Search

Treatment of acute malnutrition requires novel approaches to improve coverage, reduce costs and improve the efficiency of standard protocols that separate the management of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). The use of simplified, combined protocols to treat both MAM and SAM has drawn research and policy interest among global, regional and national stakeholders. However, the perspectives of local communities and health care workers regarding the use of protocols to treat acute malnutrition in a routine health care system are generally lacking. This was a cross‐sectional mixed‐methods study aimed at assessing the perceptions of different stakeholders on the use of a simplified, combined protocol in two districts in the Central African Republic. Most of the respondents preferred the simplified, combined protocol over the standard protocol. They generally agreed that the protocol was easy to understand, allowed more children to receive treatment and was effective in treating acute malnutrition. The protocol modifications were well received, including the expanded admission criteria, use of mid‐upper arm circumference (MUAC) only for admission and discharge criteria and reduced and simplified ready‐to‐use therapeutic food quantity to treat MAM and SAM. Some caregivers expressed concern with the use of MUAC only to declare recovery, flagging that underlying illnesses could still be present. The caregivers recommended the provision of other food basket interventions to improve the treatment. The support by caregivers and health care workers on the idea of training community health volunteers to treat acute malnutrition points to the potential of scaling up decentralized treatment to increase coverage in remote areas. Key messages: The use of the simplified, combined protocol to treat acute malnutrition received overwhelming support from most stakeholders involved in implementation.Stakeholders were supportive of the use of the protocol to provide care for both severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) children with a shorter length of stay in treatment.Most stakeholders supported the use of mid‐upper arm circumference only for the admission and discharge of children.The majority of stakeholders reported that the ready‐to‐use therapeutic food given for MAM and SAM was sufficient for the child's recovery.The idea of training and equipping community health volunteers to treat acute malnutrition was well supported by caregivers and health care workers and should be explored further. [ABSTRACT FROM AUTHOR]

Treatment of severe acute malnutrition aims at producing quick catch‐up growth in children to decrease their short‐term mortality risk. The extent to which catch‐up growth is influenced by the amount of energy provided is unclear. This study assessed whether energy provided at admission is associated with catch‐up ponderal growth among children with mid‐upper arm circumference (MUAC) < 115 mm at admission. We conducted a secondary data analysis an operational cohort in Mali. The children were treated with a simplified protocol providing 1000 kcal/day of therapeutic food until MUAC ≥ 115 mm was achieved for two consecutive weeks and 500 kcal/day thereafter until discharge with MUAC ≥ 125 mm for two consecutive weeks. Linear mixed‐effects regression models were fitted to assess the relationship between energy provided at admission (kcal/kg/day) with weight gain velocity (g/kg/day) (primary outcome), change in MUAC ‐for‐age z‐score and change in weight‐for‐age z‐score. Unadjusted models and models adjusted for sex, age, seasonality and MUAC at admission were fitted. Both models included the study site as a random effect. A 10 kcal/kg/day increase in energy provided at admission was associated with increments in all outcomes; for weight gain velocity, the mean (95% CI) increment was 0.340 [0.326, 0.354] g/kg/day and 0.466 [0.446, 0.485] g/kg/day in the unadjusted and adjusted analysis, respectively. A positive relationship exists between energy provided at admission and catch‐up ponderal growth in children with MUAC < 115 mm treated using a simplified protocol. Determining the ideal weight gain rate remains essential for assessing the benefits and risks of increased energy intake during treatment. Key messages: Among children diagnosed with severe wasting (MUAC < 115 mm), higher provisions of energy at admission (kcal/kg/day) are associated with a higher rate of weight gain, higher changes in weight‐for‐age and MUAC‐for‐age z‐scores.Children treated for severe wasting (MUAC < 115 mm) receiving Ready‐to‐use therapeutic foods (RUTFs) at a dose higher at admission than the WHO 2023 recommendation of 150–185 kcal/kg/day experience higher rates of weight gain and higher changes in weight‐for‐age and MUAC‐for‐age z‐scores.The optimal rate of weight gain in children treated for severe wasting (MUAC < 115 mm) using RUTF remains unknown. [ABSTRACT FROM AUTHOR]

A simplified, combined protocol admitting children with a mid‐upper‐arm circumference (MUAC) of <125 mm or oedema to malnutrition treatment with ready‐to‐use therapeutic food (RUTF) uses two sachets of RUTF per day of those with MUAC < 115 mm and/or oedema and one sachet of RUTF per day for those with MUAC 115–<125 mm. This treatment previously demonstrated noninferior programmatic outcomes compared with standard treatment and high recovery in a routine setting. We aimed to observe the protocol's effectiveness in a routine setting at scale, in two health districts of the Central African Republic through an observational cohort study. The pilot enrolled children for 1 year in consortium by the Ministry of Health and nongovernmental partners. A total of 7909 children were admitted to the simplified, combined treatment. Treatment resulted in an 81.2% overall recovery, with a mean length of stay (LOS) of 38.7 days and a mean RUTF consumption of 43.4 sachets per child treated. Among children admitted with MUAC < 115 mm or oedema, 67.9% recovered with a mean LOS of 48.1 days and consumed an average of 70.9 RUTF sachets. Programme performance differed between the two districts, with an overall defaulting rate of 31.1% in the Kouango‐Grimari health district, compared to 8.2% in Kemo. Response to treatment by children admitted with severe acute malnutrition (SAM) by MUAC and SAM by oedema was similar. The simplified, combined protocol resulted in a satisfactory overall recovery and low RUTF consumption per child treated, with further need to understand defaulting in the context. Key messages: The simplified, combined protocol with a mid‐upper‐arm circumference (MUAC)‐based ready‐to‐use therapeutic food (RUTF) resulted in a recovery rate that reached SPHERE standards, low length of stay and low RUTF consumption per child among all children treated.Response to treatment was similar among children admitted with severe acute malnutrition (SAM) by oedema and those admitted SAM by MUAC.Contextual factors such as insecurity and stockouts in treatment products affect programme outcomes by increasing defaulting and decreasing recovery rates.The simplified, combined protocol might present an opportunity to treat more children with less product; decentralised delivery should continue to be explored. [ABSTRACT FROM AUTHOR]

ABSTRACT A simplified, combined protocol treats children with moderate acute malnutrition (MAM), defined by mid‐upper arm circumference (MUAC) of < 125 and ≥ 115 mm and no oedema, with 1 daily sachet of ready‐to‐use therapeutic food (RUTF) and those with severe acute malnutrition (SAM), defined by MUAC < 115 mm and/or oedema, with two daily sachets of RUTF. This protocol was previously shown to result in non‐inferior recovery compared to standard treatment that used higher, weight‐based RUTF dosing among children with SAM and ready‐to‐use supplementary food (RUSF) for MAM in a cluster‐based randomised controlled trial in Kenya and South Sudan. We conducted a secondary analysis of this trial to compare linear growth among children admitted with MUAC < 115 mm. Linear and ponderal growth were calculated from admission to discharge and visualised using aggregate growth curves. HAZ change adjusted for admission characteristics was negative across the course of treatment but similar across arms [−0.21 ± 0.18 SE in the standard arm, −0.24 ± 0.18 SE in simplified; difference (95% confidence interval) 0.03 (−0.12, 0.18)]. The unadjusted mean ± SE linear growth velocity from admission to discharge was 1.8 ± 0.7 mm/week in the standard arm compared to 1.7 ± 0.7 mm/week in the simplified arm [difference = 0.09 (−0.36, 0.53)] and similar in adjusted analysis. MUAC and weight gain velocities were not significantly different by treatment arm. Reducing the RUTF dose prescribed to children during SAM treatment does not appear to affect linear growth or other growth velocities during treatment. [ABSTRACT FROM AUTHOR]