An Optimized Dose of Therapeutic Feeding Results in Noninferior Growth in Midupper Arm Circumference Compared with a Standard Dose in Children in Sierra Leone Recovering from Acute Malnutrition

Kevin B Stephenson, Sophia E Agapova, D Taylor Hendrixson, Aminata Shamit Koroma, Mark J Manary, Kevin B Stephenson, Sophia E Agapova, D Taylor Hendrixson, Aminata Shamit Koroma, Mark J Manary

Abstract

Background: Ready-to-use therapeutic food (RUTF) given at 175 kcal/kg per day throughout severe acute malnutrition (SAM) treatment is recommended. Some treatment programs have diverged from this paradigm in 2 ways: reducing the supplemental food dose to 75 kcal/kg per day when midupper arm circumference (MUAC) is >11.4 cm or simplifying to a fixed-dose regimen.

Objective: The objective was to determine if transitioning to an optimized, fixed-dose supplementary feeding regimen during SAM treatment when MUAC is >11.4 cm would result in noninferior gain in MUAC compared with standard treatment.

Methods: Using data from 2 clinical trials conducted in Sierra Leone, a retrospective dual-cohort study was performed. The 2 cohorts included children with SAM who had improved to meet criteria for moderate acute malnutrition (MAM). The standard dose cohort continued to receive weight-based RUTF at 175 kcal/kg per day, while the optimized dose cohort received fixed-dose, 500 kcal/d of supplementary feeding. The primary outcome was a noninferiority margin of 1 mm of MUAC after 4 wk of treatment, while secondary outcomes included rate of anthropometric changes as well as time-to-relapse to SAM or death.

Results: MUAC after 4 wk was noninferior (Δ: -0.1 mm; 95% CI: -0.05, 0.03; inferiority rejected P = 0.008). Rates of weight gain and MUAC gain were the same in the optimized-dose and standard-dose groups, whereas the rate of length gain was slower in the optimized-dose cohort. Time-to-relapse to SAM or death was not different (HR: 1.05; P = 0.71).

Conclusions: This study supports the practice of treating children with SAM who have recovered to meet criteria for MAM with a reduced and fixed-dose regimen of RUTF. The results also raise the question of whether this strategy might adversely impact linear growth during SAM treatment.

Keywords: child; community-based management of acute malnutrition; midupper arm circumference; moderate acute malnutrition; ready-to-use therapeutic food; severe acute malnutrition; stunting; supplementary feeding; wasting.

© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.

Figures

FIGURE 1
FIGURE 1
Mean MUAC by week of treatment and treatment group with 95% CIs, adjusted for baseline MUAC using ANCOVA. MUAC, midupper arm circumference.
FIGURE 2
FIGURE 2
Kaplan-Meier method showing the proportion alive without relapse by week of treatment and treatment group, with shaded 95% CIs (Mantel-Haenszel HR). MUAC, midupper arm circumference.

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