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Response to malnutrition treatment in low weight-for-age children: secondary analyses of ComPAS trial data

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Research summary1

Location: Kenya and South Sudan

What we know: Children who are concurrently wasted and stunted (WaSt) have a very high mortality risk but current programmes tend to focus on addressing stunting or wasting, not both.

What this article adds: A secondary analysis of moderately and severely wasted children treated in the ‘ComPAS’ trial was undertaken to assess the response to treatment according to weight-for-age z-score (WAZ) and mid-upper arm circumference (MUAC) and the type of feeding protocol given. The analysis of 4,020 children confirms that WAZ<-3 identifies the majority of children as WaSt. Those with moderately low MUAC (11.5-12.5 cm) and a severely low WAZ (<-3), not currently eligible for therapeutic care, respond similarly to treatment when provided with a supplementary diet of either one sachet per day of ready-to-use therapeutic food (RUTF) or a standard dose of ready-to-use supplementary food. Their recovery rate (54%) was better than those with severe wasting (19.6%) who were provided with a therapeutic diet and slightly worse than others with moderate wasting (59.5%). Children with a severely low MUAC (<11.5 cm) had similar recovery rates whether they were provided with a standard dose of RUTF or a simplified, reduced dosage of two sachets per day. A model that supports moderately wasted children with WAZ<-3 with a supplementary dose of lipid nutrients and those with severe wasting with a reduced therapeutic dosage should therefore be explored in order to efficiently reach the majority of children at high risk of mortality.

Background

Children who are concurrently wasted and stunted (WaSt) are among the most vulnerable of all malnourished children with a higher mortality risk than either wasting or stunting alone and about a 12 times greater risk of mortality in the absence of treatment than those with normal anthropometry (Myatt et al, 2018). Current conventions in policy and practice mean that programmes tend to focus on addressing either stunting or wasting, not both. Current therapeutic feeding programmes use mid-upper arm circumference (MUAC) < 11.5 cm, weight for height z-score (WHZ) <-3 and/or the presence of oedema as independent admission criteria. Some children who are severely wasted and concurrently stunted are included according to these criteria but moderately wasted children who are concurrently stunted will not be captured for therapeutic feeding despite having a similar near-term mortality risk to severely wasted children. Exploration of practical anthropometric criteria for identifying children with WaSt has found that severely low weight-for-age z-score (WAZ) has the highest (>90%) sensitivity and specificity for identifying these children across multiple settings (Myatt et al, 2018) and that a combination of severely low MUAC (already well evidenced to identify those at high risk of mortality and easy to use) plus a severely low WAZ could best identify those malnourished children at most risk of dying including those with WaSt and those with a severely low WHZ (Myatt et al, 2019). However, given that WAZ<-3 is not currently one of the criteria for admission to therapeutic feeding programmes, the intensity of treatment required by this additional group of children and the impact of their inclusion on therapeutic programme caseloads is yet to be evaluated. To help fill this evidence gap, a secondary analysis of data from a recent trial in Kenya and South Sudan (‘ComPAS trial’) was conducted.

Methods

The ComPAS trial database includes children with MUAC<125 mm who were treated with either a simplified, combined protocol (two sachets of ready-to-use therapeutic food (RUTF) per day for severe wasting and one sachet (2092 kJ/500 kcal) of RUTF per day for moderate wasting) or those treated with standard care (weight-based dosage of RUTF for severe wasting and one sachet per day ready-to-use supplementary food (RUSF) for moderate wasting) (Bailey et al, 2020). These two treatment groups allowed for comparison of the response to different intensities of treatment for children with WAZ<-3.

Children in the dataset were categorised into the following four groups:

Groups 1 and 3 are already included in current therapeutic feeding programmes based on MUAC definitions of severe wasting However Groups 2 and 4 would not usually qualify for therapeutic care under current guidelines although they may be eligible to receive supplementary feeding if available in their context.

Key Findings

The analysis, which included 4,020 children, confirmed previous findings that WAZ<-3 identifies the majority of WaSt children. In this dataset, 1,150 (89.5%) of children with a WHZ <-2.0 and HAZ <-2.0 (true definition of WaSt) also had a WAZ <-3.0. The analysis also found that children in Group 2 (those with moderately low MUAC (11.5-12.5 cm) and a severely low WAZ (<-3)) respond similarly to treatment in terms of both weight and MUAC gain when provided with a supplementary diet of either 2092 kJ (500 kcal)/day of RUTF or a standard dose of RUSF. Their recovery rate (54%) was better than those with severe wasting (19.6%) who received a therapeutic diet and slightly worse than others with moderate wasting (59.5%).

This analysis also confirms the particularly high vulnerability of Group 3 children (MUAC <115 and WAZ <-3) who had the lowest recovery rate (16.7%) despite being five months older on average than children in Group 1. Children in Group 3 also had the highest proportion of defaulters (39.4%) and deaths (1.9%) despite receiving therapeutic food. Children with a severely low MUAC (<11.5 cm) (Groups 1 and 3), with/without a severely low WAZ (<-3), received a reduced dosage of RUTF on average if they were in the combined protocol arm compared to the standard protocol arm. However, despite this, both trial arms had similar recovery rates, although WAZ gain was potentially slower in the combined protocol arm.

Conclusion

In summary, this data argues that children with a MUAC<125 mm and a WAZ<-3 given a supplementary dose of either RUTF or RUSF achieve a recovery rate comparable to the rate achieved by other children with MUAC<125 mm treated with the ComPAS protocol. Following further research, it may therefore be optimal for wasting programmes seeking to support the highest risk children to provide a therapeutic product to children with MUAC<115 mm and a supplementary product to children with WAZ<-3 not captured by a severely low MUAC. The poor recovery rates found in the group of children with both severely low MUAC and WAZ suggests that more research is needed into the adequacy of current therapeutic protocols for this highly vulnerable group.   


1 Bailey, J, Lelijveld, N, Khara, T, Dolan, C, Stobaugh, H, Sadler, K, Lino Lako, R, Briend, A, Opondo, C, Kerac, M and Myatt, M (2021) Response to Malnutrition Treatment in Low Weight-for-Age Children: Secondary Analyses of Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial. Nutrients13(4), p.1054.


References

Bailey, J, Opondo, C, Lelijveld, N, Marron, B, Onyo, P, Musyoki, E N, Adongo, S W, Manary, M, Briend, A and Kerac, M (2020) A simplified, combined protocol versus standard treatment for acute malnutrition in children 6–59 months (ComPAS trial): A cluster-randomized controlled non-inferiority trial in Kenya and South Sudan. PLoS Med, 17(7): e1003192.

Myatt, M, Khara, T, Schoenbuchner, S, Pietzsch, S, Dolan, C, Lelijveld, N and Briend, A (2018) Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries. Archives of Public Health, 76, 28.


Commentary on the implications of this analysis from the perspective of the ENN wasting and stunting (WaSt) project  

By Tanya Khara, ENN Technical Director and WaSt Technical Interest Group2 Coordinator

Publications from the Wasting and Stunting Technical Interest Group (Myatt et al, 2018 and Myatt et al, 2019) have highlighted the potential of weight-for-age z-score (WAZ) <-3 in identifying children with WaSt at high risk of dying and have suggested that this admission criteria be considered for treatment services. What this additional target group would need in terms of intensity of treatment to bring them out of their high-risk state (i.e., treat the wasting component of their condition) is highlighted by the group as an area requiring further study.

The findings of the above analysis that members of the WaSt TIG collaborated on are promising. They suggest that the group of children with WAZ<-3 who also have a mid-upper arm circumference (MUAC) of between 115 mm and 125 mm (i.e., who would not be included in therapeutic feeding where MUAC was the only admission criteria) did respond well to a supplementary dose (500kcal/d) of a lipid nutrient supplement delivered as part of the ComPAS protocol. This response, in terms of weight and MUAC gain, was comparable to the rate achieved by other children with MUAC<125 mm treated with a ComPAS protocol and was similar irrespective of whether ready-to-use supplementary food (RUSF) or ready-to-use therapeutic food (RUTF) was given.

The above analysis does not include the group of children who have WAZ<-3 and MUAC greater than 125 mm simply because this group was not included in the original trial and therefore results cannot be extrapolated to all children with WAZ<-3. The analysis also does not allow for exploration of what happens to this group of interest if they receive other non-lipid supplementary foods, such as corn-soy blended flour, no nutrition counselling or no care, an area that may be the subject of further study. It is also important to note that this dataset was not powered for these sub-group analyses specifically so a further analysis with a larger dataset is warranted. An initiative to do this, pooling a number of different datasets, is already underway as a collaboration between Action Against Hunger and the WaSt TIG.

The findings also support plans by the WaSt TIG to test a programme model that seeks to support children at highest risk by providing a standard therapeutic protocol to children with MUAC<115 mm and trialling a less intense protocol to children with WAZ<-3 not captured by the severely low MUAC criteria but potentially identified via growth monitoring and promotion platforms.3

The increased caseload of children if WAZ<-3 were to be added to programme admission criteria and the subsequent effects on the health service remain important factors to consider. This analysis found that, in these settings, WAZ<-3 affected 29% of children in the cohort even though this was limited to children with a MUAC<125 mm. This is an important consideration for any potential future research into how treatment programmes may accommodate this group.

 

For more information, please contact Tanya Khara at tanya@ennonline.net


2 https://www.ennonline.net/ourwork/reviews/wastingstunting

3 https://www.ennonline.net/resource/newevidenceintopractice


References

Myatt, M, Khara, T, Schoenbuchner, S, Pietzsch, S, Dolan, C, Lelijveld, N and Briend, A (2018) Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries. Archives of Public Health, 76(1), pp.1-11.

Myatt, M, Khara, T, Dolan, C, Garenne, M and Briend, A (2019) Improving screening for malnourished children at high risk of death: a study of children aged 6–59 months in rural Senegal. Public health nutrition, 22(5), pp.862-871.

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Response to malnutrition treatment in low weight-for-age children: secondary analyses of ComPAS trial data. Field Exchange 65, May 2021. p76. www.ennonline.net/fex/65/compastrialdatasecondaryanalyses

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