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Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India
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  • Published on:
    RE: Response of the authors to the E-letters
    • NITA BHANDARI, Doctor Society for Applied Studies Centre for Health Research and Development

    Drs. Dadhich and Prasad raise important issues in their comments and questions about our study on home-based management of children with uncomplicated severe acute malnutrition (SAM).  We are grateful for the opportunity to respond to them.

    In our view, there are two distinct goals in the management of children with SAM. The first, and more urgent, is to treat and move them away from severe malnutrition, a state of high risk of death. The second is to rehabilitate them to the point they are no longer malnourished. The treatments examined in the study achieved the first goal well. By the end of the treatment phase, 84.5% of the children in the RUTF-L group were no longer SAM. However, they did less well in achieving the second goal.  By the end of the treatment phase, 57% of those receiving RUTF-L had recovered to the point of no longer being malnourished. Should we have applied the same approach as most studies to calculate their WHZ - using height at enrolment and current weight, rather than concurrently measured height and weight - 81% of the children in the RUTF-L group would no longer be classified as malnourished by the end of the treatment phase.

    We note Dr. Prasad’s misunderstanding that over 40% of the children in our study remained SAM by the end of the treatment with RUTF-L. Should her interpretation have been correct, it would justify her expressed concern. However, as stated above, by the end of the treatment phase 84.5% of the c...

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    Conflict of Interest:
    None declared.
  • Published on:
    RE: Is it prudent to recommend RUTF in India based on the results of this trial?
    • Dr. JP DADHICH, Paediatrician Breastfeeding Promotion Network of India (BPNI)
    This RUTF trial from India has compared the efficacy of  RUTF (centrally produced and locally produced) with augmented energy-dense home-prepared foods (comparison group) for home based management of uncomplicated severe acute malnutrition (SAM). 
     
    I would like to draw attention of the authors on following issues. 
     
    1. The study reports that 40% children affected with SAM in the study did not recover even with a prolonged (16 weeks), supervised treatment with RUTF and other supportive measures like deworming, antibiotics at the initiation of treatment and increased access to healthcare for morbidity. The recovery rate was 17.3% with the use of locally produced RUTF and 12.1% with centrally produced RUTF at 16 weeks after the end of treatment phase. With such low recovery rates, is it prudent to make a recommendation for the policy that “Children with uncomplicated SAM can be managed at home with RUTF instead of through inpatient hospitalization”?
    2. In this trial, researchers aimed to achieve an intake of 175 kcal/kg body weight/ day for the enrolled children and collected consumption data for both the RUTF groups which were largely comparable. But they fail to do so for the comparison group stating greater difficulty in capturing valid information. Authors need to explain if this has led to a less th...
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    Conflict of Interest:
    None declared.
  • Published on:
    RE: Reading Between the Lines of the RUTF trial, India
    • Vandana Prasad, Community Paediatrician and Public Health Professional Public Health Resource Network

        Reading Between the Lines of the RUTF trial, India
    Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
    It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...

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    Conflict of Interest:
    None declared.