Effect of a package of health and nutrition services on sustained recovery in children after moderate acute malnutrition and factors related to sustaining recovery: a cluster-randomized trial

Abstract

Background: Children who recover from moderate acute malnutrition (MAM) have high rates of relapse in the year after nutritional recovery. Interventions to decrease these adverse outcomes are needed to maximize the overall effectiveness of supplemental feeding programs (SFPs).Objective: We evaluated the effectiveness of a package of health and nutrition interventions on improving the proportion of children who sustained recovery for 1 y after MAM treatment. We further explored factors related to sustained recovery.Design: We conducted a cluster-randomized clinical effectiveness trial involving rural Malawian children aged 6-62 mo who were enrolled on discharge from an SFP for MAM. We enrolled 718 children at 10 control sites and 769 children at 11 intervention sites. In addition to routine health and nutrition counseling, the intervention group received a package of health and nutrition interventions that consisted of a lipid nutrient supplement, deworming medication, zinc supplementation, a bed net, and malaria chemoprophylaxis. A survival analysis was used to determine the effectiveness of the intervention as well as to identify factors associated with sustained recovery.Results: Of 1383 children who returned for the full 12-mo follow-up period, 407 children (56%) and 347 children (53%) sustained recovery in the intervention and control groups, respectively. There was no significant difference in relapse-free survival curves between the treatment and control groups (P = 0.380; log-rank test). The risk factors for relapse or death after initial recovery were a smaller midupper arm circumference on SFP admission (P = 0.01) and discharge (P < 0.001), a lower weight-for-height z score on discharge (P < 0.01), and the receipt of ready-to-use supplementary food as opposed to ready-to-use therapeutic food during treatment (P < 0.05).Conclusion: The provision of a package of health and nutrition services in addition to traditional SFP treatment has no significant effect on improving sustained recovery in children after treatment of MAM. This trial was registered at clinicaltrials.gov as NCT02351687.

Keywords: moderate acute malnutrition; ready-to-use supplementary food; relapse; supplemental feeding program; sustained recovery; wasting.

FIGURE 1

Flow of participants through the cluster-randomized controlled clinical trial. LTFU, lost to follow-up; MAM, moderate acute malnutrition; SAM, severe acute malnutrition; SFP, supplementary feeding program.

FIGURE 2

Percentage of total relapses to MAM or SAM for control and intervention groups by number of months from initial SFP discharge. MAM, moderate acute malnutrition; SAM, severe acute malnutrition; SFP, supplementary feeding program.

FIGURE 3

Relapse-free survival curves for 12 mo after supplementary feeding program discharge for control and intervention groups that were estimated with the use of the Kaplan-Meier method. Relapse-free survival was defined as free from relapse to moderate acute malnutrition, the development of severe acute malnutrition, or death. Difference between intervention and control group curves, P = 0.380 (log-rank test).