An optimized dose of therapeutic feeding results in noninferior growth in midupper arm circumference compared with a standard dose in children in Sierra Leone recovering from acute malnutrition

Authors: STEPHENSON, KEVIN - Washington University; AGAPOVA, SOPHIA - Washington University; HENDRIXSON, D. TAYLOR - Washington University; KOROMA, AMINATA SHAMIT - Ministry Of Health & Sanitation; MANARY, MARK - Washington University

Submitted to: Current Developments in Nutrition
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 1/28/2021
Publication Date: 2/2/2021
Citation: Stephenson, K.B., Agapova, S.E., Hendrixson, D., Koroma, A., Manary, M.J. 2021. An optimized dose of therapeutic feeding results in noninferior growth in midupper arm circumference compared with a standard dose in children in Sierra Leone recovering from acute malnutrition. Current Developments in Nutrition. 5(2):nzab007. https://doi.org/10.1093/cdn/nzab007.
DOI: https://doi.org/10.1093/cdn/nzab007

Interpretive Summary: When children are treated for severe malnutrition they are given large amounts of therapeutic food until they fully recover, which prevents them from eating their normal diet and is expensive. This study compared two different doses of therapeutic food given to malnourished children and showed that a dose that decreases as the child recovers allows for a similar rate of recovery as the continuous high dose. This offers programs treating severely malnourished children the opportunity to modify the dose of therapeutic food as children improve.

Technical Abstract: Ready-to-use therapeutic food (RUTF) given at 175 kcal/kg per day throughout severe acute malnutrition (SAM) treatment is recommended. Some treatment programs have diverged from this paradigm in 2 ways: reducing the supplemental food dose to 75 kcal/kg per day when midupper arm circumference (MUAC) is >11.4 cm or simplifying to a fixed-dose regimen. The objective was to determine if transitioning to an optimized, fixed-dose supplementary feeding regimen during SAM treatment when MUAC is >11.4 cm would result in noninferior gain in MUAC compared with standard treatment. Using data from 2 clinical trials conducted in Sierra Leone, a retrospective dual-cohort study was performed. The 2 cohorts included children with SAM who had improved to meet criteria for moderate acute malnutrition (MAM). The standard dose cohort continued to receive weight-based RUTF at 175 kcal/kg per day, while the optimized dose cohort received fixed-dose, 500 kcal/d of supplementary feeding. The primary outcome was a noninferiority margin of 1 mm of MUAC after 4 wk of treatment, while secondary outcomes included rate of anthropometric changes as well as time-to-relapse to SAM or death. MUAC after 4 wk was noninferior (delta: -0.1 mm; 95% CI: -0.05, 0.03; inferiority rejected P = 0.008). Rates of weight gain and MUAC gain were the same in the optimized-dose and standard-dose groups, whereas the rate of length gain was slower in the optimized-dose cohort. Time-to-relapse to SAM or death was not different (HR: 1.05; P = 0.71). This study supports the practice of treating children with SAM who have recovered to meet criteria for MAM with a reduced and fixed-dose regimen of RUTF. The results also raise the question of whether this strategy might adversely impact linear growth during SAM treatment.