ABSTRACT

A prospective cohort study measured mortality during nutritional rehabilitation among HIV-infected and uninfected children, aged 6-59 months, with severe acute malnutrition (SAM). Children were tested for HIV and CD4% on admission to the nutrition rehabilitation unit (NRU). Mortality was assessed by following children to 4 months post discharge from the NRU or death if earlier. Overall mortality was 14.8% (67/454) and HIV prevalence was 17.4% (79/454). HIV-infected children were significantly more likely to die than uninfected children [35.4% (28/79) vs. 10.4% (39/375), P<0.001], and 85.7% of deaths occurred in children with a CD4% less than 20. Forty percent (18/45) of HIV-infected children with a CD4% <20 died, in contrast to 15% (3/20) of HIV-infected children with a CD4% >20 (P=0.05). Routine testing and treatment for HIV among all malnourished children is necessary to improve quality of care and reduce mortality among children with SAM.

The cost of ready-to-use therapeutic food (RUTF) used in community-based management of acute malnutrition has been a major obstacle to the scale up of this important child survival strategy. The current standard recipe for RUTF [peanut-based RUTF (P-RUTF)] is made from peanut paste, milk powder, oil, sugar, and minerals and vitamins. Milk powder forms about 30% of the ingredients and may represent over half the cost of the final product.The quality of whey protein concentrates 34% (WPC34) is similar to that of dried skimmed milk (DSM) used in the standard recipe and can be 25-33% cheaper. This blinded, parallel group, randomised, controlled non-inferiority clinical trial tested the effectiveness in treating severe acute malnutrition (SAM) of a new RUTF formulation WPC-RUTF in which WPC34 was used to replace DSM. Average weight gain (non-inferiority margin Δ = −1.2 g kg −1 day −1) and recovery rate (Δ = −10%) were the primary outcomes, and length of stay (LOS) was the secondary outcome (Δ = +14 days). Both per-protocol (PP) and intention-to-treat (ITT) analyses showed that WPC-RUTF was not inferior to P-RUTF for recovery rate [difference and its 95% confidence interval (CI) of 0.5% (95% CI -2.7, 3.7) in PP analysis and 0.6% (95% CI -5.2, 6.3) in ITT analysis] for average weight gain [0.2 (−0.5; 0.9) for both analyses] and LOS [−1.6 days (95% CI, −4.6, 1.4 days) in PP analysis and −1.9 days (95% CI, −4.6, 0.8 days) for ITT analysis]. In conclusion, whey protein-based RUTF is an effective cheaper alternative to the standard milk-based RUTF for the treatment of SAM.

BackgroundThe use of proportional weight gain as a discharge criterion for MUAC admissions to programs treating severe acute malnutrition (SAM) is no longer recommended by WHO. The critical limitation with the proportional weight gain criterion was that children who are most severely malnourished tended to receive shorter treatment compared to less severely malnourished children. Studies have shown that using a discharge criterion of MUAC ≥ 125 mm eliminates this problem but concerns remain over the duration of treatment required to reach this criterion and whether this discharge criterion is safe. This study assessed the safety and practicability of using MUAC ≥ 125 mm as a discharge criterion for community based management of SAM in children aged 6 to 59 months.MethodsA standards-based trial was undertaken in health facilities for the outpatient treatment of SAM in Lilongwe District, Malawi. 258 children aged 6 to 51 months were enrolled with uncomplicated SAM as defined by a MUAC equal or less than 115 mm without serious medical complications. Children were discharged from treatment as ‘cured’ when they achieved a MUAC of 125 mm or greater for two consecutive visits. After discharge, children were followed-up at home every two weeks for three months.ResultsThis study confirms that a MUAC discharge criterion of 125 mm or greater is a safe discharge criterion and is associated with low levels of relapse to SAM (1.9 %) and mortality (1.3 %) with long durations of treatment seen only in the most severe SAM cases. The proportion of children experiencing a negative outcome was 3.2 % and significantly below the 10 % standard (p = 0.0013) established for the study. All children with negative outcomes had achieved weight-for-height z-score (WHZ) above −1 z-scores at discharge. Children admitted with lower MUAC had higher proportional weight gains (p < 0.001) and longer lengths of stay (p < 0.0001). MUAC at admission and attendance were both independently associated with cure (p < 0.0001). There was no association with negative outcomes at three months post discharge for children with heights at admission below 65 cm than for taller children (p = 0.5798).ConclusionsThese results are consistent with MUAC ≥ 125 mm for two consecutive visits being a safe and practicable discharge criterion. Use of a MUAC threshold of 125 mm for discharge achieves reasonable lengths of stay and was also found to be appropriate for children aged six months or older who are less than 65 cm in height at admission. Early detection and recruitment of SAM cases using MUAC in the community and compliance with the CMAM treatment protocols should reduce lengths of stay and associated treatment costs.

BackgroundSevere malnutrition in childhood associated with HIV infection presents a serious humanitarian and public health challenge in Southern Africa. The aim of this study was to collect country wide data on HIV infection patterns in severely malnourished children to guide the development of integrated care in a resource limited setting.MethodsA cross sectional survey was conducted in 12 representative rural and urban Nutrition Rehabilitation Units (NRUs), from each of Malawi's 3 regions.All children and their caretakers admitted to each NRU over a two week period were offered HIV counselling and testing. Testing was carried out using two different rapid antibody tests, with PCR testing for discordant results. Children under 15 months were excluded, to avoid difficulties with interpretation of false positive rapid test results.The survey was conducted once in the dry/post-harvest season, and repeated in the rainy/hungry season.Results570 children were eligible for study inclusion. Acceptability and uptake of HIV testing was high: 523(91.7%) of carers consented for their children to take part; 368(70.6%) themselves accepted testing.Overall HIV prevalence amongst children tested was 21.6%(95% confidence intervals, 18.2–25.5%). There was wide variation between individual NRUs: 2.0–50.0%.Geographical prevalence variations were significant between the three regions (p < 0.01) with the highest prevalence being in the south: Northern Region 23.1%(95%CI 14.3–34.0%), Central Region 10.9%(95%CI 7.5–15.3%), and Southern Region 36.9%(95%CI 14.3–34.0%).HIV prevalence was significantly higher in urban areas, 32.9%(95%CI 26.8–39.4%) than in rural 13.2%(95%CI 9.5–17.6%)(p < 0.01).NRU HIV prevalence rates were lower in the rainy/hungry season 18.4%(95%CI 14.7–22.7%) than in the dry/post-harvest season 30.9%(95%CI 23.2–39.4%) (p < 0.001%).ConclusionThere is a high prevalence of HIV infection in severely malnourished Malawian children attending NRUs with children in urban areas most likely to be infected. Testing for HIV is accepted by their carers in both urban and rural areas. NRUs could act as entry points to HIV treatment and support programmes for affected children and families. Recognition of wide geographical variations in childhood HIV prevalence will ensure that limited resources are initially targeted to areas of highest need.These findings may have implications for the other countries with similar patterns of childhood illness and food insecurity.