Comparing two transition feeding approaches in management of severe acute malnutrition among children 6-59 months : a randomized controlled trial

Abstract

Severe acute malnutrition (SAM) remains a public health concern and a leading cause of illness and death among children under five years. SAM is associated with unacceptably high case fatality rates that have been partly attributed to poor case management, knowledge gaps and vague clinical guidance. As a consequence, the World Health Organization (WHO) has championed for great improvements in management of SAM. In 2013, WHO made a strong recommendation for direct transition from F-75 to ready-to use therapeutic feeds and proposed two transition phase feeding approaches. Nevertheless, glaring key questions and gaps in empirical data to affirm the appropriateness and outcomes of these feeding approaches used in transition phase remain. This study compared the effectiveness and safety of the two transition feeding approaches; RUTF supplemented with F75 (plan A) and RUTF exclusively (plan B) among children 6-59 months hospitalized with SAM. An open-label two arm-parallel randomized controlled study was conducted. 158 children were randomized to either plan A or plan B and followed up. Successful transition to RUTF was achieved when the child consumed all the RUTF prescribed without developing any complication. Conversely, failed transition occurred if the child developed complications like diarrhoea, vomiting, anorexia and developing or worsening of oedema. Descriptive statistics were presented as frequencies and median for categorical and continuous variables respectively. For comparisons, chi-square and Mann-Whitney test were used for categorical and continuous variables respectively. Poison regression technique was fitted to identify predictors associated with failed transition. Overall, 76% of the children enrolled on the study successfully transitioned from F75 to RUTF over 2–3 days. There was no statistical difference (p-value=0.16) in the proportion of children that successfully transitioned on either plan A or B. The length of stay on Plan A (3 days IQR 2-4) was significantly (p-value <0.001) longer than on plan B (2 days IQR 2-2). The key predictors of failed transition feeding were female gender and degree of wasting measured by MUAC and weight-for-height/length Z-scores. Females were three times more likely to fail compared to males (aRR = 3.02, 95% CI=1.03-8.83; p-value=0.04). The risk of transition feeding failure significantly decreased by 39% for every unit increase in MUAC (aRR 0.61; 95% CI = 0.38-0.99; p-value=0.04). Diarrhea was the most prevalent complication among children that failed to transition from F75 to RUTF. These findings indicate that successful transition from F75 to RUTF can be achieved safely and effectively using either plan A or B within the period recommended by the WHO. Children transitioned shorter on Plan B compared to Plan A. Health workers should be cognizant of the increased risk of failure in transition feeding hence pay close attention to the females and very severely wasted children.