This is an interim intervention report. We have spent limited time to form an initial view of this program and, at this point, our views are preliminary. We plan to consider undertaking additional work on this program in the future.
- What is the program? Treating severe acute malnutrition (SAM), i.e. very low weight for height, in children under the age of 5 with ready-to-use therapeutic foods (RUTF).
- What is its evidence of effectiveness? There appears to be limited high-quality evidence of effectiveness.
- How cost-effective is it? We have not attempted to assess the program's cost-effectiveness.
- Does it have room for more funding? We have not attempted to assess the program's room for more funding.
- Bottom line: We do not currently consider this a priority program, and, in the absence of additional information, we are not planning to conduct additional work.
Published: November 2016
Published: November 2016
What is the problem?
According to the World Health Organization (WHO), "Severe acute malnutrition is defined by a very low weight for height (below -3z scores of the median WHO growth standards), by visible severe wasting, or by the presence of nutritional oedema…. The median under-five case-fatality rate for severe acute malnutrition typically ranges from 30% to 50%."1
A 2007 WHO report states that "nearly 20 million children under five suffer from severe acute malnutrition" and that SAM "contributes to nearly 1 million child deaths every year" but notes that "WHO is currently estimating the global number of children suffering from severe acute malnutrition and the number of deaths associated with the condition."2 We have not found updated numbers that seem more reliable.
What is the program?
We focus this page on community-based treatment of uncomplicated SAM to distinguish it from inpatient treatment of complicated SAM or treatment of moderate acute malnutrition (weight for height z score (WHZ) between two and three standard deviations (SDs) below the mean).3
According to the WHO, "The community-based approach involves timely detection of severe acute malnutrition in the community and provision of treatment for those without medical complications with ready-to-use therapeutic foods or other nutrient-dense foods at home."4
Does the program have strong evidence of effectiveness?
There appears to be limited evidence demonstrating the effectiveness of RUTF (relative to a standard diet).
- The WHO guidelines for the management of severe acute malnutrition say, "The evidence, available for the development of recommendations, was in general of very low quality, as defined in the WHO handbook for guideline development. This was due to the limited availability of randomized controlled trials, trials comparing existing WHO recommendations with new treatment options, or trials documenting comparisons of diagnosis and treatment methods identified by the guideline development group as requiring review."5
- A recent Cochrane review evaluating the effect of providing RUTF to children aged 6 months to five years with severe acute malnutrition6 concludes, "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."7
- A protocol for a future Cochrane review explains the reason for conducting a review as follows: "There are strong recommendations to scale-up the community-based approach for children with uncomplicated SAM. Very few studies have looked at the effectiveness of community-based management of acute malnutrition compared to the traditional approach of facility-based treatment for uncomplicated SAM. Community-based care with ready to-use therapeutic food has been suggested as being a virtuous way to confront uncomplicated SAM in low- and middle-income settings, but the efficacy, effectiveness, and cost-effectiveness of this modern approach compared to the traditional approach of a health facility based in poor health districts with local staff is still unproven."8
- A 2013 systematic review of the evidence for treating SAM concludes, "Gaps in our ability to estimate effectiveness of overall treatment approaches for SAM and MAM persist. In addition to further impact studies conducted in a wider range of settings, more high quality program evaluations need to be conducted and the results disseminated."9 It adds, "Our review found limited high quality comparative trials evaluating the package of care offered through community-based management for uncomplicated SAM and MAM. Additionally, studies of inpatient management of SAM comparing the WHO protocol to standard care tend to be observational without adjustment for confounding."10
How cost-effective is the program?
Due to the limited evidence of effectiveness, we have not analyzed the cost-effectiveness of this program.
Does the program appear to have room for more funding?
We have not attempted to investigate this question. We have not found reliable estimates for the prevalence of severe acute malnutrition.
Focus of further investigation
We would like to better understand why limited high-quality evidence of effectiveness exists for this program and whether we should consider supporting additional research on this program.
We conducted a brief review of literature focusing on the Cochrane Library, the Lancet Series on Nutrition,11 the World Health Organization website, and the Disease Control Priorities (DCP3) report on reproductive, maternal, newborn and child health.12
- “In children under ﬁve years of age, malnutrition can be classiﬁed as moderate or severe. Moderate malnutrition - often referred to as moderate acute malnutrition (MAM) - is deﬁned as a weight for height z score (WHZ) between two and three standard deviations (SDs) below the mean. Severe malnutrition - often referred to as severe acute malnutrition (SAM) - is deﬁned as a WHZ of more than three SDs below the mean, or a mid-upper arm circumference (MUAC) of less than 115 mm, or the presence of nutritional oedema (Collins 2003; Manary 2008; WHO and UNICEF 2009).” Schoonees et al. 2013Schoonees et al-2013, Pg 6.
- ”Furthermore, hospital admission exposes people with uncomplicated SAM to additional risks of nosocomial infections and takes the mother or carer away from other children for prolonged periods, which may increase the risk for sibling malnutrition (Collins 2003). Therefore, an alternative treatment for severe uncomplicated malnutrition may be a home-based nutritional intervention, such as RUTF, which does not require specialised healthcare personnel and expensive equipment (Kruger 2008).” Schoonees et al. 2013, Pg 7.
WHO. Severe Acute Malnutrition, overview page.
"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." Schoonees et al. 2013, Pg 1.
Schoonees et al. 2013, Pg 2.
Shafiq et al. 2013, Pg 5.
Lenters et al. 2013, Pg 1.
Lenters et al. 2013, Pg 10.
DCP3: Reproductive, Maternal, Newborn, and Child Health, Chapter 11, "Management of Severe and Moderate Acute Malnutrition in Children."