NEW THIS MONDAY: TWO COCHRANE REVIEWS ON THERAPEUTIC AND SUPPLEMENTARY FEEDING

Sunday, 16th of June 2013

TWO COCHRANE REVIEWS ON THERAPEUTIC AND SUPPLEMENTARY FEEDING
READY TO USE THERAPEUTIC FOOD AS HOME BASED TREATMENT FOR SEVERELY MALNOURISHED CHILDREN BETWEEN SIX MONTHS AND FIVE YEARS OLD

http://summaries.cochrane.org/CD009000/ready-to-use-therapeutic-food-as-home-based-treatment-for-severely-malnourished-children-between-six-months-and-five-years-old

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Ready-to-use therapeutic food as home-based treatment for severely malnourished children between six months and five years old New

Schoonees A, Lombard M, Musekiwa A, Nel E, Volmink J

Published Online:

June 6, 2013

Malnourished children have a higher risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home treatment may be better. Home treatment can be food prepared by the carer, such as flour porridge, or commercially manufactured food such as ready-to-use therapeutic food (RUTF). RUTF is made according to a standard, energy-rich composition defined by the World Health Organization. Typically, RUTF is made from full-fat milk powder, sugar, peanut butter, vegetable oil, and vitamins and minerals. The benefits of RUTF include a low moisture content, a long shelf life without needing refrigeration and that it requires no preparation.

We assessed RUTF compared with a standard diet (flour porridge) for treatment, and examined whether a cheaper RUTF treatment (smaller amounts or using cheaper ingredients) can achieve similar health outcomes in severely malnourished children between six months and five years old. The main health outcomes that we investigated were recovery from severe malnutrition, relapse (getting more malnourished), death and weight gain.

We carried out a comprehensive search of trials up to April 2013 and found four studies. All studies were conducted in Malawi, with one small study that included children infected with human immunodeficiency virus (HIV). The extent to which results of the studies can be believed based on how the studies were done was poor for three studies, while the fourth study had stronger methods. Because of the sparse data for HIV, we report the main results for all children together.

For RUTF given as a total dietary replacement compared to flour porridge, we found three studies with 599 children. RUTF may improve recovery slightly, but we do not know whether

RUTF improves relapse, death or weight gain as the quality of evidence was very low.

When comparing RUTF used as a supplement to their ordinary diet with RUTF used as a total dietary replacement, we found two small studies with 210 children. For recovery, relapse, death and weight gain, the quality of evidence was very low and, therefore, we do not know what the effects are.

When comparing a cheaper RUTF containing less milk powder (10%) with standard RUTF (25% milk powder), we found one study that randomised 1874 children. For recovery, there probably was little or no difference between the groups. RUTF containing less milk powder may lead to slightly more children relapsing and to less weight gain than standard RUTF. We do not know whether the cheaper RUTF reduces the number of children dying.

Current evidence is limited and, therefore, we cannot conclude that there is a difference between RUTF and flour porridge as home treatment for severely malnourished children, or between RUTF given in different daily amounts or with different ingredients. Either RUTF or standard diet such as flour porridge can be used to treat severely malnourished children at home. Decisions should be based on availability, cost and practicality. In order to determine the effects of RUTF, more high-quality studies are needed.

Background:

Malnourished children have a higher risk of death and illness. Treating severe acute malnourished children in hospitals is not always desirable or practical in rural settings, and home treatment may be better. Home treatment can be food prepared by the carer, such as flour porridge, or commercially manufactured food such as ready-to-use therapeutic food (RUTF). RUTF is made according to a standard, energy-rich composition defined by the World Health Organization (WHO). The benefits of RUTF include a low moisture content, long shelf life without needing refrigeration and that it requires no preparation.

Objectives:

To assess the effects of home-based RUTF on recovery, relapse and mortality in children with severe acute malnutrition.

Search strategy:

We searched the following electronic databases up to April 2013: Cochrane Central Register of Clinical Trials (CENTRAL), MEDLINE, MEDLINE In-process, EMBASE, CINAHL, Science Citation Index, African Index Medicus, LILACS, ZETOC and three trials registers. We also contacted researchers and clinicians in the field and handsearched bibliographies of included studies and relevant reviews.

Selection criteria:

We included randomised and quasi-randomised controlled trials where children between six months and five years of age with severe acute malnutrition were treated at home with RUTF compared to a standard diet, or different regimens and formulations of RUTFs compared to each other. We assessed recovery, relapse and mortality as primary outcomes, and anthropometrical changes, time to recovery and adverse outcomes as secondary outcomes.

Data collection and analysis:

Two review authors independently assessed trial eligibility using prespecified criteria, and three review authors independently extracted data and assessed trial risk of bias.

Main results:

We included four trials (three having a high risk of bias), all conducted in Malawi with the same contact author. One small trial included children infected with human immunodeficiency virus (HIV). We found the risk of bias to be high for the three quasi-randomised trials while the fourth trial had a low to moderate risk of bias. Because of the sparse data for HIV, we reported below the main results for all children together.

RUTF meeting total daily requirements versus standard diet

When comparing RUTF with standard diet (flour porridge), we found three quasi-randomised cluster trials (n = 599). RUTF may improve recovery slightly (risk ratio (RR) 1.32; 95% confidence interval (CI) 1.16 to 1.50; low quality evidence), but we do not know whether RUTF improves relapse, mortality or weight gain (very low quality evidence).

RUTF supplement versus RUTF meeting total daily requirements

When comparing RUTF supplement with RUTF that meets total daily nutritional requirements, we found two quasi-randomised cluster trials (n = 210). For recovery, relapse, mortality and weight gain the quality of evidence was very low; therefore, the effects of RUTF are unknown.

RUTF containing less milk powder versus standard RUTF

When comparing a cheaper RUTF containing less milk powder (10%) versus standard RUTF (25% milk powder), we found one trial that randomised 1874 children. For recovery, there was probably little or no difference between the groups (RR 0.97; 95% CI 0.93 to 1.01; moderate quality evidence). RUTF containing less milk powder may lead to slightly more children relapsing (RR 1.33; 95% CI 1.03 to 1.72; low quality evidence) and to less weight gain (mean difference (MD) -0.5 g/kg/day; 95% CI -0.75 to -0.25; low-quality evidence) than standard RUTF. We do not know whether the cheaper RUTF improved mortality (very low quality evidence).

Authors conclusions:

Given the limited evidence base currently available, it is not possible to reach definitive conclusions regarding differences in clinical outcomes in children with severe acute malnutrition who were given home-based ready-to-use therapeutic food (RUTF) compared to the standard diet, or who were treated with RUTF in different daily amounts or formulations. For this reason, either RUTF or flour porridge can be used to treat children at home depending on availability, affordability and practicality. Well-designed, adequately powered pragmatic randomised controlled trials of HIV-uninfected and HIV-infected children with severe acute malnutrition are needed.

This record should be cited as:

Schoonees A, Lombard M, Musekiwa A, Nel E, Volmink J. Ready-to-use therapeutic food for home-based treatment of severe acute malnutrition in children from six months to five years of age. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD009000. DOI: 10.1002/14651858.CD009000.pub2

Assessed as up to date:

May 30, 2013

PROVIDING EXTRA FOOD FOR CHILDREN UNDER FIVE YEARS OF AGE IN LOW AND MIDDLE INCOME COUNTRIES

Sguassero Y, de Onis M, Bonotti AM, Carroli G

Published Online:

June 13, 2012

Undernutrition is one of the underlying causes of childhood illness and death in low- and middle-income countries. Providing extra food to children or families beyond what they normally have at home is an intervention aimed at supporting the nutritional wellbeing of the target population. We included eight studies where the participants were randomly assigned to two groups: one group received the extra food and the other group was a control, either receiving no food or food with very low nutritional content. Although the impact of supplementary feeding on child growth appeared to be negligible, it is not possible to draw any conclusions until we have studies that involve larger numbers and do not allow assessors to know who is receiving the intervention. Although it is difficult to determine whether community-based supplementary feeding helps to promote the growth of children from birth to five years in low- and middle-income countries, it is obviously vital to continue to provide food, health care and sanitation to those who need them.

Background:

Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non-governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005.

Objectives:

To evaluate the effectiveness of community-based supplementary feeding for promoting the physical growth of children under five years of age in LMIC.

Search strategy:

For this updated review we searched the following databases on 31 January 2011: CENTRAL (The Cochrane Library), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years).

Selection criteria:

Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC.

Data collection and analysis:

Two review authors independently extracted and analysed the data.

Main results:

We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the childrens age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking.

Authors conclusions:

The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children.

This record should be cited as:

Sguassero Y, de Onis M, Bonotti AM, Carroli G. Community-based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD005039. DOI: 10.1002/14651858.CD005039.pub3

Assessed as up to date:

July 31, 2011