Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food but also by illnesses and by poor infant and child feeding practices. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here, we report on the trial that took place in Kaabong, a poor agropastoral region of Karamoja, in east Uganda. While the region of Karamoja shows an acute malnutrition rate between 8.4% and 11.5% of which 2% to 3% severe malnutrition, more than half (58%) of the population in the district of Kaabong is considered food insecure.
Methods and Findings
We investigated the effect of two types of nutritional supplementation on the incidence of malnutrition in ill children presenting at outpatient clinics during March 2011 to April 2012 in Kaabong, Karamoja region, Uganda, a resource-poor region where malnutrition is a chronic problem for its seminomadic population. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed with malaria, diarrhoea, or lower respiratory tract infection. Non-malnourished children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of ready-to-use therapeutic food (RUTF), two sachets/d of micronutrient powder (MNP), or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate progression to moderate or severe acute malnutrition; it was defined as weight-for-height z-score <−2, mid-upper arm circumference (MUAC) <115 mm, or oedema, whichever came first.
Of the 2,202 randomised participants, 51.2% were girls, and the mean age was 25.2 (±13.8) mo; 148 (6.7%) participants were lost to follow-up, 9 (0.4%) died, and 14 (0.6%) were admitted to hospital. The incidence rates of NNO (first event/year) for the RUTF, MNP, and control groups were 0.143 (95% confidence interval [CI], 0.107–0.191), 0.185 (0.141–0.239), and 0.213 (0.167–0.272), respectively. The incidence rate ratio was 0.67 (95% CI, 0.46–0.98; p = 0.037) for RUTF versus control; a reduction of 33.3%. The incidence rate ratio was 0.86 (0.61–1.23; p = 0.413) for MNP versus control and 0.77 for RUTF versus MNP (95% CI 0.52–1.15; p = 0.200). The average numbers of study illnesses for the RUTF, MNP, and control groups were 2.3 (95% CI, 2.2–2.4), 2.1 (2.0–2.3), and 2.3 (2.2–2.5). The proportions of children who died in the RUTF, MNP, and control groups were 0%, 0.8%, and 0.4%.
The findings apply to ill but not malnourished children and cannot be generalised to a general population including children who are not necessarily ill or who are already malnourished.
A 2-wk nutrition supplementation programme with RUTF as part of routine primary medical care to non-malnourished children with malaria, LRTI, or diarrhoea proved effective in preventing malnutrition in eastern Uganda. The low incidence of malnutrition in this population may warrant a more targeted intervention to improve cost effectiveness.
A clinical trial set in Uganda shows that short-term supplementation with ready-to-use food in children following a bout of acute illness can prevent malnutrition. This short term measure has longer term effects in reducing morbidity in a vulnerable population.
Globally, malnutrition—poor nutrition—is thought to contribute to nearly half of all child deaths. Malnutrition can be chronic or acute. Chronic (long-term) malnutrition causes stunting. A child who is stunted has a low height for his or her age when compared to WHO Child Growth Standards, which chart the growth of a reference population. By contrast, acute malnutrition causes wasting. A wasted child has a low weight for his or her height. Malnutrition can be caused by not having enough to eat, by not eating enough of the right foods, or being unable to use the food that one does eat. In many tropical countries, recurrent infections are also an important cause of malnutrition among children. Diarrhea, lower respiratory tract infections, and malaria all have a negative effect on the growth of children. Importantly, inadequate nutrition limits recovery from infection, thereby setting up a vicious cycle of illness and malnutrition.
Why Was This Study Done?
It might be possible to reduce the global burden of malnutrition among children by breaking this vicious cycle. One way to do this might be to provide ill children with a nutritional supplement such as RUTF or a MNP. RUTF—a nutrient supplement based on peanut butter mixed with dried skim milk, vitamins, and minerals—is a paste that can be eaten directly. Micronutrients are vitamins and minerals that everyone needs in small quantities for good health; MNP is added to porridge or other meals. In this randomized controlled trial undertaken by MSF, a not-for-profit organization that delivers emergency medical aid worldwide, the researchers investigate whether short-term provision of RUTF or MNP prevents the development of malnutrition among ill children under 5 y old living in Kaabong, a poor agropastoral region in eastern Uganda, where about 10% of children are acutely malnourished.
What Did the Researchers Do and Find?
The researchers randomly assigned 2,202 non-malnourished children who visited outpatient clinics in Kaabong with malaria, diarrhea or lower respiratory tract infection to one of three trial arms. Children assigned to the two intervention arms were given RUTF or MNP by their caregivers for 14 d following each illness over a 6-mo period. Children assigned to the control arm received no supplement. The primary outcome of the trial was the incidence of the first NNO—a weight-for-height z-score below −2 (a score that compares a child’s weight-for-height with that of a reference population; a z-score of −2 or less indicates acute malnutrition), a MUAC of less than 115 mm, or nutritional edema (swelling caused by malnutrition)—during follow-up (the incidence of a condition is the proportion of a population affected by that condition during a specified time period). The incidence rates of NNO were 0.143, 0.185, and 0.213 first events/year observation in the RUTF, MNP, and control groups, respectively. Notably, the IRR of NNO for RUTF versus control was 0.67, a significant reduction in the incidence of malnutrition in the RUTF group of 33% compared with the control group (a significant reduction is unlikely to have occurred by chance). By contrast, supplementation with NMP did not significantly reduce the incidence of malnutrition.
What Do These Findings Mean?
These findings show that, among non-malnourished children with malaria, lower respiratory tract infection, or diarrhea living in Kaabong, Uganda, provision of an RUTF-based nutritional supplement for 14 d following an illness as part of routine primary medical care prevented malnutrition. Because this trial only enrolled children who were non-malnourished, these findings cannot be generalized to all ill children with an infectious illness in Kaabong or similar settings—many ill children presenting at outpatient clinics are acutely malnourished. Interestingly, a companion trial undertaken by MSF in Goronyo, Nigeria found no reduction in the incidence of malnutrition among non-malnourished and moderately acutely malnourished children following short-term supplementation with either RUTF or MNP. The researchers suggest that the different results in the two trials may reflect the higher incidence of malnutrition and illness in Goronyo compared to Kaabong. Indeed, given the low incidence of malnutrition in Kaabong, the researchers suggest that a more targeted intervention such as only providing RUTF to ill children younger than 3 y old might be more cost-effective than providing nutritional supplementation to all ill children in Kaabong and similar settings.
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001951.
A PLOS Medicine Research Article by van der Kam et al. describing the companion trial investigating the effect of short-term food supplementation for children in Nigeria after illness on the incidence of malnutrition is available
More information about this trial is available
The MSF website contains information about malnutrition around the world; "Starved for Attention" is an international multimedia campaign launched in 2010 by MSF and the VII Photo agency to rewrite the story of childhood malnutrition
The not-for-profit organization UNICEF, which protects the rights of children and young people around the world, provides detailed information on nutrition among children and statistics on malnutrition among children; a short 2013 article describes UNICEF efforts to reduce malnutrition in Uganda
The WHO Child Growth Standards are available (in several languages)
The World Food Programme is the world’s largest humanitarian agency fighting hunger worldwide; its website provides information about hunger and malnutrition in Uganda
The Emergency Nutrition Network (ENN) is an interactive website for knowledge sharing and peer support to strengthen the evidence and know-how for effective nutrition interventions in countries prone to crisis and high levels of malnutrition
The International Lipid-based Nutrient Supplements (iLiNS) project aims to help prevent malnutrition by developing Lipid-based Nutrient Supplements and test their efficiency and by collecting and sharing publications on LNS.