Effectiveness of Context-adapted Alternative Feeding Regimen on Recovery of Children Aged 6-59 Months From Moderate Acute Malnutrition and Uncomplicated Severe Acute Malnutrition in Bangladesh. A Cluster Randomized Control Trial

Background

Burden:

Acute Malnutrition (AM) which is also known as 'wasting' in children under five years of age is a major and significant global health problem. It has two forms: i) Severe Acute Malnutrition [(SAM, defined as weight-for-height/length z-score (WHZ/WLZ) less than -3 standard deviations (SDs) from the median of reference population and or Mid-Upper Arm Circumference (MUAC) < 115mm, and or presence of bipedal edema)], and ii) Moderate Acute Malnutrition [(MAM, defined as WHZ/WLZ between -3SDs and <-2SDs and or MUAC ≥ 115mm to <125mm)]. It is estimated that more than half of all under five deaths are associated with undernutrition. Both MAM and SAM pose serious consequences, leading to increased morbidity and mortality, impaired intellectual development, increased risk of non-communicable diseases (NCDs) in adulthood, and suboptimal adult work capacity. Children with SAM have approximately nine times and children with MAM have approximately three times higher risk of mortality due to common communicable diseases than if they were well-nourished. A MAM child is additionally at higher risk of developing SAM if their health and nutritional condition is not monitored. The recent Lancet analysis estimated that in 2020, the COVID19 pandemic exacerbated the problem of AM with an additional 6.7 million children - equivalent to a 14.3% increase in the number of children with wasting. More than half (3.9 million) of these children would be from South Asia alone. Although prevalence of AM in many countries have reduced, still these are far from Sustainable Development Goals (SDGs) target.

Despite Bangladesh already progressed in reduction of AM by more than half between 2007 and 2017, still it has one of the highest prevalence of AM in the world. According to Bangladesh Demographic and Health Survey (BDHS) 2017 prevalence of AM under-5 children was 8.4%, while the multiple indicator cluster survey (MICS) which included a larger sample, found a slight increase from 9.6% in 2013 to 9.8% (1.5 million) in 2019. Of the total AM, 7.5% (1.1-1.2 million) were MAM. It depicts that currently in terms of reducing the prevalence of wasting among children under five to <5 %, Bangladesh has to go far away to achieve the SDG target 2.2 by 2025. It was observed that despite having recovery rate above the minimum standards of >75%, post-discharge relapse rates of AM were very high (78% for MAM 69% while 9% for SAM) in Bangladesh and Southern Ethiopia 72.1% (37.5% for MAM and 34.6% for SAM). Chang et al. 2013 found 27% (17% for MAM and 10% for SAM) relapse cases in Malawi. Therefore, after recovery and discharge a child should be followed up to assess the maintenance of the nutritional status, because it is likely that children who recovered from AM may recur as AM after returning to the same environment.

Knowledge gap: