Weight gain among children under five with severe malnutrition in therapeutic feeding programmes: a systematic review
Grace O'Donovan1, Daniel Allen1, Thandile Nkosi-Gondwe1,2
1Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
Insights
Severe malnutrition in children shows slower weight gain in outpatient programs compared to inpatient care. This systematic review provides benchmarks for future treatment guidelines and policies.
Area of Science:
- Public Health
- Pediatrics
- Nutrition Science
Background:
- Globally, 45 million children under five experience wasting (low weight-for-height).
- Current World Health Organisation guidelines suggest 5-10 g/kg/day weight gain for wasted children, a shift from previous 10-15 g/kg/day targets.
- Understanding optimal weight gain targets is crucial for informing policy and programming.
Purpose of the Study:
- To systematically review and meta-analyze data on weight gain rates in children with severe malnutrition.
- To compare weight gain across different treatment modalities: inpatient, outpatient, and hybrid.
- To inform future policy and programming on weight gain targets for severe malnutrition.
Main Methods:
- Systematic review and meta-analysis of studies identified through Embase, Global Health, and Medline databases.
- Inclusion criteria: children aged 6-59 months with severe malnutrition undergoing inpatient, outpatient, or hybrid treatment.
- Primary outcome: mean rate of weight gain (g/kg/day); meta-regression used to explore associations with length of stay and outcomes.
Main Results:
- Analysis of 104 papers (240,650 participants) revealed mean weight gain rates of 8.8 g/kg/day (inpatient), 3.4 g/kg/day (hybrid), and 3.9 g/kg/day (outpatient).
- Weight gain in outpatient programs was significantly slower than in inpatient treatment.
- Inconsistent evidence found for an association between slower weight gain and higher mortality, with weak evidence after adjusting for program type.
Conclusions:
- Weight gain rates differ markedly between inpatient and outpatient treatment for severe malnutrition.
- Standardized reporting of weight gain calculations and further research into the sequelae of recovery rates are needed.
- The findings establish a crucial baseline for evaluating current severe malnutrition treatment programs.
Background:
Globally, some 45 million children under five years of age are wasted (low weight-for-height). Although 2023 World Health Organisation guidelines on their care did not aim to identify optimal weight gain, they did mention 5-10 g/kg/day as a target, which is a change from prior guidelines that recommended 10-15 g/kg/day, when inpatient-only care was the norm. We aimed to inform future policy/programming on weight gain targets.
Methods:
For this systematic review and meta-analysis, we searched Embase, Global Health and Medline. The final search was on 23/02/2024. Papers were included if they reported weight gain of children aged 6-59 months with severe malnutrition during inpatient (facility-based), outpatient (home-based), and hybrid treatment (initially inpatient and progressing to outpatient treatment). Summary data were extracted, and quality was assessed using a NICE Quality Appraisal Checklist. Our primary outcome was mean rate of weight gain (g/kg/day) during treatment. We conducted random-effects meta-analysis to describe pooled mean weight gain by programme type. Meta-regression investigated potential associations of weight gain with length of stay and programme outcomes. We registered the study on PROSPERO (CRD42023266472).
Findings:
Our search yielded 3173 papers. We reviewed 321 full texts, identifying 126 eligible papers. Of these, 104 papers, including some 240,650 participants, reported weight gain as g/kg/day and were eligible for meta-analysis. Mean rate of weight gain was 8.8 g/kg/day (95% CI: 7.6, 9.9; I2 = 97.8%) across 18 inpatient programmes, 3.4 g/kg/day (95% CI: 2.0, 4.7; I2 = 99.4%) across 12 hybrid programmes, and 3.9 g/kg/day (95% CI: 3.4, 4.4; I2 = 99.7%) across 60 outpatient programmes. We found inconsistent evidence of an association between slower weight gain and higher mortality: there was weak evidence of association after adjusting for programme type (coefficient = -0.4; 95% CI: -0.7, -0.02; p = 0.04; n = 118 programmes). There was high heterogeneity between studies. Details of weight gain calculation methods varied. We found no evidence for publication bias when accounting for programme type (Egger's test p-value = 0.2).
Interpretation:
Weight gain in outpatient programmes was markedly slower than in inpatient treatment. Clearer reporting of weight gain and a better understanding of the sequelae of faster/slower recovery is important to set future weight gain targets. Our results set an important baseline for current programmes to benchmark against.
Funding:
Medical Research Council/Global Challenges Research Fund, grant number: MR/V000802/1.
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