- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05994742
An Adaptive Multi-arm Trial to Improve Clinical Outcomes Among Children Recovering From Complicated SAM (Co-SAM)
Co-SAM: An Adaptive Multi-arm Trial to Improve Clinical Outcomes Among Children Recovering From Complicated Severe Acute Malnutrition
Study Overview
Status
Intervention / Treatment
Detailed Description
This is a 5-arm randomized, unblinded clinical trial comparing:
Arm 1: Standard-of-care (control) Arm 2: Antimicrobial package Arm 3: Reformulated RUTF Arm 4: Psychosocial package Arm 5: Antimicrobial package + reformulated RUTF + psychosocial package
The trial will test the superiority of each intervention arm over the standard of care arm (control). Children in the control arm (and all intervention arms) will receive RUTF for at least 2 weeks and all standard care. The trial is adaptive, meaning i) that each intervention arm will be added as it becomes available, and ii) an interim analysis will enable us to drop arms which are unpromising based on pre-specified criteria. There will be no blinding or placebo, because the very different components in each trial arm make it very challenging to blind. Children with complicated SAM will be screened and enrolled from hospital sites shortly before discharge, and interventions will be started before leaving hospital, and continued for 12 weeks through outpatient visits. Children will be followed at 2, 4, 6, 8, 12 and 24 weeks post-discharge in dedicated study clinics (with additional visits at 1, 3 and 5 weeks for caregiver-child pairs receiving the psychosocial intervention).
The primary outcome is death or hospitalization or failed nutritional recovery by 24 weeks.
The aim is to recruit 1266 children across three countries. The study is not testing new drugs but rather testing a different package of medications (Arms 2 and 5) as compared to current standard care, which the investigator believe will have greater benefit. The RUTF will be a new formula in two of the arms (3 and 5) based on research into what composition will improve health outcomes for children with complicated SAM. This will be a variant on Plumpy'Nut®, a brand that is known and trusted, produced in collaboration with the manufacturers, Nutriset.
The Psychosocial intervention (Arms 4 and 5) will involve three components:
i) The Friendship Bench, which was developed in Zimbabwe as a low-cost psychological intervention utilising problem-solving therapy (delivered by trained lay workers) and peer-to-peer support to address depression and other common mental disorders. There is a strong evidence-base for its use in urban LMIC settings. Peer support groups meet every 1-2 weeks and focus on communal problem solving, and establishing income-generation activities (such as making bags). ii) Care for Child Development is a UNICEF package that helps families build stronger relationships and solve problems in caring for the child at home, through play and communication activities to stimulate children, through a series of age-appropriate interactive modules delivered by a lay worker using 'flash' cards. It has been used in other African contexts and has good acceptability. iii) Educational and behavior-change messages around better nutrition; play for children with SAM; stigma, HIV and gender-based violence; financial planning; causes of SAM; and health-seeking behaviours.
Blood and stool will be collected at baseline, 12 and 24 weeks from all children to explore recovery of underlying pathological processes. At week 2, liver function tests will be undertaken in local laboratories. Samples will also be transported to Kenya and the Netherlands for some assays not available in each country.
Study Type
Enrollment (Estimated)
Phase
- Phase 3
Contacts and Locations
Study Contact
- Name: Isabella Cordani, BSc
- Phone Number: + 44 (0)2078822800
- Email: i.cordani@qmul.ac.uk
Study Contact Backup
- Name: Andrew Prendergast, DPhil MRCPCH
- Phone Number: +44 (0) 207 882 2269
- Email: a.prendergast@qmul.ac.uk
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Child
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Age 6-59 months, of either sex
- Hospitalised with complicated severe acute malnutrition, as per WHO definition
- Started transition to RUTF
- Caregiver willing and able to attend the study clinic for all visits
- Caregiver able and willing to give informed consent
Exclusion Criteria:
- Any acute or chronic condition which mean that receipt of one or more study interventions, or participation in the trial, would not be advisable.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Arm 1: Standard-of-care (control)
Children in the control arm will receive Ready to Use Therapeutic Food (RUTF) for at least 2 weeks, plus all standard care.
Children with HIV will receive long-term Cotrimoxazole prophylaxis and antiretroviral therapy, as per current guidelines.
|
All children will receive care according to WHO guidelines, which includes standard RUTF and any other medications required.
|
Experimental: Arm 2: Antimicrobial package
Children will receive a bundle of azithromycin (3 days every month), isoniazid (daily), rifampicin (daily) and pyridoxine (daily) for 12 weeks.
|
All children will receive care according to WHO guidelines, which includes standard RUTF and any other medications required.
Rifampicin is commonly used in the first-line management of paediatric tuberculosis, and is approved by the FDA (ID: 2862628) and the EMA (EMA/31710/2020).
Azithromycin is a macrolide antibiotic, and is approved for use in children by the FDA (ID: 3263750) and EMA (EMA/2872/2021).
Isoniazid is an antibiotic commonly used in the firstline treatment of tuberculosis, and as tuberculosis prophylaxis.
Pyridoxine is a form of vitamin B6 used to prevent peripheral neuropathy among children receiving isoniazid.
|
Experimental: Arm 3: Reformulated RUTF
Children will receive a reformulated RUTF, with increased medium-chain triglycerides (MCTs), higher hydrolysed protein content and a more bioavailable form of selenium (selenium yeast).
Children will receive RUTF for at least 2 weeks.
|
All children will receive care according to WHO guidelines, which includes standard RUTF and any other medications required.
A reformulated product designed to improve outcomes for children who have severe acute malnutrition.
|
Experimental: Arm 4: Psychosocial package
Caregiver-child pairs will receive a low-cost, co-designed intervention to strengthen caregiver support, enhance income generation and promote child play. This is delivered over 12 weeks and comprises: i) The Friendship Bench, developed as a low-cost psychological intervention utilising problem-solving therapy (delivered by trained lay workers) and peer-to-peer support to address depression and other common mental disorders. ii) Care for Child Development is a UNICEF package that helps families build stronger relationships and solve problems in caring for the child at home, through play and communication activities in a series of age-appropriate interactive modules delivered by a lay worker using 'flash' cards. iii) Educational and behaviour-change messages around better nutrition; play for children with SAM; stigma, HIV and gender-based violence; financial planning; causes of SAM; and health-seeking behaviours. |
All children will receive care according to WHO guidelines, which includes standard RUTF and any other medications required.
The Friendship Bench was developed in Zimbabwe as a low-cost psychological intervention utilising problemsolving therapy (delivered by trained lay workers) and peer-to-peer support to address depression and other common mental disorders.
There is a strong evidence base for its use in urban LMIC settings.
Peer support groups meet every 1-2 weeks and focus on communal problem solving, and establishing income-generation activities (such as making bags).
Care for Child Development is a UNICEF package that helps families build stronger relationships and solve problems in caring for the child at home, through play and communication activities to stimulate children, through a series of age-appropriate interactive modules delivered by a lay worker using 'flash' cards.
It has been used in other African contexts and has good acceptability.
Educational and behaviour-change messages around better nutrition; play for children with SAM; stigma,HIV and gender-based violence; financial planning; causes of SAM; and health-seeking behaviours.
These have been developed with caregivers affected by SAM in a previous study, through a series of codesign workshops, ensuring these are contextually relevant.
|
Experimental: Arm 5: Antimicrobial package + reformulated RUTF + psychosocial package
A combination of all interventions from arms 2, 3 and 4, plus standard care delivered for 12 weeks.
|
All children will receive care according to WHO guidelines, which includes standard RUTF and any other medications required.
Rifampicin is commonly used in the first-line management of paediatric tuberculosis, and is approved by the FDA (ID: 2862628) and the EMA (EMA/31710/2020).
Azithromycin is a macrolide antibiotic, and is approved for use in children by the FDA (ID: 3263750) and EMA (EMA/2872/2021).
Isoniazid is an antibiotic commonly used in the firstline treatment of tuberculosis, and as tuberculosis prophylaxis.
Pyridoxine is a form of vitamin B6 used to prevent peripheral neuropathy among children receiving isoniazid.
A reformulated product designed to improve outcomes for children who have severe acute malnutrition.
The Friendship Bench was developed in Zimbabwe as a low-cost psychological intervention utilising problemsolving therapy (delivered by trained lay workers) and peer-to-peer support to address depression and other common mental disorders.
There is a strong evidence base for its use in urban LMIC settings.
Peer support groups meet every 1-2 weeks and focus on communal problem solving, and establishing income-generation activities (such as making bags).
Care for Child Development is a UNICEF package that helps families build stronger relationships and solve problems in caring for the child at home, through play and communication activities to stimulate children, through a series of age-appropriate interactive modules delivered by a lay worker using 'flash' cards.
It has been used in other African contexts and has good acceptability.
Educational and behaviour-change messages around better nutrition; play for children with SAM; stigma,HIV and gender-based violence; financial planning; causes of SAM; and health-seeking behaviours.
These have been developed with caregivers affected by SAM in a previous study, through a series of codesign workshops, ensuring these are contextually relevant.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Mortality.
Time Frame: 24 weeks post-randomisation
|
All-cause mortality.
|
24 weeks post-randomisation
|
Readmission to hospital.
Time Frame: 24 weeks post-randomisation
|
Overnight admission to a health facility for any reason.
This includes cases where there was a clinical plan to hospitalise the child, which was refused by the caregiver.
|
24 weeks post-randomisation
|
Failed nutritional recovery.
Time Frame: 24 weeks post-randomisation
|
Failed nutritional recovery is defined as either: i) Persistent WHZ<-2 or MUAC<12.5cm or bilateral pedal oedema at week 12; or ii) WHZ<-2 or MUAC<12.5cm or bilateral pedal oedema at any time between baseline and week 24 post-randomisation in a child who had previously recovered.
|
24 weeks post-randomisation
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in weight-for-height Z-score
Time Frame: 24 weeks post-randomisation
|
Change in weight-for-height Z-score between baseline and 24 weeks post-randomisation according to age- and-sex appropriate WHO reference standards.
|
24 weeks post-randomisation
|
Change in mid-upper arm circumference
Time Frame: 24 weeks post-randomisation
|
Change in size of mid-upper arm in centimetres between baseline and 24 weeks.
|
24 weeks post-randomisation
|
Change in weight-for-age Z-score
Time Frame: 24 weeks post-randomisation
|
Change in weight-for-age Z-score between baseline and 24 weeks post-randomisation according to age- and sex-appropriate WHO reference standards.
|
24 weeks post-randomisation
|
Change in height-for-age Z-score
Time Frame: 24 weeks post-randomisation
|
Change in height-for-age Z-score between baseline and 24 weeks post-randomisation according to age- and sex-appropriate WHO reference standards.
|
24 weeks post-randomisation
|
Number of participants with suspected or confirmed tuberculosis,pneumonia, diarrhoea or malaria
Time Frame: 24 weeks post-randomisation
|
Physician-diagnosed suspected or confirmed infection, as defined by WHO guidelines, between baseline and 24 weeks post-randomisation.
|
24 weeks post-randomisation
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Change in anthropometry: Weight-for-height Z score (WHZ)
Time Frame: 4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in WHZ between baseline and 4 weeks post-randomisation, and baseline and 12 weeks post-randomisation.
|
4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in anthropometry: Weight-for-age Z score (WAZ)
Time Frame: 4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in WAZ between baseline and 4 weeks post-randomisation, and baseline and 12 weeks post-randomisation.
|
4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in anthropometry: Height-for-age Z score (HAZ)
Time Frame: 4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in HAZ between baseline and 4 weeks post-randomisation, and baseline and 12 weeks post-randomisation.
|
4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in anthropometry: Mid-upper arm circumference (MUAC)
Time Frame: 4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in MUAC between baseline and 12 weeks post-randomisation.
|
4 weeks post-randomisation and 12 weeks post-randomisation
|
Change in caregiver mental health
Time Frame: 24 weeks post-randomisation
|
Change in Shona Symptom Questionnaire score (and proportion meeting cut-off score >8) between baseline and 24 weeks post-randomisation.
This is a widely used 10-item self-report questionnaire.
Each item is scored from 0-3, leading to a total score between 0-30, with higher scores indicating more severe depressive symptoms.
|
24 weeks post-randomisation
|
Concentration of lipid mediators/proteins
Time Frame: 12 weeks and 24 weeks post-randomisation
|
LC-MS measurement of fatty acids, acylcarnitines, polyamines, amino acids, glycolysis intermediates, TCA cycle intermediates, nucleotides, prostaglandins, serotonin, bile acids, lysophosphatidylcholines, phosphatidylcholines, cholesterol and derivatives, organic acids and tri/di/monoglycerides.
|
12 weeks and 24 weeks post-randomisation
|
Concentration of metabolites
Time Frame: 12 weeks and 24 weeks post-randomisation
|
Luminex measurement of Insulin, Insulin-like growth factor 1, leptin, ghrelin, cortisol, growth hormone, Glucagon-like peptide-1, Peptide YY, Monocyte chemoattractant protein-1, and Plasminogen activator inhibitor-1.
|
12 weeks and 24 weeks post-randomisation
|
Concentration of inflammatory mediators
Time Frame: 12 weeks and 24 weeks post-randomisation
|
Luminex measurement of chemokines, cytokines and circulating growth factors.
|
12 weeks and 24 weeks post-randomisation
|
Collaborators and Investigators
Sponsor
Collaborators
Study record dates
Study Major Dates
Study Start (Estimated)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Nutrition Disorders
- Malnutrition
- Child Nutrition Disorders
- Severe Acute Malnutrition
- Physiological Effects of Drugs
- Molecular Mechanisms of Pharmacological Action
- Anti-Infective Agents
- Nucleic Acid Synthesis Inhibitors
- Enzyme Inhibitors
- Antimetabolites
- Micronutrients
- Hypolipidemic Agents
- Lipid Regulating Agents
- Anti-Bacterial Agents
- Leprostatic Agents
- Cytochrome P-450 Enzyme Inducers
- Vitamins
- Cytochrome P-450 CYP3A Inducers
- Vitamin B Complex
- Antitubercular Agents
- Antibiotics, Antitubercular
- Cytochrome P-450 CYP2B6 Inducers
- Cytochrome P-450 CYP2C8 Inducers
- Cytochrome P-450 CYP2C19 Inducers
- Cytochrome P-450 CYP2C9 Inducers
- Fatty Acid Synthesis Inhibitors
- Rifampin
- Azithromycin
- Vitamin B 6
- Pyridoxine
- Isoniazid
Other Study ID Numbers
- 150522
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
IPD Sharing Time Frame
IPD Sharing Access Criteria
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
- SAP
- ICF
- ANALYTIC_CODE
- CSR
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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