|Efficacy and effectiveness of community-based treatment of severe malnutrition
The author concluded that day-care nutrition centres, residential nutrition centres, primary health clinics and domiciliary rehabilitation can, if adequately resourced and planned, be effective in the treatment of severe malnutrition. The author's conclusions appear to be supported by the review but, given the absence of a validity assessment and differences between the studies, the reliability of the findings is unclear.
To evaluate the effectiveness of community-based rehabilitation programmes for severely malnourished children in non-emergency situations.
MEDLINE, PubMed, POPLINE, CAB Abstracts (via BIDS) and the Cochrane Library were searched from 1980 to 2005; the search terms were not reported. In addition, 93 contacts were asked for details of additional published and unpublished studies.
Study designs of evaluations included in the review
Inclusion criteria were not specified in terms of study design.
Specific interventions included in the review
Studies that evaluated community-based rehabilitation programmes in non-emergency situations were eligible for inclusion. In the review, these programmes were defined as treatments that were implemented at home with some external input, or treatments given at a primary health clinic, community day-care centre or residential centre and aimed at catch-up growth. Studies of supplementary feeding programmes for the prevention of malnutrition and studies set in hospital compounds were excluded. The included studies evaluated day-care nutrition centres, residential nutrition centres, primary health clinics and domiciliary rehabilitation (with and without the provision of food). The studies were conducted in a variety of countries. The duration of the interventions, where reported, ranged from 10 days to a mean of 8.7 months; some studies continued the treatment until the child reached a predefined weight.
Participants included in the review
Studies of severely malnourished children were eligible for inclusion. The review defined severe malnutrition as a weight-for-height z-score of less than three standard deviations or the presence of oedema. Studies of children with mild to moderate malnutrition were excluded. All of the included studies were of children aged less than 5 years (or with a mean age of less than 5 years).
Outcomes assessed in the review
Inclusion criteria were not specified in terms of outcomes, but it was clear that the review focused on studies that assessed mortality and weight gain.
How were decisions on the relevance of primary studies made?
The author did not state how the papers were selected for the review, or how many reviewers performed the selection.
Assessment of study quality
The author did not report any formal assessment of validity. However, some aspects of quality such as sample size, adequacy of reporting and losses to follow-up were noted in the text.
The author did not state how the data were extracted for the review, or how many reviewers performed the data extraction.
For each study, where possible, mortality and relapse rates during rehabilitation and follow-up were presented together with measures of weight gain or progress. Each study was classified as effective (mortality less than 5% and a weight gain of at least 5 g/kg per day) or not effective.
Methods of synthesis
How were the studies combined?
The studies were grouped by type of rehabilitation programme and combined in a narrative. Studies that were classified as effective were described in detail in the text.
How were differences between studies investigated?
Potential reasons for the lack of effectiveness of interventions were discussed. Studies in which weight loss may have been confounded by loss of oedema fluid were noted in the text.
Results of the review
Thirty-three studies (n=10,932) were included: 11 randomised controlled trials (RCTs; n=1,840), 1 non-randomised controlled study (n=1,178), 2 case-control studies (n=1,250) and 19 observational studies (n=6,664).
Methodological problems included small sample size, inadequate information and a high rate of loss to follow-up. Day-care nutrition centres (6 studies: 1 RCT, 1 case-control and 4 observational studies). All of the studies provided meals cooked on site and, overall, the effectiveness of the interventions was described as low with the exception of one assessed in an observational study (n=161) conducted in Bangladesh. This study assessed an intervention (mean duration 4 weeks) which included high doses of vitamin A, antibiotics if required, three meals plus two snacks per day made from low-cost energy-rich locally available food, staffing by trained volunteers, health education and active participation of the mothers. Residential nutrition centres (4 observational studies). One small observational study conducted in South Africa was described as assessing an effective intervention, but the reviewers suggested that this intervention may have been better resourced than usual. The intervention (mean duration 10 days) included three meals plus three snacks per day made from high-energy, high-protein family foods, and teaching income generation skills and self-sufficiency skills to the mothers. Primary health clinics (7 studies: 1 case-control study and 6 observational studies). Two studies, including 1 case-control study (n=1,038) conducted in Guinea Bissau and 1 observational study (n=373 with oedema) conducted in Malawi, were classified as assessing effective interventions. The case-control study (mean duration 13 weeks) included attendance at day-care centres after a village discussion, and three to four milk-based meals per day, plus food to take home. The observational study included an in-patient stay (mean 19 days), antibiotics, and a milk-based diet followed by enriched porridge in six feeds per day. Domiciliary rehabilitation (16 studies: 10 RCTs, 1 non-randomised controlled study and 5 observational studies). Seven studies (6 RCTs and 1 observational study) were reported to show effective home-based rehabilitation interventions with or without the provision of food. These included: 1 RCT conducted in Bangladesh comparing in-patient care, day-care and day-care followed by domiciliary care; 1 RCT conducted in Bangladesh comparing domiciliary rehabilitation plus either home visits or clinic visits with continued in-patient care; 2 RCTs (n=47 in Senegal, and n=260 in Malawi), both with in-patient care (duration 7 to 12 days), comparing local and imported ready-to-use-therapeutic-food (RUTF); 1 RCT (282 human immunodeficiency virus(HIV)-negative and 93 HIV-positive children in Malawi) providing in-patient care (mean duration 11 to 14 days) followed by home care with one-third of a ration of RUTF or a fortnightly ration of 34 kg of maize/soy flour; 1 RCT (n=95 in Sierra Leone) comparing in-patient care with in-patient care followed by care at home with RUTF provided; and 1 observational study (n=2,209 in Niger) comparing in-patient care, care at home with RUTF provided and in-patient care followed by care at home.
One study in Bangladesh reported that domiciliary rehabilitation was half the cost of day-care and one-fifth the cost of in- patient treatment. One study in Malawi reported lower costs of local compared with imported RUTF ($22 versus $55 per child).
Day-care nutrition centres, residential nutrition centres, primary health clinics and domiciliary rehabilitation can, if adequately resourced and planned, be effective in the treatment of severe malnutrition. Where children can be monitored they should be rehabilitated in the community rather than hospital, but only if either carers can make energy and protein-rich foods or RUTF is provided.
The review addressed a clear question that was defined in terms of the participants and intervention; inclusion criteria were not defined for outcomes or study design. Several relevant sources were searched and attempts were made to minimise publication bias. It is not clear whether any language limitations were applied, so the potential for language bias could not be assessed. Study validity was not formally assessed, making it difficult to determine the reliability of the data. The review methods were also poorly reported, so it is difficult to assess their reliability in terms of the potential for reviewer error and bias. However, in view of the differences between the studies, a narrative synthesis grouped by intervention type appeared appropriate. Potential reasons for differences between the studies were also discussed. The author's conclusions appear to be supported by the review but, given the absence of a validity assessment and the high level of heterogeneity between the studies, the reliability of the findings is unclear.
Implications of the review for practice and research
Practice: The author stated that there is an urgent need to provide additional resources to improve hospital treatment of people with severe malnutrition and to establish community-based programmes for rehabilitation and prevention. They stated that the choice of delivery system for community rehabilitation programmes should take local conditions into account. Programmes need to provide a high-energy intake (more than 150 kcal/kg per day), high-protein intake (4 to 6 g/kg per day) plus micronutrients.
Research: The author stated that there is a need for future research to compare the cost-effectiveness of different methods of delivering community-based rehabilitation, including the location of treatment and type of food; to evaluate the effectiveness of incorporating community-based rehabilitation programmes into routine health services; to determine the most effective number of visits; to develop effective transfer systems between hospital and clinics; to identify the characteristics of children that fail to gain weight rapidly; to assess the effects of home visits on the wider community; to determine whether community-rehabilitation programmes can encourage nutrition-related activated within clinics; and to identify and evaluate teaching programmes for mothers and caregivers.
Ashworth A. Efficacy and effectiveness of community-based treatment of severe malnutrition. Food and Nutrition Bulletin 2006; 27(3): S24-S48
Subject indexing assigned by NLM
Child Health Services /economics; Child Nutrition Disorders /mortality /prevention & Child Nutritional Physiological Phenomena; Child, Preschool; Community Health Services /economics /methods; Cost-Benefit Analysis; Day Care /economics /methods; Dietary Proteins /administration & Energy Intake; Female; Health Care Costs; Home Care Services /economics; Hospitalization /economics; Humans; Infant; Male; Micronutrients /administration & Treatment Outcome; Weight Gain; control /therapy; dosage; dosage
Date bibliographic record published
Date abstract record published
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