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Program in international and Community Nutrition and Department of Nutrition, University of California, Davis, CA, UsA (K. H. Brown). Africa regional Office, Helen Keller international, Dakar, senegal (d. H. nyirandutiye, S. Jungjohann).

Correspondence: K. H. Brown, Department of Nutrition, University of California, One shields Avenue, Davis, CA 95616, UsA khbrown@ucdavis.edu

Management of children with acute malnutrition in resource-poor settingsKenneth H. Brown, Daniele H. Nyirandutiye and Svenja Jungjohann

Abstract | Approximately 11% of children worldwide suffer from moderate or severe acute malnutrition, which is defined as low weight for height or mid-upper arm circumference with respect to international standards, or the presence of bipedal edema. These children have a considerably increased risk of dying. experience from the past two decades indicates that children with uncomplicated moderate or severe acute malnutrition can be managed successfully as outpatients, by use of appropriate treatment of infections and either lipid-based, ready-to-use therapeutic foods or appropriately formulated home diets, along with psychosocial care. Children’s caregivers prefer community-based treatment, which is also less costly than inpatient care. Children with severe acute malnutrition and life-threatening complications require short-term inpatient care for treatment of infections, fluid and electrolyte imbalances, and metabolic abnormalities. initial dietary management relies on low-lactose, milk-based, liquid formulas but semi-solid or solid foods can be started as soon as appetite permits, after which children can be referred for ambulatory treatment. National programs for the community-based management of acute malnutrition (CMAM) provide periodic anthropometric and clinical screening of young children, and referral of those who meet established criteria. This review describes the main components of the treatment of young children with acute malnutrition in resource poor settings and some recent advances in CMAM programs.

Brown, K. H. et al. Nat. Rev. Endocrinol. 5, 597–603 (2009); published online 29 september 2009; doi:10.1038/nrendo.2009.194

IntroductionClassical clinical presentations of severe, acute child-hood malnutrition include edematous malnutrition (often referred to as kwashiorkor in the earlier clinical literature) and severe wasting, also known as marasmus. more recently, diagnoses of severe and moderate forms of malnutrition are being made primarily on the basis of a combina tion of anthropometric criteria and clinical examination for the presence of edema. in particular, acute malnutrition refers to low weight for height (wasting) with respect to international standards and/or the presence of bipedal edema, and chronic malnutrition refers to low height for age (stunting), with or without accompanying wasting. to simplify field procedures for minimally trained community health workers, and to obviate the need to carry a balance and height board to poorly accessible field sites, measurement of mid-upper arm circumference can be used instead of weight for height.1

the specific cut-off criteria used in the diagnosis of moderate and severe forms of acute malnutrition, as currently recommended by wHo, are shown in table 1, although individual country protocols may apply slightly different criteria. in settings that have a high preva-lence of undernutrition, the presence of edema that is not attributable to underlying renal, cardiac, or hepatic disease is almost always considered to indicate severe, acute malnutrition (sam), although other underlying

conditions, such as protein-losing enteropathy,2 may contribute to the occurrence of edema.

according to the latest uniCeF report of the state of the world’s Children,3 the combined global prevalence of moderate acute malnutrition (mam) and sam is approximately 11% (as defined by anthropometric cri-teria), although consider able regional variation exists (table 2). uniCeF does not report data separately for mam and sam, but a review of results from more than 500 nutritional status surveys in 31 low-income countries reported a prevalence of sam of ~3%4 and several agen-cies and meeting reports have estimated that as many as 10–20 million children worldwide may suffer from sam.5,6 notably, children with a weight for height Z-score <–3 sD or those with a score between –3 and –2 sD have, respectively, a ninefold or threefold increased risk of mor-tality compared with children whose weight for height Z-score is >–1 sD.7

the past two decades have witnessed an increased focus of attention on the treatment and prevention of acute malnutrition. increased recognition of the elevated risk of mortality among children with acute malnutrition is the first of three main reasons for this new impetus.7–9 the second reason is that systematic protocols for the assessment and treatment of malnourished children have been developed and disseminated worldwide.10 lastly, specifically developed liquid formulas and ready-to-use therapeutic foods (rutF) that simplify approaches to dietary therapy have become more widely available.11

competing interestsThe authors declare no competing interests.

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in parallel with these modern advances in the treat-ment of childhood malnutrition, appreciation of the drawbacks of the former primary reliance on facility-based management of malnourished children has grown. these drawbacks include limited inpatient capacity and competing parental childcare and income-generating responsibilities that prevent caregivers from exploit-ing available clinical services.12 such factors reduce the potential coverage and usage of programs that rely exclusively on inpatient treatment protocols. For these

Key points

Moderate and severe acute malnutrition are relatively common in resource-poor ■settings, which leads to high rates of infant and child mortality

Children can be screened for acute malnutrition by measurement of either ■weight for height or mid-upper arm circumference and inspection for the presence of bipedal edema

Treatment algorithms have been developed that are based on the severity of ■malnutrition and the presence of clinical complications or reduced appetite

Children with severe acute malnutrition and good appetite can be managed ■as ambulatory patients by infection treatment and the use of ready-to-use therapeutic foods (rUTF) or appropriately formulated home diets

The optimal management of children with moderate acute malnutrition (namely ■use of rUTF versus specialized home-prepared diets) is being investigated to develop simple, effective and affordable dietary regimens

reasons, community-based strategies to identify and treat children with malnutrition are being developed and expanded.5 earlier detection of acute malnutrition in the community also offers the potential to treat children before complications occur.

this review outlines the screening and major com-plications of acute malnutrition in young children and discusses the appropriate components of therapy for chil-dren with sam and mam, with a primary focus on spe-cific aspects of the dietary management of these children in community settings in resource-poor environments.

Community mobilization and screeninglarge-scale community-based programs for the pre-vention, detection, and treatment of acute malnutrition generally include an initial phase of social mobilization and communication to heighten community awareness of the problem of malnutrition, disseminate informa-tion on its associated health risks, and encourage use of available services. this phase is followed by periodic population-based screenings to classify children accord-ing to severity of malnutrition and, therefore, enable referral to the appropriate level of treatment services. Four nutritional risk categories can be identified: non-acutely mal nourished, mam (table 1), sam without clinical complications (table 1), or sam with clinical complications. in the last risk category, clinical complica-tions are defined as the presence of severe edema, signs of systemic infection, or poor appetite. malnourished indivi duals may not exhibit the usual inflammatory responses to infection and related clinical signs, there-fore, poor appetite may be the only indication of an other wise undetected systemic infection.13

as Figure 1 illustrates, after nutritional status screening, caregivers of nonmalnourished children are reminded of the importance of periodic nutritional assess ments, and in some programs they may receive specific nutritional counseling and/or other preventive services. Children with mam or sam without complications are generally referred to a local treatment center for outpatient dietary management and treatment of concurrent infections. the relatively small proportion of children with sam and clinical complications that are severe are treated at inpatient centers, as described below; however, outpatient treatment could be considered for children with sam and complications that are not severe. Children treated as inpatients are referred back to the community for con-tinuing dietary management as soon as their underlying medical complications have stabilized and metabolic homeostasis has been achieved.

Treatment: general principleschildren with SAM and complicationsthe major clinical complications of sam are fluid and electrolyte imbalances and other metabolic distur bances, systemic infections, and deficits of macro nutrients and micronutrients. these conditions require urgent at tention. thus, treatment is divided into two phases: initial

Table 1 | Criteria for severe or moderate acute malnutrition in young children*

criteria SAM‡ MAM§

weight for height Z-score <–3 sD; or weight <70% reference median for height

Z-score <–2 sD and ≥–3 sD;or weight <80% and ≥70% reference median for height

Mid-upper arm circumference <115 mm <125 mm and ≥115 mm

Bipedal edema Present or absent Absent

*Based on a wHO and UNiCeF document on the application of wHO 2006 Growth standards for the identification of severe acute malnutrition in infants and children.34 The wHO 2006 growth standard40 is the recommended source of anthropometric reference data. ‡sAM may be considered to be present if one of the anthropometric criteria is fulfilled or bipedal edema is present. §MAM may be considered to be present if one of the anthropometric criteria is fulfilled and bipedal edema is absent. Note, the mid-upper arm circumference cut-off for MAM is still under review. individual country programs may choose different diagnostic criteria for sAM and MAM, depending on local resources and other factors.

Table 2 | Prevalence of wasting and stunting by UN region*

region children aged <5 years(millions)

Wasting‡

(%)Stunting§

(%)

west and Central Africa 66.3 10 36

east and southern Africa 61.3 7 40

All sub-saharan Africa 127.6 9 38

Middle east and North Africa 44.8 8 26

south Asia 175.2 18 38

east Asia and Pacific 144.4 Nr 16

Latin America and Caribbean 55.6 2 16

All developing countries 562.1 11 30

world 629.1 11 28

*Data from the UNiCeF’s state of the world’s Children 2009.3 ‡weight for height Z-score <–2 sD. §Height-for-age Z-score <–2 sD. Abbreviation: Nr, not reported.

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stabilization and treatment of life-threatening clinical complications, followed by nutritional rehabilitation.

management of fluid and electrolyte balance in severely malnourished children is particularly challenging because sam is often accompanied by diarrhea, and sam and diarrhea affect fluid and electrolyte balance in different ways. in particular, children with sam generally have sodium retention and increased total body water, whereas children with diarrhea generally have sodium and water deficits. By contrast, potassium deficits are common to both of these conditions and are often quite profound; therefore, potassium replacement is an important compo nent of treatment. indeed, one trial found that the case fatality rate was reduced by one-third when children with edematous malnutrition received 8 mmol potas-sium/kg body weight daily in the maintenance diet rather than the standard provision of 4 mmol potassium/kg body weight daily.14

in children with sam and diarrhea, fluids need to be replaced and sodium deficits treated to maintain intra-vascular volume (as assessed clinically by pulse rate and blood pressure) without inducing excess tissue fluid retention and edema, which would increase the risk of congestive heart failure. Furthermore, sufficient potas-sium supplementation should be provided. specially for-mulated oral rehydration solutions with reduced sodium content (45 mmol/l, rather than the standard 75 mmol/l

solution) and increased potassium content (40 mmol/l, instead of 20 mmol/l) have been developed for children with sam.10,15,16

severely malnourished children may not display the usual clinical signs of infection13 and laboratory diag-nosis may not be feasible; therefore, infections should be treated presumptively by the use of broad spectrum antibiotics, selected on the basis of local antibiotic sensi-tivity patterns. antimalarial drugs are also included in the treatment regimen in regions where malaria is endemic. age-appropriate immunizations are provided, as necessary, to prevent hospital-acquired infections, and antihelminthic drugs are administered in settings with a high prevalence of intestinal parasites. a recent meta-analysis of 17 studies of Hiv prevalence among children undergoing treatment for sam in sub-saharan africa found that nearly 30% were infected with Hiv and that Hiv-infected children had an almost threefold increased risk of case fatality compared with those who were not infected.17 thus, children with sam from areas where Hiv is endemic should be screened for Hiv status, and if found to be Hiv-positive they may require more intensive therapy than noninfected children.

severely malnourished children with medical complica-tions are susceptible to hypoglycemia and tempera-ture instability, so frequent feeding must be provided around the clock and children must be protected from

Community-based or facility-based screening(examine for presence of edema and measure WHZ and/or MUAC)

WHZ ≥–2 SD andMUAC ≥125 mmwithout edema

Deterioration of nutritional status Appearance of complication orloss of appetite

WHZ <–3 SD orMUAC <115 mm and poor appetiteor edema (++/+++)

SAM with complications

Inpatient therapeuticfeeding center

·Treatment of complications·Antibiotics·Malaria treatment·Therapeutic milk formula (F-75 F-100)·Antihelminths·Measles vaccination·Vitamin A supplementation·Nutrition education

WHZ <–3 SD orMUAC <115 mm and adequate appetite(edema + or no edema)

SAM without complications

Outpatient therapeuticfeeding program

·RUTF·Antibiotics·Malaria treatment·Antihelminths·Measles vaccination·Vitamin A supplementation·Nutrition education

MAM

Supplementary feeding program

·Supplementary food (RUSF, fortified cereal or dietary counseling)·Vitamin A supplementation·Antihelminths·Iron (or MMN) supplement·Nutrition education

Nonacutely malnourished

Preventative services

·Nutrition education·Immunizations·Vitamin A supplementation·Antihelminths·Schedule for next screening

WHZ <–2 SD, ≥–3 SD, orMUAC <125 mm, ≥115 mmwithout edema

No complications, improved appetite:transfer to outpatient treatment program

Figure 1 | screening and treatment algorithm for acutely malnourished children, 6–59 months of age (based on material from the wHO/UNiCeF 2009 Guidelines34 and wHO 2006 Growth standards40). edema +, puffiness of dorsum of feet; edema ++, pitting edema of lower extremities; edema +++, generalized edema. Abbreviations: MAM, moderate acute malnutrition; MMN, multiple micronutrient supplement; MUAC, mid-upper arm circumference; sAM, severe acute malnutrition; rUsF, ready-to-use supplementary food; rUTF, ready-to-use therapeutic food; wHZ, weight for height Z-score.

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cold exposure. special reduced-lactose, milk-based formulas—F-75 and F-100, as described in detail in the wHo treatment manual10—have been developed to meet the nutritional needs of such children. F-75 is a low-lactose, low-protein milk that provides 75 kcal/100 ml, which is used in the initial stabilization phase. F-100 has higher energy (100 kcal/100 ml) and protein content than F-75, and is used to promote tissue synthesis during the early rehabilitation phase. liquid formulas are generally well accepted even by anorectic children, but they can be delivered by nasogastric tube, if necessary, to children who refuse to drink.

a single high-dose vitamin a capsule (50,000–200,000 iu, depending on age) is recommended during the first day of treatment in areas with endemic vitamin a deficiency and xerophthalmia. Despite the high risk of iron deficiency in children with sam, iron supplements are withheld during the first 1–2 weeks of treatment to avoid their possible contribution to oxidative stress.

nutritional rehabilitation of children with sam has been evaluated in controlled clinical trials. aspects of nutritional therapy that have been studied include the level of energy intake and velocity of recovery; the minimum dietary energy density required for rapid com-pensatory weight gain; the amount and source of protein intake; the amounts of selected minerals, vitamins, and antioxidants; the site of rehabilitation (facility-based versus community-based); and the importance of psycho-social stimulation. space limitations preclude a detailed discussion of each of these topics, but energy intake and velocity of recovery will be discussed briefly below.

studies conducted in the 1960s in Jamaica demonstrated the clear relationship between energy intake and rate of weight gain during recovery from sam among hospital-ized children who received a milk-based diet.18 these studies found that children gained 3–16 g/kg body weight per day when they consumed ~110–200 kcal/kg body weight per day during the period of nutritional recovery; intakes of 175 kcal/kg body weight per day were associated with mean weight gains of ~10 g/kg body weight per day. investigators in Peru later showed that ad libitum energy intake by malnourished children during nutritional recov-ery was directly related to the energy density of their diets and frequency of feeding, and that mean energy intakes of 175 kcal/kg body weight per day were achievable with dietary energy densities of ~1.5 kcal/g when four or five meals were provided daily.19

Concerns that overly rapid weight gain during nutri-tional recovery might result in excessive accrual of body fat prompted the investigators in Peru to compare the body composition of children who were randomly assigned to receive enough of a milk-based formula diet to permit either weight gain of 6 g/kg body weight per day or 12 g/kg body weight per day.20 the investigators found that children in both groups achieved the same final percentage fat mass, which was consistent with refer ence norms. they concluded that rapid weight gain with a nutritionally complete diet significantly reduced

the time required for compensatory growth during recovery from malnutrition without adversely affecting the children’s final body composition.

Children with sam and complications can be managed as outpatients, as described below for children with sam without complications, as soon as any acute infections are controlled and appetite returns (usually within a few days to a week).

children with SAM without complicationsthe general approaches for the treatment of children who have sam without complications are the same as for those who have sam with complications, except that the former can tolerate oral feedings and oral antibiotic therapy for infections, so facility-based treatment is not necessary.

the availability of lipid-based, rutF represents a recent major advance in the treatment of children with sam without complications. these products, which are usually prepared from peanut paste, milk powder or soy protein, vegetable oil, sugar, and vitamin and mineral pre-mixes, have very low water activity, so they are resistant to bacterial proliferation and do not require refrigera-tion.11 the products are energy dense (~4.5 kcal/g) and well accepted by young children, and they allow for high energy intakes and rapid rates of weight gain.

as summarized in table 3, several studies have docu-mented favorable responses to rutF as compared with milk-based formulas21 or cereal–legume blends22–24 for the nutritional rehabilitation of severely malnourished children. Furthermore, rutF produced locally in africa has performed as well as rutF imported from europe.25 successful community-based nutritional rehabilitation has been achieved under operational conditions, even in emergency settings.26–28 one study also found a bene-ficial effect on recovery from stunting among refugee children who received a micronutrient-fortified rutF and treatment for parasites compared with children in a non intervention group. However, children who received the same treatment regimen with unfortified rutF did not grow more rapidly than those in the non intervention group.29 on the basis of the various sets of success-ful results and the logistical advantages of rutF, these products have become the mainstay of community-based treatment programs when they are available.

with the increased availability of such user-friendly therapeutic diets, the site of nutritional rehabilitation can be shifted more easily from facility-based to community-based treatment. several investigators have compared the results of these two approaches in randomized trials. two studies found greater rates of weight gain among hospital-ized children than those treated in the community,30,31 but another found that children treated at home and followed in the community gained more weight than those treated at home and followed at the same (more distant) hospital where they initially received stabilization therapy.32 in all cases, the community-based approaches were consider-ably less expensive than hospital-based treatment, and the mortality rates and longer term nutritional status (when

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measured after 3–6 months) did not differ. notably, the children’s caregivers consistently preferred community-based approaches to hospital-based treatment. thus, to maximize the number of children who can benefit from treatment, community-based programs are clearly advan-tageous, even though the course of treatment may need to be prolonged.

ashworth reviewed the effectiveness of 33 community- based treatment programs for children with sam, includ-ing domiciliary rehabilitation programs and programs at community residential centers, day-care facilities, and primary health-care clinics.33 although she found that only one-third of the reviewed programs were con-sidered effective (defined as mortality rates <5% and mean rate of weight gain >5 g/kg body weight per day), this effectiveness depended more on the type of services that were provided than the site where these services were delivered. in particular, she concluded that provision of high-energy intakes (either as rutF or as a result of high-quality nutritional counseling concerning appropriately formulated, energy-dense home diets), adequate protein, and supplemental micronutrients were all essential for adequate nutritional recovery.

wHo and uniCeF have recently revised their guide-lines on indicators of nutritional recovery.34 Previously, specific cut-offs of weight for height Z-scores were

suggested as criteria for defining recovery and terminat-ing the intensive phase of nutritional therapy. How ever, it is now recognized that some younger children with mid-upper arm circumference below the cut-off for sam may actually have weight for height Z-scores above the respective cut-offs, so the newly proposed criterion of recovery is weight gain of 15–20% over baseline weight and absence of edema for at least 2 weeks, regardless of the initial weight for height Z-score.

children with MAMChildren who become severely wasted must first pass through a period of moderate wasting before their weight for height Z-score falls below –3 sD. thus, an important strategy for the prevention of sam is to identify and treat mam successfully. Children with mam also have an elevated mortality risk; therefore, nutritional therapy of these children is further justified for its own sake. indeed, the higher prevalence of mam than sam means that children with mam actually account for a similar number of malnutrition-associated deaths as children with sam.9 treatment of mam consists of appropriate therapy for accompanying infections and an enhanced therapeutic diet.

the nutritional requirements for compensatory growth during recovery from mam have received only limited

Table 3 | studies of ready-to-use therapeutic food in the treatment of children with severe acute malnutrition

Study inclusion criteria N (age) Study design Treatment groups (duration) outcome

Diop et al. (2003)21

wHZ<–2 sD; no edema (mixed MAM, sAM)

70 (6–36 months)

rCT rUTF (13 days) vs F-100 (17 days), both offered in unlimited amounts, and local recipes

energy intake and weight gain with rUTF

Manary et al. (2004)22

Nr(mean wAZ –3.4 sD);Hiv neg

186* (12–60 months)

rCT‡ rUTF vs maize–soy flour blend + vM (16 weeks), both at 175 kcal/kg Bw/day

% recovery; weight, height, and MUAC gain with rUTF

sandige et al. (2004)25

wHZ <–2 sD or edema;Hiv neg

182 (12–60 months)

systematically assigned CT

Local rUTF vs imported rUTF (16 weeks), both at 175 kcal/kg Bw/day

95% recovery rate (wHZ >–0.5 sD) by median of 43 days; no group-wise differences

Ndekha et al. (2005)24

Hiv pos and “severely malnourished” (mean wAZ ~ –3.6 sD)

65* (12–60 months)

rCT‡ rUTF (71 days) vs maize–soy flour blend + vM (115 days), both at 175 kcal/kg Bw/day

weight gain and % recovery with rUTF

Ciliberto et al. (2005)23

wHZ <–2 sD or mild edema, no anorexia (mixed MAM, sAM; sAM analyzed separately)

1,178 (10–60 months)

Pre-post, step-wedge

rUTF (175 kcal/kg Bw/day) vs F-100, followed by a “generous amount” of maize–soy flour blend (8 weeks)

weight, height, and MUAC gain and fewer treatment failures with rUTF (MAM or sAM)

Collins and sadler (2002)26

weight for height <70% median or edema (no exclusions)

170 (6–120 months)

Observational rUTF (~1000 kcal/day) + maize–soy flour blend (~2000 kcal/day); no comparison group (median 42 days)

85% recovery; 4% fatality in emergency relief program; weight gain ~3 g/kg Bw/day

Ciliberto et al. (2006)27

Mild edema; no anorexia

219 (12–60 months)

Observational rUTF (175 kcal/kg Bw/day); no comparison group (8 weeks)

83% recovery; 5% fatality; weight gain ~3 g/kg Bw/day

Linneman et al. (2007)28

weight for height <70% median; no edema, anorexia

2,131 (6–60 months)

Observational rUTF (175 kcal/kg Bw/day); no comparison group (8 weeks)

89% recovery; 1% fatality in standard operational setting

*Only the two groups that received 175 kcal/kg Bw/day of the respective food supplements were included in this analysis. ‡Diets assigned by day of hospital discharge. Abbreviations: Bw, body weight; CT, (systematically assigned) controlled trial; F100, wHO-recommended reduced-lactose, milk-based therapeutic formula; MAM, moderate acute malnutrition; MUAC, mid-upper arm circumference; Nr, not reported; rCT, randomized clinical trial; rUTF, ready-to-use therapeutic food; sAM, severe acute malnutrition; vM, vitamins and minerals; wAZ; weight for age Z-score; wHZ, weight for height Z-score.

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research attention. in a recent review paper, Golden cor-rectly concluded that these requirements must fall some-where between the theoretical requirements of healthy children and the requirements for the rehabilitation of children with sam, which can be accomplished with the F-100 formula or appropriately formulated rutF.35 some investigators have proposed the use of rutF for the community-based treatment of children with mam because of the success reported with rutF for the treat-ment of severely malnourished children. However, lipid-based products are more expensive than fortified cereal–legume blends, so the use of rutF for children with mam remains controversial.

although fortified cereal–legume blends are the dietary option most often proposed for the treatment of mam, concerns have been raised that the currently available preparations, such as corn–soy blend, may not contain optimal levels of all nutrients for the full age range of children covered by community-based pro-grams; furthermore, antinutritional factors, like phytate, antitrypsin, lectins, and hemaglutinins, which are present in wholegrain and partially milled cereals and legumes, can interfere with nutrient utilization.36 thus, several studies have been conducted to compare treatment out-comes with the respective dietary regimens. the few available trials have produced mixed results, although the outcomes are difficult to interpret because of differences in the study entry criteria, the duration of treatment, and the amounts of therapeutic foods that were provided.

in one trial, moderately underweight, stunted malawian children who were assigned to receive either rutF or a maize–soy flour blend, each of which provided 500 kcal per day for 12 weeks, had no significant differences in weight gain or linear growth during the period of supple-mentation.37 By contrast, another study by some of the same researchers found that a mixed group of children with either sam or mam who received ~1,000 kcal per day rutF (to provide ~175 kcal/kg body weight per day) had significantly greater recovery rates, weight gain, and linear growth than their counterparts who received “a generous supply of maize-soybean flour supplemented with vitamins and minerals, according to specifications of the world Food Program”.28

Finally, a new effectiveness trial in malawi compared rates of recovery from mam among outpatient chil-dren 6–60 months of age with initial weight for height Z-score <–2 sD but ≥–3 sD who received an additional 75 kcal/kg body weight per day as milk–peanut rutF, soybean–peanut rutF, or corn–soy blend.38 Children

who received either form of rutF had slightly greater recovery rates within 8 weeks of treatment (80% versus 72%), shorter times to recovery, and faster rates of weight gain and change in mid-upper arm circumference (but not height) than those who received the corn–soy blend. However, the two forms of rutF cost two to four times more than the corn–soy blend, so it is uncertain whether the small differences in treatment outcomes would merit the additional costs implied, although a formal cost-effectiveness analysis (including clinic staff time and household opportunity costs) has not yet been reported.

Conclusionstremendous progress has been achieved in the manage-ment of children with sam and mam by extending the reach of treatment programs through community mobilization activities and community-based diagnosis and treatment. However, questions remain concerning the most cost-effective dietary regimens that are simple enough to apply in isolated communities by minimally trained field staff. even in clinical settings, high staff turnover necessitates frequent retraining, and increased effort is needed to incorporate the newer nutritional rehabilitation approaches in the curricula of schools of medicine, nursing, and other applied health profes-sions and to bring these newer approaches into more widespread use.39 nevertheless, great scope for opti-mism exists, as case fatality rates generally fall as soon as systematic treatment protocols are implemented and related staff training is completed. in addition, national governments and international donors are increasingly investing in community-based management of acute malnutrition activities.

Review criteria

The PubMed database was searched for articles published in the english language from 1988–2008 that included any one of the following search terms or keywords: “acute malnutrition”, “protein-energy malnutrition”, “marasmus”, “kwashiorkor”, “nutritional rehabilitation”, or “ready-to-use therapeutic food”. The searches were restricted to clinical trials that were conducted in humans, specifically, children from birth to 5 years. we also accessed relevant documents prepared by wHO staff members and participants in expert consultations, and we retrieved related articles cited in the foregoing references.

1. Briend, A., Prudhon, C., Prinzo, Z. w., Daelmans, B. M. & Mason, J. B. Putting the management of severe malnutrition back on the international agenda. Food Nutr. Bull. 27 (Suppl. 3), s3–s6 (2006).

2. Amadi, B. et al. reduced production of sulfated glycosaminoglycans occurs in Zambian children with kwashiorkor but not marasmus. Am. J. Clin. Nutr. 89, 592–600 (2009).

3. UNiCeF. state of the world’s Children 2009: Maternal and Newborn Health (UNiCeF, New York, 2009).

4. Myatt, M. & Duffield, A. weight-for-height and MUAC for estimating the prevalence of acute undernutrition? [online] http://www.humanitarianreform.org/humanitarianreform/Portals/1/cluster%20approach%20page/clusters%20pages/Nutrition/Myatt_sAve_UK_

MUAC_Nutrition_Cluster_Oct22_07_section1_2_Optimized.pdf (2007).

5. Prudhon, C., Prinzo, Z. w., Briend, A., Daelmans, B. M. & Mason, J. B. Proceedings of the wHO, UNiCeF, and sCN informal consultation on community-based management of severe malnutrition in children. Food Nutr. Bull. 27 (Suppl. 3), s99–s104 (2006).

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6. wHO, world Food Programme, United Nations system standing Committee on Nutrition & UNiCeF. Community-based management of severe acute malnutrition [online] http:// www.who.int/nutrition/publications/severemalnutrition/978-92-806-4147-9_eng.pdf (2007).

7. Black, r. e. et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 371, 243–246 (2008).

8. schroeder, D. G. & Brown, K. H. Nutritional status as a predictor of child survival: summarizing the association and quantifying its global impact. Bull. World Health Organ. 72, 569–579 (1994).

9. Pelletier, D. L., Frongillo, e. A. Jr, schroeder, D. G. & Habicht, J. P. The effects of malnutrition on child mortality in developing countries. Bull. World Health Organ. 73, 443–448 (1995).

10. world Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers [online] http://whqlibdoc.who.int/hq/1999/ a57361.pdf (1999).

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AcknowledgmentsHelen Keller international’s programs to institutionalize the community-based management of acute malnutrition in Burkina Faso, Mali and Niger are funded by the United states Agency for international Development Office of Foreign Disaster Assistance, the richard and rhoda Goldman Fund and the Monsanto Fund, with in-kind support from UNiCeF and the world Food Program.

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