Menu ENN Search

Effect of adding RUSF to ageneral food distribution on child nutritional status and morbidity: a cluster randomised controlled trial

Summary of research1

Child during appetite test at a health facility offering treatment in Monrovia, Liberia

The authors of a recent study hypothesized that including a daily dose of 46 g of Lipid based Nutrient Supplement (LNS) as Ready to Use Supplementary Food (RUSF), for consumption by children between 6 and 36 months of age as part of a household food distribution programme would reduce cumulative wasting incidence during the seasonal hunger gap (June to October).

The study was conducted in the city of Abeche, the capital city of the Ouaddai¨ region in eastern Chad. Since 2006, this part of the country has been characterised by chronic political instability, which has led to the decline in nutritional status of children under 5 years of age. Recently, the non-governmental organisation Action Contre la Faim – France (ACF-France) conducted two cross-sectional nutritional surveys of children under 5 years in Abeche. A first survey was conducted at the beginning of the rainy season (June 2009) and revealed a prevalence of wasting of 20.6%, with 3.2% severe wasting, using the National Centre for Health Statistics (NCHS) growth reference. A second survey was carried out during the post-harvest period (January 2010) and reported a wasting prevalence of 16.8%, with 2% severe wasting

The study was conducted in seven vulnerable sectors of the city of Abeche that were preselected from a total of 45 administrative sectors. These seven sectors were identified based on data from a community network organised by ACF-France involving a set of socio-economic, sanitary and nutritional (proportion of children admitted to ACF-France nutrition rehabilitation programmes) criteria. The selected sectors were subdivided into 14 geographical clusters using main roads and rivers as cluster boundaries. The cluster was the unit of randomisation andrandom assignment was conducted through an official ceremonial gathering with officials and community members. Seven clusters were assigned to the intervention group and seven to the control group.

The researchers designed the study as a two-arm cluster-randomised controlled pragmatic trial, targeting children from 6 to 36 months of age from vulnerable households. A household was considered to be ‘‘vulnerable’’ when it met one of the following criteria: (1) household head being disabled, pregnant or lactating, or (2) an economic dependency ratio of 4:1 or more (number of economically inactive versus active household members). The inclusion criteria for the study were being non-wasted (weight-for-height >80% of the NCHS reference median, and lack of bilateral pitting oedema) and being from a ‘‘vulnerable’’ household.

The study used the NCHS growth reference for enrolment in the study, to conform with the Chad national protocol for the management of malnutrition. However, the researchers opted to analyze the data using the WHO international growth standards to make the results more comparable to recent studies. None of the study conclusions were altered when analysing the outcome data using the NCHS growth reference.

The primary study outcome was the cumulative incidence of acute malnutrition or wasting defined as weight-for-height Z-score (WHZ), or presence of bilateral pitting oedema. In order to detect a 50% reduction in the cumulative incidence of wasting over a period of 4 months, with a statistical power of 80%, a sample size of 1,220 children was calculated to be needed. Taking into account a study dropout of 15%, a total sample size of 1,435 children was projected. Secondary outcomes included mean WHZ change over time, prevalence of stunting at end point defined as height-for-age Z score (HAZ), mean HAZ change over time, mid upper arm circumference (MUAC) change over time, mean haemoglobin concentration at end point, prevalence of anaemia at end point (haemoglobin <110 g/l).

Study interventions

Households of both the intervention and control groups received a monthly food package representing a daily ration of 425g of sorghum, 25 g of legumes, 25 g of bleached palm oil, 20 g of sugar, and 5 g of iodized salt. This ration was estimated to cover approximately 86% (<1,800 kcal) of the daily energy requirements for a population at risk of an emergency. The number of food rations distributed per household was proportional to its size. Children from the intervention group received a monthly quantity of RUSF (Plumpy’Doz, Nutriset) representing a daily ration of 46g (<247 kcal/d). Recommendations on dosage and frequency of consumption by targeted children were made to caretakers and repeated at each follow-up visit. The intervention lasted 4 months (June 2010 to September 2010). Prior to this intervention, an acceptability test was conducted in a convenience sample of 30 nonwasted children.

The study team encouraged the mothers to bring their children with them to the monthly food distributions, regardless of their intervention status. Children were enrolled from early June to mid-July 2011 and scheduled to come for four follow-up visits. At each visit, child anthropometric measurements and morbidity were recorded. Children who were classified as moderately wasted (weight-for-height =70- <80% of NCHS reference median) or severely wasted (weight-for-height <70% of NCHS reference median) were discharged from the study and referred to a community-based management of acute malnutrition programme located within the city’s nutrition rehabilitation centres. All participating mothers were given a family food ration as described above.

The study team used a pretested questionnaire to collect data on socioeconomic and demographic characteristics of enrolled households. Child age at screening was estimated using a locally adapted event calendar if a birth certificate was unavailable. Anthropometric measurements were conducted monthly. Episodes of diarrhoea, respiratory tract infection, and fever were recalled for 1 week before the monthly interview. Respiratory tract infection was diagnosed through reports by the mother/ caregiver of persistent cough or difficulty in breathing during the last week (yes/no). A diarrheal episode was defined as having at least three loose stools within a day. Fever episodes were diagnosed by mother/caretaker during the last week (yes/ no). In case of death, the team carried out a verbal autopsy adapted from WHO standards. Haemoglobin concentration was measured at baseline (June) and at the end of the intervention (November) or when a child was discharged from the study, using a daily calibrated electronic device HemoCue Hb 201+. Standardised forms were used to collect data.

Results

The overall sample size was 1,038 children in 784 households: 598 children in the intervention group and 440 children in the control group.

Table 1 details the effects of preventive RUSF on child anthropometry. Compared to baseline values, mean WHZ for both control and intervention groups were slightly higher at end point, while mean HAZ was slightly lower. There was no difference in the incidence of wasting (incidence rate ratio: 0.86; 95% CI: 0.67, 1.11; p= 0.25) or mean change in WHZ (20.002 WHZ/month; 95% CI: 20.032, 0.028; p =0.89) between the arms. The difference in weight increase between groups was 0.02 kg/month (95% CI: 20.01, 0.04; p=0.10). Children in the intervention group had a significantly higher linear growth velocity of 0.03 HAZscore/ month (95% CI: 0.02, 0.05; p<0.001) compared to the control group . This observed difference was equivalent to a small difference in height gain of 0.09 cm/month (95% CI: 0.04, 0.14; p<0.001).

Table 1: Effects of preventative RUSF on child anthropometry
Outcome Control Arm (n=440) Intervention Arm (n=598) p-Value
Wasting
End point mean WHZ (SD) –1.09 (0.95) –1.05 (0.93)  
Intervention effect (95% CI), Z-score/mo - a Reference –0.002 (–0.032, 0,028) 0.89
Cumulative episode WHZ<–2 174 241  
Number of observed child-months 1,427 2,199  
Number of episodes per child-months (95% CI) - b 0.12 (0.10, 0.14) 0.11 (0.09, 0.14)  
Incidence rate ratio (95% CI) - c Reference 0.86 (0.67, 1.11) 0.25
Stunting
End point mean HAZ (SD) –2.06 (1.39) –1.79 (1.46)  
Intervention effect (95% CI), Z-score/mo - a Reference 0.03 (0.01, 0.04) <0.001
End point prevalence of stunting percent (n) 52.3 (230) 46.2 (276)  
OR of end point stunting (95% CI) - d Reference 0.69 (0.45,1.07) 0.099
MUAC
End point MUAC, cm (SD) 14.1 (1.2) 14.3 (1.1)  
Intervention effect (95% CI), cm/mo - a Reference 0.01 ( –0.02, 0.04) 0.49

a Analyzed using a linear mixed model with random effects cluster, household, and child, adjusted for child’s ae at baseline, child’s sex, SES, and baseline value.

b Confidence intervals are estimated from a Poisson model adjusted for clustering.

c Analyzed using a mixed Poisson regression model with random effects cluster, household, and child, adjusted for child’s age at baseline, child’s sex, SES, and baseline value.

d Analyzed using a mixed logistic model with random effects cluster and household, adjusted for child’s age at baseline, child’s child’s sex, SES, and baseline value.

doi: 10.1371/journal.pmed.1001313.t003

 

Identical ponderal (weight)growth in control and intervention groups was confirmed by a lack of difference in MUAC growth. Age at inclusion was not found to modify the intervention effects on child anthropometric measurements. After adjustment for age, sex, socioeconomic status, and morbidity status at inclusion, the study found that children from the RUSF group had lower risk of self-reported diarrhoea by 29.3% (95% CI: 20.5, 37.2; p<0.001) and fever by 22.5% (95% CI: 14.0, 30.2; p<0.001), compared to the control group. RUSF significantly increased mean haemoglobin concentration at end point by 3.8 g/l (95% CI: 0.6, 7.0; p= 0.02), resulting in significantly lower odds of anaemia (OR: 0.52; 95% CI: 0.34, 0.82; p= 0.004) for children in the intervention group.

The absence of an effect on wasting incidence could have multiple explanations. First, the energy contribution of RUSF may have been ‘‘diluted’’ by the general food distribution, which mainly provided a supplement of energy and protein. Second, the energy dose of 46 g (<247 kcal) daily RUSF and the duration of the supplementation could have been insufficient to support ponderal growth, particularly for the older children in the cohort. Furthermore, it is possible that the RUSF may have been shared with other children in the household. However, if this were done to a large extent, the observed intervention effects on secondary outcomes like HAZ and haemoglobin concentration are hard to explain.

The absence of an effect on ponderal growth, but modest effects on morbidity, linear growth, and, most of all, haemoglobin could suggest that a multiple micronutrients (MMN) effect is at play. For example, zinc, one of the micronutrients added to RUSF, is currently recommended as adjunct therapy by the United Nations Children’s Fund and WHO for the treatment of diarrhoea.

These observations could lead to the speculative hypothesis that supplementation with MMN supplements like powders or tablets might result in the same effects as RUSF, if basic food rations were provided.

One important additional benefit that LNS offer is the lipid component. In addition to providing a small amount of essential fatty acids, which hold a potential to support child growth, the lipid component serves as an essential matrix that ensures that fat-soluble vitamins like vitamin A, D, and E are properly absorbed. Particularly when the child’s diet is poor in fat, this would provide leverage to increase the efficacy of supplemented fat-soluble vitamins. Therefore, more mechanistic studies are required to elucidate the additional contribution to the efficacy of the MMNs by the functional fat fraction of the RUSF.

The study had a number of limitations. The projected sample size was not attained, limiting the study’s statistical power. The study participantswere not blinded with respect to the intervention assignment because of the type of supplement (paste) provided to children. Clusters were not always geographically separated from each other. And finally, child morbidity was recorded through caretaker recall, which could have resulted in underestimation.

In conclusion, adding child-targeted RUSF supplementation to a general food distribution resulted in increased haemoglobin status and linear growth, accompanied by a reduction in diarrhoea and fever episodes. However the study did not find clear evidence that adding RUSF to a household food ration distribution of staple foods was more effective in preventing acute malnutrition. Other context-specific alternatives for preventing acute malnutrition should therefore be investigated.

Show footnotes

1Huybregts L et al (2012). The Effect of Adding Ready-to- Use Supplementary Food to a General Food Distribution on Child Nutritional Status and Morbidity: A Cluster- Randomized Controlled Trial. PLOS Medicine. www.plosmedicine.org. September 2012, volume 9, issue, 9, e1001313, pp 1-11

More like this

FEX: Effect of mass supplementation with RUSF during an anticipated nutritional emergency

Summary of published research1 A woman and her dauguher receive RUSF distribution in Niger Location: Niger What we know already: Ready to Use Supplementary Foods (RUSF) are...

FEX: Effect of short-term RUTF distribution on children in Niger

Summary of published research1 Mothers and children arriving for their monthly surveillance visits, as part of the trial Researchers from the Harvard School of Public Health...

FEX: Treatment of SAM and MAM in low- and middle-income settings: a systematic review

Summary of research1 Location: Global What we know: Worldwide, 33 million children under 5 years are moderately malnourished and 19 million are severely malnourished. The...

FEX: Independent and combined effects of improved WASH and improved complementary feeding on child stunting and anaemia in rural Zimbabwe

Summary of research1 Location: Zimbabwe What we know: Stunting and anaemia remain prevalent in children; plausible interventions have shown limited or inconsistent...

FEX: Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali

Summary of research1 Location: Mali What we know: Community-led total sanitation (CLTS) is being scaled up, but there is limited evidence on child health impacts. What this...

FEX: Wasting is associated with stunting in early childhood

Summary of published research1 Location: Africa, Asia, Latin America What we know already: Wasting and stunting are respectively short term and longer term conditions of...

FEX: Recovery rate of children with moderate acute malnutrition treated with ready-to-use supplementary food (RUSF) or improved corn-soya blend (CSB+)

Summary of research * Location: Cameroon. What we know: A wide range of nutritional products are currently used to treat MAM; there is no definitive consensus on the most...

FEX: Evaluation of an integrated health-nutrition-WASH project to reduce malnutrition prevalence in children under two in Bangladesh

By Monsurul Hoq and John Brogan Monsurul Hoq was working as a Statistician Epidemiologist during the study. He has experience in monitoring and evaluation of community-based...

FEX: Impact of an integrated agriculture and nutrition and health behaviour change communication programme for women in Burkina Faso

Summary of research1 Location: Burkina Faso What we know: The agricultural sector has great potential to contribute to improving nutrition.; However, current evidence of...

FEX: Risk factors associated with severe acute malnutrition in infants under six months in India: a cross sectional analysis

By Susan Thurstans Susan is a registered nurse and midwife with over 12 years' experience in maternal and child health and nutrition programmes in both development and...

FEX: TreatFOOD study in Burkina Faso

Summary of presentation1 of published research2 View this article as a pdf By Susan Shepherd Dr Susan Shepherd is Director of Clinical and Operational Research for...

FEX: Cash-based intervention and risk of acute malnutrition among children in internally displaced persons camps in Somalia

Research snapshot1 Cash-based interventions (CBI) have been used in Somalia since 2011, a country with one of the highest prevalences of acute child malnutrition in the world....

FEX: MUAC vs WHZ in predicting mortality in hospitalised children under five years of age

Summary of research1 This research contributes to the evidence base regarding which anthropometric indicators identify malnourished sick children most at risk of death. Low...

FEX: WASH interventions and their effects on the nutritional status of children

Summary of research1 Location: Global What we know: Water, sanitation and hygiene (WASH) interventions are frequently implemented to improve health and reduce infectious...

FEX: Micronutrient powders v iron-folic acid tablets in controlling anaemia in pregnancy

Summary of research1 The major cause of anaemia in pregnancy is iron deficiency, which is preventable. It is estimated that 56% of pregnant women in developing countries...

en-net: Coverage prevalence survey for blanket SFP for chronic malnutrition

Our programme is a blanket supplementary feeding programme (BSFP) that is targeting very high rates of chronic malnutrition, the largest nutrition problem in the country. We...

FEX: MUAC Versus Weight-for-Height in Assessing Severe Malnutrition

Summary of published paper1 An infant having MUAC measured during the study in Kenya Current WHO guidelines for the management of severe malnutrition in children recommend...

FEX: Relationships between wasting and stunting and their concurrent occurrence in Ghanaian pre-school children

Summary of research* Location: Ghana. What we know: Wasting is a short-term health issue, but repeated episodes may lead to stunting (long-term or chronic malnutrition). This...

FEX: Chronic disease outcomes after SAM in Malawian children (ChroSAM): A cohort study

Summary of research* Location: Malawi What we know: Little is known about the long-term health effects of survivors of severe acute malnutrition (SAM), particularly risk of...

FEX: Impact of a conditional cash transfer programme on determinants of child health in Colombia

Summary of research1 Location: Colombia What we know: Conditional cash transfer (CCT) programmes have demonstrated large impacts on child education, health and nutritional...

Close

Reference this page

Effect of adding RUSF to ageneral food distribution on child nutritional status and morbidity: a cluster randomised controlled trial. Field Exchange 44, December 2012. p6. www.ennonline.net/fex/44/effect

(ENN_4320)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.