Das Jai K, Salam Rehana A, Saeed Marwah, Kazmi Faheem Ali, Bhutta Zulfiqar A
Division of Women and Child Health Aga Khan University Hospital Karachi Pakistan.
Division of Women and Child Health, Aga Khan University Karachi Pakistan.
Campbell Syst Rev. 2020 Apr 9;16(2):e1082. doi: 10.1002/cl2.1082. eCollection 2020 Jun.
Childhood malnutrition is a major public health concern as it is associated with significant short- and long-term morbidity and mortality.
To comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization protocol using facility- and community-based approaches as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use and vitamin A supplementation.
We searched relevant electronic databases till 11 February 2019. No date or language restrictions were applied.
We included randomised controlled trials (RCTs) and quasi-experimental studies including controlled before-after (CBA) studies and interrupted time series (ITS) studies.
Two review authors independently screened studies for relevance, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software and set out the main findings of the review in "Summary of findings" tables.
This review summarises findings from a total of 42 studies (48 papers) including 35,017 children. Thirty-three of the included studies were RCTs; six studies were quasi-experimental and three studies were cost studies. Majority of the studies were judged to be at high risk of bias for blinding of the participants, personnel and outcome assessment. Majority of the outcomes were rated as either moderate or low quality. Outcomes were downgraded mainly due to study limitations, high heterogeneity, imprecision and small sample size. : Integrated community-based management probably improves recovery rate by 4% [risk ratio (RR): 1.04; 95% confidence interval (CI): 1.00 to 1.09; one study; 1,957 participants; moderate-quality outcome], and reduces weight gain by 0.8 g·kg·day [mean difference (MD): -0.80 g·kg·day; 95% CI: -0.82 to -0.78; one study; 1,957 participants; moderate-quality outcome] compared with no community-based strategies, while mortality was similar between the two groups (RR: 0.93; 95% CI: 0.60 to 1.45; one study; 1,957 participants; moderate-quality outcome). : There was no evidence of effect on recovery (RR: 1.00; 95% CI: 0.80, 1.25; one study; 60 participants; very-low-quality evidence) and mortality (RR: 1.21; 95% CI: 0.75 to 1.94; two studies; 473 participants; low-quality outcome). : There was no evidence of effect on weight gain (MD: 2 g·kg·day; 95% CI: -0.23 to 4.23; three studies; 266 participants; very-low-quality outcome) and mortality (RR: 1.20; 95% CI: 0.34 to 4.22; two studies; 168 participants; low-quality outcome). : There was no evidence of effect on recovery rate when standard RUTF was compared to non-milk/peanut butter-based RUTF (RR: 1.03; 95% CI: 0.99 to 1.08; five studies; 5743 participants; I 50%; moderate quality outcome), energy-dense, home-prepared food (RR: 1.14; 95% CI 0.95 to 1.36; four studies; 959 participants; I 75%; low quality outcome), or high oleic RUTF (RR: 1.06; 95% CI: 0.85 to 1.31; one study; 141 participants; moderate quality outcome). Standard RUTF may improve weight gain by 0.5 g·kg·day (MD: 0.5 g·kg·day; 95% CI: 0.02 to 0.99; three studies; 3,069 participants; low-quality outcome) when compared with non-milk/peanut butter-based RUTF and by 5.5 g·kg·day when compared with F100 (MD: 5.50 g·kg·day; 95% CI: 2.92 to 8.08; one study; 70 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUTF was compared with other foods (RR: 0.99; 95% CI: 0.69 to 1.41; nine studies; 7,667 participants; low-quality outcome). : There was no evidence of effect on recovery rate when standard RUSF was compared with local/home made food (RR: 0.92; 95% CI: 0.64 to 1.33; three studies; 435 participants; low-quality outcome) and whey RUSF (RR: 0.96; 95% CI: 0.92 to 1.00; one study; 2230 participants; high-quality outcome); while standard RUSF may improve recovery by 7% when compared with corn-soy blend (CSB) (RR: 1.07; 95% CI: 1.02 to 1.13; six studies; 5,744 participants; low-quality outcome). There was no evidence of effect on weight gain when standard RUSF was compared with local home made food (MD: -0.75 g·kg·day; 95% CI: -2.03 to 0.43; one study; 73 participants; low-quality outcome) and whey RUSF (MD: -0.16 g·kg·day; 95% CI: -0.33 to 0.01; one study; 2,230 participants; high-quality outcome); while standard RUSF may improve weight gain by 0.49 g·kg·day when compared with CSB (MD: 0.49 g·kg·day; 95% CI: 0.10 to 0.87; five studies; 4,354 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUSF was compared with other foods (RR: 0.98; 95% CI: 0.57 to 1.68; eight studies; 8,310 participants; moderate-quality outcome). : Prophylactic antibiotic therapy for uncomplicated SAM improves recovery rate by 6% (RR: 1.06; 95% CI: 1.03 to 1.08; two studies; 5,166 participants; high-quality outcome), probably improves weight gain by 0.67 g·kg·day (MD: 0.67 g·kg·day; 95% CI: 0.28, 1.06; two studies; 5,052 participants; moderate-quality outcome) and probably reduces mortality by 26% (RR: 0.74; 95% CI: 0.55, 0.98; three studies; 6944 participants; moderate quality outcome) compared to no antibiotics group. : There was no evidence of effect on weight gain (MD: 0.05 g·kg·day; 95% CI: -0.08 to 0.18; one study; 207 participants; moderate-quality outcome) and mortality (RR: 7.07; 95% CI: 0.37 to 135.13; one study; 207 participants; moderate-quality outcome).
AUTHORS’ CONCLUSIONS: Limited data show some benefit of integrated community-based screening, identification and management of SAM and MAM on improving recovery. Facility-based screening and management of uncomplicated SAM has no benefit on recovery and mortality, while the effect of F100 for SAM is similar to RUTF for weight gain and mortality. Local food and whey RUSF have similar effects as standard RUSF on recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate, weight gain and reduces mortality, while limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.
儿童营养不良是一个重大的公共卫生问题,因为它与严重的短期和长期发病及死亡相关。
根据世界卫生组织当前的方案,全面审查使用基于机构和社区的方法管理重度急性营养不良(SAM)和中度急性营养不良(MAM)的证据,以及即食治疗食品(RUTF)、即食补充食品(RUSF)、预防性使用抗生素和补充维生素A的有效性。
我们检索了截至2019年2月11日的相关电子数据库。未设日期或语言限制。
我们纳入了随机对照试验(RCT)和准实验研究,包括前后对照(CBA)研究和中断时间序列(ITS)研究。
两位综述作者独立筛选研究的相关性,提取数据,评估偏倚风险,并使用GRADE方法对证据质量进行评级。我们使用Review Manager软件进行统计分析,并在“结果总结”表中列出综述的主要结果。
本综述总结了总共42项研究(48篇论文)的结果,涉及35,017名儿童。纳入的研究中33项为RCT;6项为准实验研究,3项为成本研究。大多数研究在参与者、人员和结果评估的盲法方面被判定为高偏倚风险。大多数结果被评为中等或低质量。结果被降级主要是由于研究局限性、高异质性、不精确性和小样本量。:与无基于社区的策略相比,基于社区的综合管理可能使恢复率提高4%[风险比(RR):1.04;95%置信区间(CI):1.00至1.09;一项研究;1,957名参与者;中等质量结果],并使体重增加减少0.8克·千克·天[平均差(MD):-0.80克·千克·天;95%CI:-0.82至-0.78;一项研究;1,957名参与者;中等质量结果],而两组之间的死亡率相似(RR:0.93;95%CI:0.60至1.45;一项研究;1,957名参与者;中等质量结果)。:没有证据表明对恢复(RR:1.00;95%CI:0.80,1.25;一项研究;60名参与者;极低质量证据)和死亡率(RR:1.21;95%CI:0.75至1.94;两项研究;473名参与者;低质量结果)有影响。:没有证据表明对体重增加(MD:2克·千克·天;95%CI:-0.23至4.23;三项研究;266名参与者;极低质量结果)和死亡率(RR:1.20;95%CI:0.34至4.22;两项研究;168名参与者;低质量结果)有影响。:当将标准RUTF与非牛奶/花生酱基RUTF(RR:1.03;95%CI:0.99至1.08;五项研究;5743名参与者;I²=50%;中等质量结果)、能量密集的家庭自制食品(RR:1.14;95%CI 0.95至1.36;四项研究;959名参与者;I²=75%;低质量结果)或高油酸RUTF(RR:1.06;95%CI:0.85至1.31;一项研究;141名参与者;中等质量结果)相比时,没有证据表明对恢复率有影响。与非牛奶/花生酱基RUTF相比,标准RUTF可能使体重增加0.5克·千克·天(MD:0.5克·千克·天;95%CI:0.02至0.99;三项研究;3,069名参与者;低质量结果),与F100相比时使体重增加5.5克·千克·天(MD:5.50克·千克·天;95%CI:2.92至8.08;一项研究;70名参与者;低质量结果)。当将标准RUTF与其他食物相比时,没有证据表明对死亡率有影响(RR:0.99;95%CI:0.69至1.41;九项研究;7,667名参与者;低质量结果)。:当将标准RUSF与当地/家庭自制食品(RR:0.92;95%CI:0.64至1.33;三项研究;435名参与者;低质量结果)和乳清RUSF(RR:0.96;95%CI:0.92至1.00;一项研究;2230名参与者;高质量结果)相比时,没有证据表明对恢复率有影响;而与玉米-大豆混合食品(CSB)相比,标准RUSF可能使恢复率提高7%(RR:1.07;95%CI:1.02至1.13;六项研究;5,744名参与者;低质量结果)。当将标准RUSF与当地家庭自制食品(MD:-0.75克·千克·天;95%CI:-2.03至0.43;一项研究;73名参与者;低质量结果)和乳清RUSF(MD:-0.16克·千克·天;95%CI:-0.33至0.01;一项研究;2,230名参与者;高质量结果)相比时,没有证据表明对体重增加有影响;而与CSB相比,标准RUSF可能使体重增加0.49克·千克·天(MD:0.49克·千克·天;95%CI:0.10至0.87;五项研究;4,354名参与者;低质量结果)。当将标准RUSF与其他食物相比时,没有证据表明对死亡率有影响(RR:0.98;95%CI:0.57至1.68;八项研究;8,310名参与者;中等质量结果)。:对于无并发症的SAM,预防性抗生素治疗使恢复率提高6%(RR:1.06;95%CI:1.03至1.08;两项研究;5,166名参与者;高质量结果),可能使体重增加0.67克·千克·天(MD:0.67克·千克·天;95%CI:0.28,1.06;两项研究;5,052名参与者;中等质量结果),与不使用抗生素组相比可能使死亡率降低26%(RR:0.74;95%CI:0.55,0.98;三项研究;6944名参与者;中等质量结果)。:没有证据表明对体重增加(MD:0.05克·千克·天;95%CI:-0.08至0.18;一项研究;207名参与者;中等质量结果)和死亡率(RR:7.07;95%CI:0.37至135.13;一项研究;207名参与者;中等质量结果)有影响。
有限的数据显示,基于社区的SAM和MAM综合筛查、识别和管理在改善恢复方面有一些益处。基于机构的无并发症SAM筛查和管理对恢复和死亡率没有益处,而F100对SAM在体重增加和死亡率方面的效果与RUTF相似。在MAM中,当地食物和乳清RUSF在恢复率和体重增加方面与标准RUSF有相似的效果,而标准RUSF对CSB有额外的益处。无并发症SAM的预防性抗生素给药可提高恢复率、增加体重并降低死亡率,而有限的数据表明,在SAM儿童中,高剂量维生素A补充与低剂量维生素A补充在体重增加和死亡率方面相当。