Hypoallergenic and Anti-inflammatory Feeds in Malawian Children With Severe Acute Malnutrition (SAM)

Study Overview
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Brief Summary
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Children with complicated severe acute malnutrition (SAM), such as inability to take adequate feeds, infection and diarrhoea, require in-patient management. Despite following a well-established World Health Organisation (WHO) protocol, outcomes are poor. Case fatality often exceeds 20%. Amongst survivors discharged home, many subsequently die, have long-term poor growth or recurrence of SAM. It has long been recognized that children with SAM have intestinal inflammation and that this persists despite management according to WHO guidelines. The inflammation is thought to result from increased exposure to microbial pathogens in the gut in areas with poor sanitation. The damaged lining of the intestine impairs food digestion and absorption, likely allows gut bacteria to enter the blood stream to cause sepsis and also exposes the gut immune cells to microbial and food antigens causing the inflammation to persist. Failure to treat the intestinal inflammation is likely to contribute to the poor response to treatment and poor long-term outcomes in many children with SAM. The intestinal inflammation seen in SAM is very similar to that which occurs in food intolerance (e.g. intolerance to cow's milk protein) and inflammatory bowel disease. In these conditions, the inflammation is treated very effectively with hypoallergenic (elemental) and anti-inflammatory (polymeric) formulas. These are nutritionally complete feeds that have a similar composition to the feeds used for nutritional rehabilitation in SAM. We aim to undertake a pilot study to see if an elemental and/or polymeric formula are tolerated by children with SAM and help to reduce intestinal inflammation. We also aim to learn more about the intestinal inflammation in general that occurs in SAM by observing carefully the effect of these specific formulae and to do in-depth metabolic analyses.

Detailed Description
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We will study children admitted to the Moyo ward at the Queen Elizabeth Central Hospital, Blantyre, Malawi with complicated SAM. Following informed consent, children will be recruited once they have completed the initial stabilisation phase of management and enter the transition phase to nutritional rehabilitation. They will be randomly allocated to one of 3 arms, either 1) standard feeds (F-100 and/or ready-to-use therapeutic feeds), 2) a polymeric therapeutic formula or 3) an elemental therapeutic formula. The alternative feeds will be supplemented with micronutrients to be equivalent in composition to F-100. All children will remain admitted to the ward for 2 weeks and receive exclusively the allocated formula. All other aspects of the management of SAM will follow current practice based on WHO guidelines.

Official Title
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Hypoallergenic and Anti-inflammatory Feeds to Treat Intestinal Inflammation in Malawian Children With Severe Acute Malnutrition: A Pilot Randomized Controlled Clinical Trial (SAM)

Conditions
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Severe Malnutrition, Enteritis

Intervention / Treatment
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* Dietary Supplement: Polymeric formula
* Dietary Supplement: Elemental formula
* Other: Standard management


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age 6-23 months SAM diagnosed according to WHO criteria: (Weight-for-height z score <-3 and/or mid-upper arm circumference <11.5 cms and/or nutritional oedema) Admitted to hospital because of SAM with medical complications or fails an appetite test Completed stabilization phase and entering the second phase in refeeding; the transition Phase Willing to stay on the ward for 2 weeks after the stabilization phase (travel expenses will be provided) Exclusion Criteria: Specific cause of malnutrition (e.g. cerebral palsy, other organ disease) Sibling admitted with SAM at the same time Unwilling to stay on ward for at least 2 weeks Declined to give consent Participating in another study

Ages Eligible for Study
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Minimum Age: 6 Months
Maximum Age: 23 Months

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Standard management<br>Standard management consists of F-100 and/or ready-to-use therapeutic food (RUTF) according to usual practice for 14 days | Other: Standard management<br>* Standard management with F-100 and/or RUTF<br>|
| Experimental: Polymeric formula<br>Exclusive polymeric formula supplemented with micronutrients in equivalent volume to F-100 for 14 days | Dietary Supplement: Polymeric formula<br>* Polymeric formulae are recommended in the management of inflammatory bowel disease in children<br>|
| Experimental: Elemental formula<br>Exclusive elemental formula supplemented with micronutrients in equivalent volume to F-100 for 14 days | Dietary Supplement: Elemental formula<br>* Elemental formulae are recommended in cow's milk and other food intolerances in children.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in faecal calprotectin | Validated marker of intestinal inflammation | 14 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Days with diarrhoea | number of days with 3 or more loose/watery stools | 1-14 days | 
| Weight gain | change in weight in g/kg/day | 1-14 days | 
| Episodes of sepsis | Clinical diagnosis | 1-14 days | 
| Death | number of children who die | 1-14 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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severe acute malnutrition, polymeric therapeutic formula, elemental therapeutic formula