Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Jul;20(3):e13641.
doi: 10.1111/mcn.13641. Epub 2024 Apr 16.

Effectiveness of a nonweight-based daily dosage of ready-to-use therapeutic food in children suffering from uncomplicated severe acute malnutrition: A nonrandomized, noninferiority analysis of programme data in Afghanistan

Paluku Bahwere  1 , Grace Funnell  2 , Ahmad Nawid Qarizada  2 , Sophie Woodhead  2 , Wilfred Bengnwi  2 , Minh Tram Le  2
Affiliations

Effectiveness of a nonweight-based daily dosage of ready-to-use therapeutic food in children suffering from uncomplicated severe acute malnutrition: A nonrandomized, noninferiority analysis of programme data in Afghanistan

Paluku Bahwere et al. Matern Child Nutr. 2024 Jul.

Abstract

Severe acute malnutrition (SAM) remains a major global public health problem. SAM cases are treated using ready-to-use therapeutic food (RUTF) at a dosage of ∼200 kcal/kg/day per the standard treatment protocol (STD). Emerging evidence on simplifications to the standard protocol, which among other adaptations, includes reducing the daily RUTF dosage, indicates that it is effective and safe for treating children with SAM. In response to a foreseen stock shortage of RUTF, the government of Afghanistan endorsed the temporary use of a modified treatment protocol in which the daily RUTF dosage was prescribed at 1000 kcal/day (irrespective of body weight) until the child achieved moderate acute malnutrition status (weight-for-height z-score ≥ -3 or mid-upper arm circumference [MUAC] ≥ 115 mm), at which point 500 kcal/day was prescribed until cured (modified treatment protocol [MTP]). In this paper, we report the results of this nonweight-based daily RUTF dosage experience. Data of 2042 children with SAM, treated using either the STD protocol (n = 269) or the MTP protocol (n = 1773) from August 2019 to March 2021 in five provinces, were analyzed. The per-protocol analyses confirmed noninferiority of MTP protocol when compared to STD protocol for recovery rate [93.3% vs. 90.2%; ∆ (95% confidence interval, CI) = 3.1 (-0.9; 7.2) %] and length-of-stay [82.6 vs. 75.6 days; ∆ (95% CI) = 6.9 (3.3; 10.5) days], considering the margin of noninferiority of -10% and +14 days, respectively. Weight gain velocity was smaller in the MTP protocol group than in the STD protocol group [3.7 (1.7) vs. 5.2 (2.9) g/kg/day; ∆ (95% CI) = -1.5 (-1.8, -1.2); p < 0.001]. The STD group had a significantly higher mean than the MTP group for absolute MUAC gain [∆ (95% CI) = 1.7 (1.0; 2.3) mm; p < 0.001] and the MUAC velocity [∆ (95% CI) = 0.29 (0.20; 0.37) mm/week; p < 0.001]. Our results confirm the noninferiority of a nonweight-based daily dosage and support the endorsement of this modification as an alternative to the standard protocol in resource-constrained contexts.

Keywords: Afghanistan; community‐based; effectiveness; management of acute malnutrition; noninferiority; ready‐to‐use therapeutic food; reduced dosage; severe acute malnutrition; simplified protocol; single dosage; wasting.

PubMed Disclaimer

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Study inclusion flowchart. ComPAS, Combined Protocol for Acute Malnutrition Study; MAM, moderate acute malnutrition; IMAM, Management of Acute Malnutrition; RUTF, ready‐to‐use therapeutic food; SAM, severe acute malnutrition.
Figure 2
Figure 2
Noninferiority graph of the comparison of recovery rates. CI, confidence interval.
Figure 3
Figure 3
Difference in the length of stay: noninferiority analysis. CI, confidence interval.
Figure 4
Figure 4
(a, b) Weight and mid‐upper arm circumference (MUAC) trajectories according to treatment group. MTP, modified treatment protocol; STD, standard treatment protocol.
See this image and copyright information in PMC

References

    1. Action Against Hunger USA . (2021). State of the evidence 2021: Modifications aiming to optimize acute malnutrition management in children under five.
    1. Alvarez, J. L. , Dent, N. , Browne, L. , Myatt, M. , & Briend, A. (2016). Putting child kwashiorkor on the map (CMAM Forum Technical Brief). UNICEF, ACF, and ECHO (via the CMAM Forum).
    1. Ashworth, A. (2006). Efficacy and effectiveness of community‐based treatment of severe malnutrition. Food and Nutrition Bulletin, 27(3 Suppl), S24–S48. - PubMed
    1. Bagriansky, J. , Champa, N. , Pak, K. , Whitney, S. , & Laillou, A. (2014). The economic consequences of malnutrition in Cambodia, more than 400 million US dollar lost annually. Asia Pacific Journal of Clinical Nutrition, 23(4), 524–531. 10.6133/apjcn.2014.23.4.08 - DOI - PubMed
    1. Bahwere, P. , Balaluka, B. , Wells, J. C. , Mbiribindi, C. N. , Sadler, K. , Akomo, P. , Dramaix‐Wilmet, M. , & Collins, S. (2016). Cereals and pulse‐based ready‐to‐use therapeutic food as an alternative to the standard milk‐ and peanut paste‐based formulation for treating severe acute malnutrition: A noninferiority, individually randomized controlled efficacy clinical trial. The American Journal of Clinical Nutrition, 103(4), 1145–1161. 10.3945/ajcn.115.119537 - DOI - PubMed