTwo surveys were implemented simultaneously one in each of the two programme areas. Each survey used a stratified design with strata defined using the centric systematic area sample method. Thirty 100 km2 quadrats were sampled. The community or communities located closest to the centre of each quadrat were sampled using a case-finding approach. Cases were defined as children aged under 5 years with ≤ 70% of the weight-for-height median or bilateral pitting oedema. Receipt of treatment was ascertained by the child's presence in a therapeutic feeding programme or by documentary evidence. Coverage in each quadrat was estimated in two ways, a period estimate that provides an estimation of coverage for the recent period preceding the survey and a point estimate that provides an estimation of coverage at the exact point in time of the survey.ResultsOverall the period coverage was 24.55% (95% confidence interval (CI) = 17.8–31.4%) in the TFC programme and 73.64% (95% CI = 66.0–81.3%) in the CTC programme. The point coverage was 20.04% (95% CI = 13.8–26.3%) in the TFC programme and 59.95% (95% CI = 51.4–68.5%) in the CTC programme.ConclusionsIn this context, CTC gave substantially higher programme coverage than a TFC programme. Given effective treatment, this enabled higher impact of CTC on severe malnutrition in this population.

BACKGROUND: The cost of current standard ready-to-use therapeutic food (RUTF) is among the major obstacles to scaling up community-based management of acute malnutrition (CMAM), an important child survival strategy. Identifying a cheaper alternative is a global public health priority. OBJECTIVE: We sought to compare the efficacy of soya-maize-sorghum RUTF (SMS-RUTF) with that of standard peanut paste-based RUTF (P-RUTF). DESIGN: We used a nonblinded, parallel-group, simple randomized controlled trial along with a day care approach that enrolled 2 groups of children aged 6-23 and 24-59 mo, respectively, with severe acute malnutrition (SAM). RESULTS: Intention-to-treat (ITT) and per-protocol (PP) analyses showed noninferiority of SMS-RUTF compared with P-RUTF for the recovery rate [ITT: Δ = -2.0% (95% CI: -7.6%, 3.6%); PP: -1.9% (95% CI: -5.3%, 1.4%)], weight gain [Δ = -0.7 g · kg(-1)· d(-1)(95% CI: -1.3, 0.0 g · kg(-1)· d(-1))], and length of stay [Δ = 2.0 d (95% CI: -1.7, 5.8 d)] in children ≥24 mo of age. In children ≤23 mo of age, the recovery rate of SMS-RUTF was inferior to that of P-RUTF [ITT: Δ = -20.8% (95% CI: -29.9%, -11.7%); PP: -17.2% (95% CI: -25.6%, -8.7%)]. Treatment with SMS-RUTF resulted in a greater increase in hemoglobin [0.670 g/dL (95% CI: 0.420, 0.921 g/dL);P< 0.001]. Treatment with both RUTFs resulted in the replenishment of all of the amino acids tested except for methionine. There were no differences at discharge between RUTF groups in fat mass [Δ = 0.3 kg (95% CI: -0.6, 1.6 kg);P= 0.341] or fat mass index [Δ = 0.4 kg/m(2)(95% CI: -0.3, 1.1 kg/m(2));P= 0.262]. By contrast, comparisons of fat-free mass indicated lower concentrations than the community controls after treatment with either of the 2 RUTFs [Δ = -1.3 kg (95% CI: -2.4, -0.1 kg) andP= 0.034 for comparison between community controls and the SMS-RUTF group; Δ = -1.8 kg (95% CI: -2.9, -0.6 kg) andP= 0.003 for comparison between community controls and the P-RUTF group]. CONCLUSION: SMS-RUTF can be used to treat SAM in children aged ≥24 mo to reduce the costs of CMAM programs. More research is required to optimize SMS-RUTF for younger children. This trial was registered in the Pan African Clinical Trial Registry as PACTR201303000475166.

Summary Background In emergency nutritional relief programmes, therapeutic feeding centres are the accepted intervention for the treatment of severely malnourished people. These centres often cannot treat all the people requiring care. Consequently, coverage of therapeutic feeding centre programmes can be low, reducing their effectiveness. We aimed to assess the effectiveness of outpatient treatment for severe malnutrition in an emergency relief programme. Methods We did a retrospective cohort study in an outpatient therapeutic feeding programme in Ethiopia from September, 2000, to January, 2001. We assessed clinical records for 170 children aged 6–120 months. The children had either marasmus, kwashiorkor, or marasmic kwashiorkor. Outcomes were mortality, default from programme, discharge from programme, rate of weight gain, and length of stay in programme. Findings 144 (85%) patients recovered, seven (4%) died, 11 (6%) were transferred, and eight (5%) defaulted. Median time to discharge was 42 days (IQR 28–56), days to death 14 (7–26), and days to default 14 (7–28). Median rate of weight gain was 3·16 g kg −1 day −1 (1·86–5·60). In patients who recovered, median rates of weight gain were 4·80 g kg −1 day −1 (2·95–8·07) for marasmic patients, 4·03 g kg −1 day −1 (2·68–4·29) for marasmic kwashiorkor patients, and 2·70 g kg −1 day −1 (0·00–4·76) for kwashiorkor patients. Interpretation Outpatient treatment exceeded internationally accepted minimum standards for recovery, default, and mortality rates. Time spent in the programme and rates of weight gain did not meet these standards. Outpatient care could provide a complementary treatment strategy to therapeutic feeding centres. Further research should compare the effectiveness of outpatient and centre-based treatment of severe malnutrition in emergency nutritional interventions.

Community‐based Management of Acute Malnutrition using ready‐to‐use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut‐based RUTF (P‐RUTF) makes it too expensive. The effectiveness of milk‐free RUTF has not been reported hitherto. This non‐blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk‐free soy–maize–sorghum‐based RUTF (SMS‐RUTF) with P‐RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS‐RUTF (n = 12; 824 enrolled) or P‐RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome. The recovery rates for SMS‐RUTF and P‐RUTF were 53.3% and 60.8% for the intention‐to‐treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were −7.6% (−14.9, 0.6%) and −3.5% (−9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P

Background Food aid provided by the United States has saved lives for almost two centuries. Delivering the right products is important, but of equal concern are the ways in which products are delivered and to whom. Objective The study addresses how food products are currently used, whether interventions are appropriate to achieve nutrition objectives, and whether nutrition targets could be met more cost-effectively with a different mix of products or programs. Methods The team conducted consultations with a broad range of stakeholders. A survey of Title II implementing partners was conducted, focusing on procurement and logistics, and uses of FBFs and other foods. Input of implementing partners, civil society, and donor organizations was obtained through individual consultations, international and small group meetings. More than 400 individuals accessed the project's website. The project convened a panel of experts in food technology and science, food policy, law, industry, medicine, development and humanitarian work, and the maritime industry, and held regular joint meetings with USDA and USAID. The draft report was widely disseminated and posted on the website. Results and conclusions There is wide variation in the quantities of fortified blended foods provided to target populations. Most of these foods are used in health/nutrition programs, but they are also used in general family rations or as an incentive or pay. Clearer programming guidance and improved decision tools are needed to match products to nutrition goals, and programs should consider delivering nutrients across a basket of commodities, not single products. The evidence base for the effectiveness and cost-effectiveness of specific foods and programs needs to be strengthened and should be supported by FFP. Research is needed to provide guidance on nutrition support for HIV/AIDS. Additional investments are needed in effective behavior change communication.

Summary Background Severe acute malnutrition affects 13 million children worldwide and causes 1–2 million deaths every year. Our aim was to assess the clinical and nutritional efficacy of a probiotic and prebiotic functional food for the treatment of severe acute malnutrition in a HIV-prevalent setting. Methods We recruited 795 Malawian children (age range 5 to 168 months [median 22, IQR 15 to 32]) from July 12, 2006, to March 7, 2007, into a double-blind, randomised, placebo-controlled efficacy trial. For generalisability, all admissions for severe acute malnutrition treatment were eligible for recruitment. After stabilisation with milk feeds, children were randomly assigned to ready-to-use therapeutic food either with (n=399) or without (n=396) Synbiotic2000 Forte. Average prescribed Synbiotic dose was 10 10 colony-forming units or more of lactic acid bacteria per day for the duration of treatment (median 33 days). Primary outcome was nutritional cure (weight-for-height >80% of National Center for Health Statistics median on two consecutive outpatient visits). Secondary outcomes included death, weight gain, time to cure, and prevalence of clinical symptoms (diarrhoea, fever, and respiratory problems). Analysis was on an intention-to-treat basis. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN19364765. Findings Nutritional cure was similar in both Synbiotic and control groups (53·9% [215 of 399] and 51·3% [203 of 396]; p=0·40). Secondary outcomes were also similar between groups. HIV seropositivity was associated with worse outcomes overall, but did not modify or confound the negative results. Subgroup analyses showed possible trends towards reduced outpatient mortality in the Synbiotic group (p=0·06). Interpretation In Malawi, Synbiotic2000 Forte did not improve severe acute malnutrition outcomes. The observation of reduced outpatient mortality might be caused by bias, confounding, or chance, but is biologically plausible, has potential for public health impact, and should be explored in future studies. Funding Department for International Development (DfID).

Background In Malawi and other high HIV prevalence countries, studies suggest that more than 30% of all severely malnourished children admitted to inpatient nutrition rehabilitation units are HIV-infected. However, clinical algorithms designed to diagnose paediatric HIV are neither sensitive nor specific in severely malnourished children. The present study was conducted to assess : i) whether HIV testing can be integrated into Community-based Therapeutic Care (CTC); ii) to determine if CTC can improve the identification of HIV infected children; and iii) to assess the impact of CTC programmes on the rehabilitation of HIV-infected children with Severe Acute Malnutrition (SAM). Methods This community-based cohort study was conducted in Dowa District, Central Malawi, a rural area 50 km from the capital, Lilongwe. Caregivers and children admitted in the Dowa CTC programme were prospectively (Prospective Cohort = PC) and retrospectively (Retrospective Cohort = RC) admitted into the study and offered HIV testing and counseling. Basic medical care and community nutrition rehabilitation was provided for children with SAM. The outcomes of interest were uptake of HIV testing, and recovery, relapse, and growth rates of HIV-positive and uninfected children in the CTC programme. Student's t-test and analysis of variance were used to compare means and Kruskall Wallis tests were used to compare medians. Dichotomous variables were compared using Chi2 analyses and Fisher's exact test. Stepwise logistic regression with backward elimination was used to identify predictors of HIV infection (α = 0.05). Results 1273 and 735 children were enrolled in the RC and PC. For the RC, the average age (SD) at CTC admission was 30.0 (17.2) months. For the PC, the average age at admission was 26.5 (13.7) months. Overall uptake of HIV testing was 60.7% for parents and 94% for children. HIV prevalence in severely malnourished children was 3%, much lower than anticipated. 59% of HIV-positive and 83% of HIV-negative children achieved discharge Weight-For-Height (WFH) ≥ 80% of the NCHS reference median (p = 0.003). Clinical algorithms for diagnosing HIV in SAM children had poor sensitivity and specificity. Conclusion CTC is a potentially valuable entry point for providing HIV testing and care in the community to HIV infected children with SAM.

Severe acute malnutrition (SAM) is defined as a weight-for-height measurement of 70% or less below the median, or three SD or more below the mean National Centre for Health Statistics reference values, the presence of bilateral pitting oedema of nutritional origin, or a mid-upper-arm circumference of less than 110 mm in children age 1-5 years. 13 million children under age 5 years have SAM, and the disorder is associated with 1 million to 2 million preventable child deaths each year. Despite this global importance, child-survival programmes have ignored SAM, and WHO does not recognise the term "acute malnutrition". Inpatient treatment is resource intensive and requires many skilled and motivated staff. Where SAM is common, the number of cases exceeds available inpatient capacity, which limits the effect of treatment; case-fatality rates are 20-30% and coverage is commonly under 10%. Programmes of community-based therapeutic care substantially reduce case-fatality rates and increase coverage rates. These programmes use new, ready-to-use, therapeutic foods and are designed to increase access to services, reduce opportunity costs, encourage early presentation and compliance, and thereby increase coverage and recovery rates. In community-based therapeutic care, all patients with SAM without complications are treated as outpatients. This approach promises to be a successful and cost-effective treatment strategy.

Background Acute malnutrition is an underlying factor in almost 50% of the 10 to 11 million children under 5 years of age who die each year of preventable causes. Inpatient treatment for severe acute malnutrition is associated with high opportunity and economic costs for affected families and health service providers. Community-based therapeutic care attempts to address these problems and to maximize population-level impact through improving coverage, access, and cost-effectiveness of treatment. The community-based therapeutic care model Community-based therapeutic care programs provide effective care to the majority of acutely malnourished people as outpatients, using techniques of community mobilization to engage the affected population and maximize coverage and compliance. People with severe acute malnutrition without medical complications are treated in an outpatient therapeutic program with ready-to-use therapeutic food and routine medication. Those suffering from severe acute malnutrition with medical complications are treated in an inpatient stabilization center according to standard World Health Organization protocols until they are well enough to be transferred to the outpatient therapeutic program. Impact of community-based therapeutic care programs Twenty-one (21) community-based therapeutic care programs were implemented in Malawi, Ethiopia, and North and South Sudan between 2000 and 2005. These programs, which treated 23,511 cases of severe acute malnutrition, achieved recovery rates of 79.4% and mortality rates of 4.1%. Coverage rates were approximately 73%. Of the severely malnourished children who presented, 76% were treated solely as outpatients. Initial data indicate that these programs are affordable, with the cost-effectiveness of emergency community-based therapeutic programs varying from US$12 to US$132 per year of life gained.

Paluku Bahwere, Kate Sadler, Steve CollinsValid International, Oxford, United KingdomObjective: A prospective descriptive study to assess acceptability and effectiveness of a locally made ready-to-use therapeutic food (RUTF) in HIV-infected chronically sick adults (CSA) with mid-upper-arm circumference (MUAC)

Patrick Kolsteren and colleagues assertion that there is little evidence to support the scale-up of community-based therapeutic care is incorrect and disregards published studies on the topic and the recent experience of many humanitarian agencies and national ministries of health in Africa. Kolsteren and colleagues base their assertion largely on one article in a supplement to Food and Nutrition Bulletin which described three small trials in Malawi. They do not cite an article in the same supplement that presents data from 23 511 unselected cases of severe acute malnutrition treated in 21 community-based therapeutic care programmes implemented in Malawi Ethiopia and Sudan between 2001 and 2005. These programmes achieved recovery mortality and default rates of 79.4% 4.1% and 11.0% respectively. 76% of cases were treated solely as outpatients. These results far exceed international standards with mortality rates four to five times lower than the average in hospitals where severe acute malnutrition is treated exclusively on an inpatient basis. Furthermore evidence is now building that community-based therapeutic care can be effectively managed by national ministries of health with limited external support. This is in contrast to the repeated failure of many developing countries to implement the more resource-intensive 1998 WHO inpatient protocols. This integrated model has also enabled far higher numbers of patients to be treated than was previously possible using the exclusive inpatient approach. For example in Niger in 2005 Medecins Sans Frontieres treated 60 000 cases of severe acute malnutrition and achieved mortality rates of about 5% and cure rates of more than 80%. 70% of these children were treated exclusively as outpatients. (excerpt)