Optimising the management of acute malnutrition
Authors: Richard Mbusa Kambale, Isia Nancy Francisca
Journal: The Lancet Global Health (2022)

Acute malnutrition affects 47 million children aged under 5 years and contributes to nearly 1 million children's deaths annually worldwide. Africa and Asia bear 96% of the global burden of acute malnutrition.1UNICEFWHOInternational Bank for Reconstruction and Development/The World BankLevels and trends in child malnutrition: key findings of the 2021 edition of the joint child malnutrition estimates. United Nations Children's Fund, New York, NY2021Google Scholar, 2UN IGMELevels & trend in child mortality: estimates developed by the UN Inter-agency Group for for Child Mortality Estimation.https://reliefweb.int/sites/reliefweb.int/files/resources/Levels-and-trends-in-child-mortality-IGME-English_2021.pdfDate: 2021Date accessed: February 14, 2022Google Scholar For decades, all children with acute malnutrition were treated as inpatients with fortified milk formulas. In 2007, with the introduction and widespread acceptance of ready-to-use therapeutic foods (RUTF) and ready-to-use supplementary foods (RUSF), a Community Management of Acute Malnutrition (CMAM) programme was endorsed by WHO and UN.3WHOWorld Food ProgrammeUN System Standing Comittee on NutritionUNICEFCommunity-based management of severe acute malnutrition.https://apps.who.int/iris/handle/10665/44295Date: 2007Date accessed: February 14, 2022Google Scholar Thereby children with uncomplicated severe acute malnutrition are treated in the outpatient therapeutic programme with RUTF, whereas children with moderate acute malnutrition are managed in the outpatient supplementary feeding programme with RUSF.4Ministère de la Santé PubliqueProtocole national de Prise en Charge Intégrée de la Malnutrition Aigüe, PCIMA, République Démocratique du Congo.https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/pcima_rdc_15_12_2015_version_mai_2016_13_janv_2017.pdfDate: 2016Date accessed: February 14, 2022Google Scholar Several low-income and middle-income countries (LMICs), including the Democratic Republic of the Congo, currently use this CMAM approach. Unfortunately, due to the underfunding of these programmes, they are hampered by many frequent stockouts of nutritional products, mainly due to their high cost. Consequently, global access to acute malnutrition treatment remains low (<20%).5No Wasted LivesAccelerating action for children with acute malnutrition.https://static1.squarespace.com/static/58da81cdd1758e39ca705526/t/5a7adf8171c10b8aa3b4462f/1518002053092/No+Wasted+Lives+Brochure+2018.pdfDate: 2018Date accessed: February 14, 2022Google Scholar In this issue of The Lancet Global Health, Cécile Cazes and colleagues6Cazes C Phelan K Hubert V et al.Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trial.Lancet Glob Health. 2022; 10: e510-e520Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar assess whether a single protocol for moderate acute and severe acute malnutrition management, using only RUTF at a decreasing dose as weight and mid-upper-arm circumference increase (OptiMA strategy), could achieve similar or higher individual efficacy, increase coverage, and minimise costs compared with the current programmes recommended in the Democratic Republic of the Congo (standard strategy; one programme for severe acute malnutrition using RUTF at an increasing dose as weight increases, another for moderate acute malnutrition using a fixed dose of RUSF). The authors found that the OptiMA strategy was superior to the standard one in terms of favourable outcomes (being alive, not acutely malnourished, and with no further episodes of acute malnutrition throughout the 6-month observation period), time to nutritional improvement, and treatment cost. These findings have several implications for approaches to acute malnutrition treatment. First, in several conflict or food-insecure zones, interventions are mostly focused on severe acute malnutrition management. Consequently, the moderate acute malnutrition programmes are only partially functional or non-existent. Yet, moderate acute malnutrition is more prevalent than severe acute malnutrition (31 million children vs 14 million children),1UNICEFWHOInternational Bank for Reconstruction and Development/The World BankLevels and trends in child malnutrition: key findings of the 2021 edition of the joint child malnutrition estimates. United Nations Children's Fund, New York, NY2021Google Scholar it can easily progress to severe acute malnutrition, and the risk of mortality is three-times compared with well nourished children.7Black RE Allen LH Bhutta ZA et al.Maternal and child undernutrition: global and regional exposures and health consequences.Lancet. 2008; 371: 243-260Summary Full Text Full Text PDF PubMed Scopus (3720) Google Scholar The OptiMA strategy appears to be more effective in terms of treating more children (both moderate acute malnutrition and severe acute malnutrition) at the same time, in a single programme, and also in preventing severe acute malnutrition from developing (only 5% of children with moderate acute malnutrition in the OptiMA group deteriorated to severe acute malnutrition within 6 months, compared with 16% in the standard group). Second, the current standard strategy of separating the treatment of moderate acute malnutrition and severe acute malnutrition into two different programmes appears to be more expensive because they are staff-intensive and require both RUTF and RUSF. By integrating moderate acute malnutrition and severe acute malnutrition treatment into one programme, and using only RUTF, the OptiMA strategy provides major advantages in allowing more children to access treatment at a lower cost. This finding is interesting for LMICs experiencing stock-outs of nutritional inputs due to underfunded programmes. Finally, although the trial was performed and supervised by well trained staff and there was close follow-up, 235 children (135 [30%] of 446 in the standard group vs 100 [22%] of 450 in the OptiMA group) relapsed after their nutritional recovery. The standards set by the SPHERE humanitarian charter focus on short-term successes only, despite evidence of high post-treatment relapse and mortality highlighted by several reports.8Stobaugh HC Mayberry A McGrath M et al.Relapse after severe acute malnutrition: a systematic literature review and secondary data analysis.Matern Child Nutr. 2019; 15e12702Crossref PubMed Scopus (30) Google Scholar, 9Ngari MM Fegan G Mwangome MK et al.Mortality after inpatient treatment for severe pneumonia in children: a cohort study.Paediatr Perinat Epidemiol. 2017; 31: 233-242Crossref PubMed Scopus (32) Google Scholar In this trial, monitoring the children 4 months after their nutritional recovery allowed diagnosis of these relapse cases. This finding emphasises the need to implement a follow-up policy for children following discharge from nutrition programmes as there is a potential risk of relapse in areas of food insecurity. Several key questions still need addressing. First, in resource-poor settings, the high cost of RUTF and RUSF limits their availability. Several non-inferiority, randomised controlled clinical trials were conducted in the Democratic Republic of the Congo and in Malawi comparing the efficacy of cereal-based formulas (maize, sorghum, and soya) mixed with vegetable oil and sugar with that of standard peanut paste-based RUTF for treating acute malnutrition. Findings from these trials suggested the non-inferiority of cereal-based formulas compared with peanut paste-based RUTF for children's recovery rate, weight gain, and length of programme stay.10Bahwere P Balaluka B Wells JCK Mbiribindi CN Sadler K Akomo P 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 non-inferiority, individually randomized controlled efficacy clinical trial.Am J Clin Nutr. 2016; 103: 1145-1161Crossref PubMed Scopus (48) Google Scholar, 12Bahwere P Akomo P Mwale M et al.Soya, maize, and sorghum-based ready-to-use therapeutic food with amino acid is as efficacious as the standard milk and peanut paste–based formulation for the treatment of severe acute malnutrition in children: a non-inferiority individually randomized controlled efficacy clinical trial in Malawi.Am J Clin Nutr. 2017; 106: 1100-1112PubMed Google Scholar Thus, these cereal-based formulas RUTF should be encouraged as an alternative nutritional therapy because of their availability and lower cost in resource-poor settings. Second, several metagenomics studies in children with malnutrition provided evidence that microbiota immaturity was involved in the development or maintenance of malnutrition.12Gupta SS Mohammed MH Ghosh TS Kanungo S Nair GB Mande SS Metagenome of the gut of a malnourished child.Gut Pathog. 2011; 3: 7Crossref PubMed Scopus (90) Google Scholar, 13Tidjani AM Million M Traore SI et al.Gut bacteria missing in severe acute malnutrition, can we identify potential probiotics by culturomics?.Front Microbiol. 2017; 8: 899Crossref PubMed Scopus (70) Google Scholar Current evidence suggests that RUTF and RUSF are insufficient to permanently restore gut microbiota maturity, which returns to an immature state 4 months following nutritional treatment.14Subramanian S Huq S Yatsunenko T et al.Persistent gut microbiota immaturity in malnourished Bangladeshi children.Nature. 2014; 510: 417-421Crossref PubMed Scopus (691) Google Scholar Further studies should examine the use of the combined action of nutritional and microbiota-targeted interventions to permanently restore the gut microbiota and thus improve the nutritional status of children with malnutrition. Some encouraging results have been reported among children with malnutrition in Uganda treated with a combination of RUTF and probiotics.15Castro-Mejía JL O'Ferrall S Krych L et al.Restitution of gut microbiota in Ugandan children administered with probiotics (Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp. lactis BB-12) during treatment for severe acute malnutrition.Gut Microbes. 2020; 11: 855-867Crossref PubMed Scopus (19) Google Scholar Finally, malnutrition is the result of a complex set of determinants, the most important being food insecurity and infections. Nutritious, diversified, and safe foods, and a healthy environment encompassing access to basic health services, water, sanitation, and hygiene16Black RE Victoria CG Walker SP et al.Maternal and child undernutrition and overweight in low-income and middle-income countries.Lancet. 2013; 382: 427-451Summary Full Text Full Text PDF PubMed Scopus (4023) Google Scholar are other keys to prevent relapse and death of these children following their nutritional recovery. We declare no competing interests. Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trialIn this non-inferiority trial treating children with MUAC of less than 125 mm or oedema, decreasing RUTF dose according to MUAC and weight increase proved to be a superior strategy to the standard protocol in the Democratic Republic of the Congo. These results demonstrate the safety and benefits of an approach that could substantially increase access to treatment for millions of children with acute malnutrition in sub-Saharan Africa. Full-Text PDF Open Access