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Moderate Acute Malnutrition (MAM) Contributes to 10% of childhood deaths under five. Field Exchange 2007; 31: 3. Moderate Acute Malnutrition (MAM) A n ineffective standard of care. http://www.wfp.org/nutrition/special-nutritional-products :: accessed 6 May 2012.
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Moderate Acute Malnutrition (MAM) Contributes to 10% of childhood deaths under five Field Exchange 2007; 31: 3
Moderate Acute Malnutrition (MAM) An ineffective standard of care http://www.wfp.org/nutrition/special-nutritional-products :: accessed 6 May 2012
Improving the Standard of Care Parallel approaches to replacing CSB Journal of Nutrition 2009; 139: 773 World Food Programme http://www.nutriset.fr/en/product-range/produit-par-produit/plumpy-sup.html :: accessed 6 May 2012
Supplementary Foods for Moderate Acute MalnutritionProspective, randomized, investigator-blinded clinical effectiveness trial Population :: Children 6-59 months old with moderate acute malnutrition (MAM) who qualify for community-based therapy (i.e., demonstrate an appetite and a reliable caretaker) -3 < Weight-for-height Z-score (WHZ) < -2 without edema Within walking distance of one of 18 rural clinic sites in southern Malawi Exclusions :: obvious chronic debilitating illness (excluding HIV & TB); recently enrolled in a therapeutic feeding program for acute malnutrition (inpatient or outpatient) Intervention :: One of two untested supplementary foods at a dose of 75 kcal/kg/d CSB++ developed by World Food Programme, manufactured in Malawi :: $0.16/d 58% maize flour, 20% de-hulled soy flour, 9% sugar, 8% milk powder, 3% oil, multivitamin mix Plumpy’Sup® developed and manufactured by Nutriset in France :: $0.38/d Peanut paste, sugar, vegetable fat, whey, soy protein isolates, maltodextrin, cocoa, multivitamin mix “Soy/whey RUSF” Comparison :: Soy-peanut ready-to-use-supplementary food (RUSF) manufactured in Malawi :: $0.22/d Peanut paste, sugar, oil, extruded soy flour, multivitamin mix (no animal source proteins) “Soy RUSF” Outcomes Primary :: adverse effects; nutritional recovery (WHZ > -2); mortality Secondary :: time to recovery; growth parameters (gains in height, weight, MUAC)
Supplementary Foods for Moderate Acute MalnutritionPrimary Outcomes p=0.0289 RR 1.56 (1.05 - 2.31) 2.4% difference (0.3% - 4.5%) p=0.2641 RR 0.98 (0.94 - 1.02) 1.8% difference (-1.3% - 5.0%) p=0.9430 RR 1.00 (0.97 - 1.04) 0.2% difference (-2.8% - 3.2%) p=0.2352 RR 1.02 (0.99 - 1.06) 2.0% difference (-1.1% - 5.1%)
Supplementary Foods for Moderate Acute MalnutritionSummary of findings • Primary Outcomes • No adverse reactions to study foods • Recovery and Mortality • Contrary to all previous experience with fortified blended flours, CSB++ proved comparable to ready-to-use supplementary food (RUSF) products • Locally-produced RUSF without animal source protein (soy RUSF) comparable to commercial product with animal source protein (soy/whey RUSF) • Secondary Findings • Children receiving CSB++ • …took two days longer to recover • …had less weight gain and MUAC gain (but comparable height gain) • …were slightly more likely to progress to marasmus • HIV remains the strongest risk factor for failure to recover from MAM • ART insufficient to make up the difference • Default rate of only 1.3% • Exceptionally low compared to prior studies and operational programs
Supplementary Foods for Moderate Acute MalnutritionDifferences between CSB and CSB++ • Increased energy density due to added oil, sugar, milk powder • More phosphorus (28%), potassium (49%), vitamin B6 (316%), vitamin B12 (121%), vitamin C (141%), vitamin D (115%), zinc (43%), riboflavin (62%) • Addition of vitamin K (113 g / 100 g) and pantothenic acid (7.4 mg / 100 g) • Tighter specifications regarding aflatoxin and coliform contamination • Reduced anti-nutrient content by including less soy beans and maize and by dehulling soy beans • Animal source food included (milk powder)
Supplementary Foods for Moderate Acute MalnutritionA paradigm shift • Cost comparison of supplementary foods studied • CSB++ :: $0.03 per 100 kcal • Soy RUSF :: $0.04 per 100 kcal • Soy/whey RUSF :: $0.07 per 100 kcal • Operational concerns about fortified blended flours :: the old dogma • Requires cooking (water, firewood, dishes) :: may discourage preparation and increase spoilage • Similar in taste and appearance to staple foods :: may encourage sharing • Low energy density compared to RUSF :: requires children to eat large volumes of food • Typical programs scoop flour out of 25-50 kg bags into family containers, whereas this study provided CSB++ in sealed 250 g plastic bags (1-2 days ration) :: may have led to decreased contamination and spillage and promoted the understanding that CSB++ is a medicinal food
Supplementary Foods for Moderate Acute MalnutritionHIV* as a strong predictor of failure to recover p = 0.0090 RR 1.38 (1.01-1.88) p = 0.0224 P < 0.0001