Menu ENN Search

How do children with severe underweight and wasting respond to treatment?

View this article as a pdf

This is a summary of the following paper: Odei Obeng-Amoako G, Stobaugh H, Wrottesley S et al (2023) How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies. Maternal & Child Nutrition, 19, e13434. https://doi.org/10.1111/mcn.13434

Evidence shows that the most effective combination of indicators for identifying the highest risk of death in malnourished children under the age of five is a weight-for-age z-score (WAZ) < -3 and a mid-upper arm circumference (MUAC) < 11.5 cm (Khara et al, 2023). While including WAZ < -3 as an additional independent criterion for admission may improve the targeting of therapeutic treatment to the most vulnerable, a low WAZ is not widely used for this purpose, and there are various questions about its programmatic implications. This article presents findings from a pooled secondary analysis of existing research and programmatic data to better understand the growth trajectories and response to treatment of wasted children with WAZ < -3 within wasting treatment programmes, both supplementary and therapeutic.

According to the data used by the article, nine countries in Africa and Asia, a low WAZ was common among moderately wasted children (40% of admissions) and severely wasted children (60% of admissions). These proportions varied by context, with the highest prevalence of WAZ < -3 in India (90%) and the lowest in Kenya (32%). A low WAZ was more common in male than in female children, as well as in children aged between two and five compared to children below two years of age.

Wasted children with WAZ < -3 had lower recovery rates, a higher risk of death and a higher risk of transfer to inpatient care. While they gained weight in similar patterns to other wasted children, those with a low WAZ had markedly lower anthropometric measurements (height-for-age z-score [HAZ], weight-for-height z-score [WHZ] and MUAC) at admission and end of care. This suggests that these children have further to catch up and may require longer, or more tailored, treatment. This is particularly relevant for moderately wasted children with WAZ < -3, who are not currently eligible for therapeutic feeding in many contexts.

Overall, children admitted to community-based management of acute malnutrition (CMAM) programmes demonstrated modest HAZ gains during treatment. Children with moderate wasting had the lowest HAZ gains. Such children are likely to receive lower-intensity treatment than children who are severely wasted, and this may be insufficient to support catch-up growth. Particularly for children with severely low WAZ, a minimum intensity or quality of treatment may be required to promote linear growth, or at least to maintain HAZ.

Further, this analysis shows that children with oedema and severely low WAZ are at a comparatively greater risk of death than other groups, and are more likely to be stunted at admission. Treatment programmes do not currently consider these vulnerabilities, and more work is needed to understand and mitigate these risks.

As a next step, an intervention trial is needed to further explore these hypotheses. This trial should include non-wasted children with WAZ < -3, who are not currently represented in data from CMAM programmes.

References

Khara T, Myatt M, Sadler K et al (2023) Anthropometric criteria for best-identifying children at high risk of mortality: A pooled analysis of twelve cohorts. Public Health Nutrition, 26, 4. https://pubmed.ncbi.nlm.nih.gov/36734049/

Postscript: Response from the authors

Natasha Lelijveld is a Senior Nutritionist at the Emergency Nutrition Network (ENN)

This analysis, conducted by a sub-group of the Wasting and Stunting Technical Interest Group (WaSt TIG), supports evidence that children with wasting and WAZ < -3 are even more vulnerable to mortality and do not achieve traditional definitions of nutritional recovery as often as other wasted children. Wasted children with WAZ < -3 do gain weight in a similar pattern to other children with wasting, but they have further to catch up and therefore a longer or higher-intensity treatment may be needed. This is especially true for children with moderate wasting and WAZ < -3, who are only eligible for low-intensity treatment (if anything) in many settings. Those with severe wasting and low WAZ would already be eligible for ready-to-use therapeutic food (RUTF), but a higher intensity of RUTF is unlikely to be feasible. As a result, longer-treatment might be more suitable for them. Children with severely low WAZ as well as oedema are likely to require the greatest support, as they have the highest mortality risk.

The optimal length of treatment is something we would like to explore in a future analysis, both for wasted children with WAZ < -3 and for wasted children in general. Currently, many CMAM programmes have a ‘non-response’ definition of “no recovery within 16 weeks of starting treatment”. Some programmes have even shorter treatment timelines than this. There is wide heterogeneity in terms of treatment times and recovery definitions within the database we used for this analysis, since it is a compilation of data from 13 CMAM programmes. Going forward, we therefore plan to explore the appropriateness of existing definitions of non-response, including the characteristics of so-called ‘non-responders’ and at which timepoint weight gain tends to plateau. Please see the Wasting and Stunting area of the ENN website, where you can find the WaSt TIG plans for this work.1

The definition of nutritional recovery also warrants exploration, since there was also much variation regarding this in our dataset. Our analysis classified a large proportion of children as ‘early discharge’ and ‘non-response’, which led to a very low recovery rate (approximately 25%). Our definition of recovery for this analysis was ‘both MUAC > 12.5 and WHZ > -2’, which was not the case for all the programmes included in the data. Some programmes discharged children once MUAC had recovered, but not WHZ. We do not know what would have happened to those children had they continued treatment; it is likely that some would have recovered according to our definition. In order to explore whether this affected our conclusions on children with severely low WAZ, we conducted an analysis using the different programmes’ individual definitions of recovery (see Appendix Table 10 of the paper). This analysis showed that our conclusions remained the same, but the effect size of poor outcomes for those with WAZ < -3 diminished. This is an important consideration for anyone who is using our effect size to determine the sample size for a future study.

We very much hope that researchers will use our analysis to inform further studies. While continued secondary data analyses are needed, we do ultimately need intervention trials (such as the one outlined in the protocol designed by the WaSt TIG)2 as these will include non-wasted children with WAZ < -3 (who are currently not represented in the available data from CMAM programmes), as well as a controlled range of treatment lengths and intensities. Primary research studies will ultimately confirm the type of treatment needed for vulnerable children with WAZ < -3 to survive and thrive.

For more information, please contact Tanya Khara at tanya@ennonline.net or Natasha Lelijveld at natasha@ennonline.net

Read more...

More like this

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

View this article as a pdf Research summary1 Location: Kenya and South Sudan What we know: Children who are concurrently wasted and stunted (WaSt) have a very high mortality...

Resource: How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies

Abstract Children with weight-for-age z-score (WAZ) <−3 have a high risk of death, yet this indicator is not widely used in nutrition treatment programming. This...

FEX: Finding the best criteria to identify children at high risk of mortality

View this article as a pdf This article is a summary of the following paper: Khara T, Myatt M, Sadler K, Bahwere P, Berkeley J, Black R (TBC) Anthropometric criteria for best...

FEX: Improving screening for malnourished children at high risk of death

Research snapshot1 The purpose of this study was to investigate whether children with concurrent wasting and stunting (WaSt) require therapeutic feeding and to better...

FEX: Effect of nutrition survey ‘cleaning criteria’ on estimates of malnutrition prevalence and disease burden: secondary data analysis

Summary of research1 Location: Global What we know: Standardised methods for collection and reporting malnutrition prevalence data in nutrition surveys are used. What this...

FEX: Making connections: Joint meeting of WaSt Technical Interest Group and MAMI Special Interest Group

ENN coordinates two international technical groups, the Management of at-risk Mothers and Infants under six months Special Interest Group (MAMI SIG) and the Wasting and...

FEX: Summary of wasting and stunting project meeting

In May, the Technical Interest Group (TIG) of the ENN-facilitated Wasting and Stunting (WaSt) project1 held its bi-annual meeting, made possible through the generous support of...

Resource: The WaSt study Protocol and Opportunities for Collaboration: bringing new evidence on undernutrition and mortality risk into practice.

The ENN and the Wasting Stunting Technical Interest Group (WaSt TIG), with funding from USAID via the Bureau of Humanitarian Affairs (BHA) and Bureau for Global Health, in 2018...

Resource: Anthropometric criteria for best-identifying children at high risk of mortality: a pooled analysis of twelve cohorts

Abstract Objective: To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme...

FEX: Wasting and Stunting Technical Interest Group (WaSt TIG) meeting

On the 15th of January 2018 the Wasting and Stunting (WaSt) Technical Interest Group (TIG) held their third face-to-face meeting at Trinity College, Oxford. This group of 30...

FEX: A reflection on the 2021 Lancet Maternal & Child Nutrition Series through a WaSt lens

View this article as a pdf This article provides a summary of the Lancet Maternal & Child Nutrition Series to date, reflecting upon the 2021 series from the perspective of the...

WaSt TIG - the work so far

We have had three phases of work thus far and are currently in the fourth. A special section in FEX summarises a lot of the work of the WaSt TIG so far as well as experiences...

Resource: Bringing new evidence on undernutrition and mortality risk into practice- Protocol for a prospective cohort study

Lisez cet article en français Introduction The ENN coordinated Wasting and Stunting Technical Interest Group (WaSt TIG) have been investigating the relationship...

FEX: Improving complementary feeding practices through smartphone-based maternal education in Iran

View this article as a pdf Research snapshot1 Mothers' poor nutrition-related knowledge, attitudes and practices are considered to be major causes of malnutrition in...

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: Editorial perspective on the continuum of care for children with acute malnutrition

View this article as a pdf Lisez cet article en français ici By Jeremy Shoham and Marie McGrath, Field Exchange Co-Editors Rationale for FEX special edition We are...

FEX: Children who are both wasted and stunted are also underweight and have a high risk of death

Research snapshot1 Wasting and stunting tend to be addressed as separate issues, despite evidence of common causality and the fact that children may suffer simultaneously from...

en-net: Key questions regarding MUAC only programming - towards a research agenda

I have started this thread in the hope that we can come together there to work out what we need to do to move forward with an informed debate on issues around MUAC-only...

FEX: Patterns of wasting and stunting in Venezuela

View this article as a pdf This is a summary of the following paper: Raffalli S & Villalobos C (2021) Recent patterns of stunting and wasting in Venezuelan children:...

FEX: Defining and treating “high-risk” moderate acute malnutrition using expanded admission criteria (Hi-MAM Study): A cluster-randomised controlled trial protocol

View this article as a pdf By Natasha Lelijveld, David Taylor Hendrixson, Claire Godbout, Alyssa Los, Jukka M Leppänen, Aminata Koroma and Mark Manary Natasha Lelijveld...

Close

Reference this page

How do children with severe underweight and wasting respond to treatment?. Field Exchange 69, May 2023. p27. www.ennonline.net/fex/69/how-do-children-with-severe-under-weight-and-wasting-respond-to-treatment

(ENN_7598)

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.