Ready-to-Use Therapeutic Food (RUTF) Containing Low or No Dairy Compared to Standard RUTF for Children with Severe Acute Malnutrition: A Systematic Review and Meta-Analysis

Abstract

Ready-to-use therapeutic food (RUTF) containing less dairy may be a lower-cost treatment option for severe acute malnutrition (SAM). The objective was to understand the effectiveness of RUTF containing alternative sources of protein (nondairy), or <50% of protein from dairy products, compared with standard RUTF in children with SAM. The Cochrane Library, MEDLINE, Embase, CINAHL, and Web of Science were searched using terms relating to RUTF. Studies were eligible if they included children with SAM and evaluated RUTF with <50% of protein from dairy products compared with standard RUTF. Meta-analysis and meta-regression were completed to assess the effectiveness of intervention RUTF on a range of child outcomes. The quality of the evidence across outcomes was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A total of 5868 studies were identified, of which 8 articles of 6 studies met the inclusion criteria evaluating 7 different intervention RUTF recipes. Nondairy or lower-dairy RUTF showed less weight gain (standardized mean difference: -0.20; 95% CI: -0.26, -0.15; P < 0.001), lower recovery (relative risk ratio: 0.93; 95% CI: 0.87, 1.00; P = 0.046), and lower weight-for-age z scores (WAZ) near program discharge (mean difference: -0.10; 95% CI: -0.20, 0.0; P = 0.047). Mortality, time to recovery, default (consecutive absences from outpatient therapeutic feeding program visits), nonresponse, and other anthropometric measures did not differ between groups. The certainty of evidence was high for weight gain and ranged from very low to moderate for other outcomes. RUTF with lower protein from dairy or dairy-free RUTF may not be as effective as standard RUTF for treatment of children with SAM based on weight gain, recovery, and WAZ evaluated using meta-analysis, although further research is required to explore the potential of alternative formulations. This review was registered at https://www.crd.york.ac.uk/prospero/ as CRD42020160762.

Keywords: CMAM; DIAAS; PDCAAS; meta-analysis; meta-regression; network meta-analysis; protein quality; severe acute malnutrition.

FIGURE 1

Study flow diagram of articles included and excluded in this systematic review of RUTF containing low or no dairy for children with SAM. RUTF, ready-to-use therapeutic food; SAM, severe acute malnutrition.

FIGURE 2

Meta-analysis of the rate of weight gain in grams per kilogram of body weight per day with pooled (A) or separate (B) intervention arms in studies evaluating RUTF containing low or no dairy for children with severe acute malnutrition. RUTF <50% represents RUTF with <50% of protein coming from dairy products. FSMS, milk-free soya, maize, and sorghum; MSMS, milk, soya, maize, and sorghum; REML, restricted maximum likelihood; RUTF, ready-to-use therapeutic food.

FIGURE 3

Cumulative meta-analysis of the rate of weight gain in grams per kilogram of body weight per day in studies evaluating ready-to-use therapeutic food containing low or no dairy for children with severe acute malnutrition. FSMS, milk-free soya, maize, and sorghum; MSMS, milk, soya, maize, and sorghum; REML, restricted maximum likelihood.

FIGURE 4

Meta-analysis of recovery in studies evaluating RUTF containing low or no dairy for children with severe acute malnutrition. RUTF <50% represents RUTF with <50% of protein coming from dairy products. REML, restricted maximum likelihood; RUTF, ready-to-use therapeutic food.

FIGURE 5

Meta-analysis of mortality in studies evaluating RUTF containing low or no dairy for children with severe acute malnutrition. RUTF <50% represents RUTF with <50% of protein coming from dairy products. REML, restricted maximum likelihood; RUTF, ready-to-use therapeutic food.

FIGURE 6

Meta-analysis of default in studies evaluating RUTF containing low or no dairy for children with severe acute malnutrition. RUTF <50% represents RUTF with <50% of protein coming from dairy products. REML, restricted maximum likelihood; RUTF, ready-to-use therapeutic food.

FIGURE 7

Meta-analysis of nonresponse in studies evaluating RUTF containing low or no dairy for children with severe acute malnutrition. RUTF <50% represents RUTF with <50% of protein coming from dairy products. REML, restricted maximum likelihood; RUTF, ready-to-use therapeutic food.

FIGURE 8

Meta-regression of the relation between protein digestibility–corrected amino acid score (A) and digestible indispensable amino acid score (B) and the standardized mean difference in weight gain, respectively, in studies evaluating ready-to-use therapeutic food containing low or no dairy for children with severe acute malnutrition. The bubble sizes are proportional to the inverse of the variance for the standardized mean difference in weight gain. The solid line represents the linear prediction for the means of weight gain as a function of each of the protein-quality scores.