Community-based management of acute malnutrition in Malian children: a cluster randomized trial
Ackatia-Armah, Robert Samuel
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Acute malnutrition (AM), characterized by wasting, affects 55 million children under five years of age in developing countries. In Mali, the prevalence of AM exceeds 15% in some seasons. There is currently no consensus on the most effective dietary treatment strategy for children with moderate AM (MAM). Twelve health centers in rural Mali were randomly assigned to provide children with MAM (defined as mid-upper arm circumference (MUAC) < 12.5 and ≥ 11.0 cm or weight-for-length Z-score (WLZ) <-2.0 WHO standard and >70% NCHS reference median) 1 of 4 dietary regimens: 1) lipid-based, ready-to-use supplementary food (Supplementary Plumpy, SP); 2) special corn soy blend for MAM (CSB++); 3) locally processed, fortified food (Misola, MI); or 4) locally milled flours (millet and cowpea) plus oil, sugar and micronutrient powder (HFM). 1264 non-edematous children aged 6-35 months with MAM were offered ~500 kcal/d of assigned diet in addition to their usual food intake for 12 weeks. Hemoglobin (Hb) was measured in 1154 children, and plasma ferritin and transferrin receptor were measured in a subset of 452 children. 1178 children (93.2%) completed the study and attendance at weekly/bi-weekly follow-up visits was >85% in all groups. The adjusted mean (95% CI) change in weight in kg from baseline was greater with SP and CSB++ than other regimens (1.16 (1.08, 1.24), 1.04 (0.96, 1.13), 0.91 (0.82, 0.99), 0.83 (0.74, 0.92) for the respective study groups, p<0.001 ANOVA). MUAC changes followed a similar pattern. For length, SP and CSB++ differed significantly from HFM only. Recovery from MAM (defined as WLZ>-2.0, MUAC> 12.5cm) was higher with SP than the three other regimens (73%, 68%, 61%, 58% respectively, p less than O.OOO1). Total cost per treatment based on median time to recovery was $2.20 for SP, $1.43 for CSB++, $1.83 for MI and $1.65 for HFM. Anemia rates remained high (>81 %) in all groups after treatment. SP generally provided greater improvement in iron status compared to MI while CSB++ and HFM had intermediate effects. SP was more effective than other dietary regimens for the treatment of MAM and improvement of iron status; however, the benefits must be considered in relation to product costs and availability.
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