Effectiveness of interventions to manage acute malnutrition in children under 5 years of age in low‐ and middle‐income countries: A systematic review

BACKGROUND: Childhood malnutrition is a major public health concern as it is associated with significant short‐ and long‐term morbidity and mortality. OBJECTIVES: To comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization protocol using facility‐ and community‐based approaches as well as the effectiveness of ready‐to‐use therapeutic food (RUTF), ready‐to‐use supplementary food (RUSF), prophylactic antibiotic use and vitamin A supplementation. SEARCH METHODS: We searched relevant electronic databases till 11 February 2019. No date or language restrictions were applied. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi‐experimental studies including controlled before‐after (CBA) studies and interrupted time series (ITS) studies. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for relevance, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software and set out the main findings of the review in “Summary of findings” tables. MAIN RESULTS: This review summarises findings from a total of 42 studies (48 papers) including 35,017 children. Thirty‐three of the included studies were RCTs; six studies were quasi‐experimental and three studies were cost studies. Majority of the studies were judged to be at high risk of bias for blinding of the participants, personnel and outcome assessment. Majority of the outcomes were rated as either moderate or low quality. Outcomes were downgraded mainly due to study limitations, high heterogeneity, imprecision and small sample size. Community‐based strategies to screen and manage SAM/MAM versus no community‐based strategies (two studies): Integrated community‐based management probably improves recovery rate by 4% [risk ratio (RR): 1.04; 95% confidence interval (CI): 1.00 to 1.09; one study; 1,957 participants; moderate‐quality outcome], and reduces weight gain by 0.8 g·kg(−1)·day(−1) [mean difference (MD): −0.80 g·kg(−1)·day(−1); 95% CI: −0.82 to −0.78; one study; 1,957 participants; moderate‐quality outcome] compared with no community‐based strategies, while mortality was similar between the two groups (RR: 0.93; 95% CI: 0.60 to 1.45; one study; 1,957 participants; moderate‐quality outcome). Facility‐based strategies to screen and manage uncomplicated SAM versus other standard of care (four studies): There was no evidence of effect on recovery (RR: 1.00; 95% CI: 0.80, 1.25; one study; 60 participants; very‐low‐quality evidence) and mortality (RR: 1.21; 95% CI: 0.75 to 1.94; two studies; 473 participants; low‐quality outcome). Facility‐based management with RUTF versus F100 (“catch‐up” formula to rebuild wasted tissues containing 100 kcal and 2.9 g protein per 100 ml) for SAM (three studies): There was no evidence of effect on weight gain (MD: 2 g·kg(−1)·day(−1); 95% CI: −0.23 to 4.23; three studies; 266 participants; very‐low‐quality outcome) and mortality (RR: 1.20; 95% CI: 0.34 to 4.22; two studies; 168 participants; low‐quality outcome). Community‐based management of SAM with standard RUTF compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUTF was compared to non‐milk/peanut butter‐based RUTF (RR: 1.03; 95% CI: 0.99 to 1.08; five studies; 5743 participants; I(2) 50%; moderate quality outcome), energy‐dense, home‐prepared food (RR: 1.14; 95% CI 0.95 to 1.36; four studies; 959 participants; I(2) 75%; low quality outcome), or high oleic RUTF (RR: 1.06; 95% CI: 0.85 to 1.31; one study; 141 participants; moderate quality outcome). Standard RUTF may improve weight gain by 0.5 g·kg(−1)·day(−1) (MD: 0.5 g·kg(−1)·day(−1); 95% CI: 0.02 to 0.99; three studies; 3,069 participants; low‐quality outcome) when compared with non‐milk/peanut butter‐based RUTF and by 5.5 g·kg(−1)·day(−1) when compared with F100 (MD: 5.50 g·kg(−1)·day(−1); 95% CI: 2.92 to 8.08; one study; 70 participants; low‐quality outcome). There was no evidence of effect on mortality when standard RUTF was compared with other foods (RR: 0.99; 95% CI: 0.69 to 1.41; nine studies; 7,667 participants; low‐quality outcome). RUSF for MAM compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUSF was compared with local/home made food (RR: 0.92; 95% CI: 0.64 to 1.33; three studies; 435 participants; low‐quality outcome) and whey RUSF (RR: 0.96; 95% CI: 0.92 to 1.00; one study; 2230 participants; high‐quality outcome); while standard RUSF may improve recovery by 7% when compared with corn–soy blend (CSB) (RR: 1.07; 95% CI: 1.02 to 1.13; six studies; 5,744 participants; low‐quality outcome). There was no evidence of effect on weight gain when standard RUSF was compared with local home made food (MD: −0.75 g·kg(−1)·day(−1); 95% CI: −2.03 to 0.43; one study; 73 participants; low‐quality outcome) and whey RUSF (MD: −0.16 g·kg(−1)·day(−1); 95% CI: −0.33 to 0.01; one study; 2,230 participants; high‐quality outcome); while standard RUSF may improve weight gain by 0.49 g·kg(−1)·day(−1) when compared with CSB (MD: 0.49 g·kg(−1)·day(−1); 95% CI: 0.10 to 0.87; five studies; 4,354 participants; low‐quality outcome). There was no evidence of effect on mortality when standard RUSF was compared with other foods (RR: 0.98; 95% CI: 0.57 to 1.68; eight studies; 8,310 participants; moderate‐quality outcome). Prophylactic antibiotic versus no antibiotic (three studies): Prophylactic antibiotic therapy for uncomplicated SAM improves recovery rate by 6% (RR: 1.06; 95% CI: 1.03 to 1.08; two studies; 5,166 participants; high‐quality outcome), probably improves weight gain by 0.67 g·kg(−1)·day(−1) (MD: 0.67 g·kg(−1)·day(−1); 95% CI: 0.28, 1.06; two studies; 5,052 participants; moderate‐quality outcome) and probably reduces mortality by 26% (RR: 0.74; 95% CI: 0.55, 0.98; three studies; 6944 participants; moderate quality outcome) compared to no antibiotics group. High‐dose vitamin A versus low‐dose vitamin A (two studies): There was no evidence of effect on weight gain (MD: 0.05 g·kg(−1)·day(−1); 95% CI: −0.08 to 0.18; one study; 207 participants; moderate‐quality outcome) and mortality (RR: 7.07; 95% CI: 0.37 to 135.13; one study; 207 participants; moderate‐quality outcome). AUTHORS’ CONCLUSIONS: Limited data show some benefit of integrated community‐based screening, identification and management of SAM and MAM on improving recovery. Facility‐based screening and management of uncomplicated SAM has no benefit on recovery and mortality, while the effect of F100 for SAM is similar to RUTF for weight gain and mortality. Local food and whey RUSF have similar effects as standard RUSF on recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate, weight gain and reduces mortality, while limited data suggest that high‐dose vitamin A supplementation is comparable with low‐dose vitamin A supplementation for weight gain and mortality among children with SAM.