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Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm
Suvi T Kangas1, Césaire T Ouédraogo2, Moctar Tounkara3
1International Rescue Committee, New York, USA. suvi.kangas@rescue.org.
Insights
This study investigates if children with low weight-for-age z-score (WAZ) but adequate mid-upper-arm circumference (MUAC) benefit from ready-to-use therapeutic foods (RUTF). It compares simplified vs. standard treatment protocols for severe childhood malnutrition.
Area of Science:
- Pediatric Nutrition
- Global Health
- Malnutrition Treatment
Background:
- Current malnutrition admission criteria may not identify all children at risk of mortality.
- Community-based data suggest weight-for-age z-score (WAZ) and MUAC combined identify at-risk children.
- Evidence gaps exist regarding treatment benefits for children with WAZ <-3 and MUAC ≥125 mm.
Purpose of the Study:
- To determine if children with WAZ <-3 and MUAC ≥125 mm benefit from ready-to-use therapeutic foods (RUTF).
- To assess if a simplified RUTF treatment protocol is non-inferior to the standard weight-based protocol.
- To inform optimal admission criteria and treatment strategies for severe childhood malnutrition.
Main Methods:
- Prospective, individually randomized controlled 3-arm trial in Mali.
- Recruitment of 1397 children aged 6-59 months with MUAC ≥125 mm and WAZ <-3.
- Comparison of no treatment, simplified RUTF, and standard RUTF protocols, with WAZ as the primary outcome at 2 months.
Main Results:
- Primary endpoint: WAZ at 2 months.
- Secondary endpoints: other anthropometric measurements at 6 months.
- Sample size calculated to show superiority of simplified vs. no treatment and non-inferiority vs. standard treatment.
Conclusions:
- The trial will generate evidence on the efficacy of RUTF for children with specific anthropometric deficits.
- Findings will guide the selection of admission criteria for malnutrition treatment programs.
- The study aims to establish the most efficient and effective treatment protocol for severe childhood malnutrition.
Background:
Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol.
Methods:
This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ.
Discussion:
This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol.
Trial Registration:
This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.
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