Ready‐to‐use therapeutic food (RUTF) for home‐based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age

Background

Malnourished children usually look very thin or wasted and they have a high risk of death and illness. Treating severely malnourished children in hospitals is not always desirable or practical in rural settings, and home‐based treatment may be better. Home‐based treatment can be food prepared by a caregiver (such as flour porridge or energy‐ and nutrient‐dense locally available foods), or ready‐to‐use therapeutic food (RUTF) provided by a clinic. RUTF is usually made according to a standard, energy‐rich composition defined by the World Health Organization (WHO). Typically, the ingredients for standard RUTF include milk powder, sugar, peanut butter, vegetable oil, vitamins and minerals; but ingredients vary depending on local availability, cost and acceptability. Benefits of RUTF include a long shelf life without refrigeration and they require no preparation. This is an update of our previous review, where definite conclusions about the effects of RUTF could not be drawn from the four studies that were available at that time.

Review question

We assessed standard RUTF compared to an alternative dietary approach (e.g. flour porridge or locally available foods) and examined whether smaller amounts and different formulations of RUTF can achieve similar health outcomes in severely malnourished children aged between six months and five years. The main health outcomes that we investigated were recovery from severe malnutrition, deterioration or relapse, death and the rate of weight gain.

Included study characteristics

We searched databases for studies up to the October 2018, and found 15 studies with 7976 children. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. One small study included only children infected with HIV, another study analysed children with and without HIV separately for the main outcome (recovery), while the other studies included children who were not infected with HIV or who were untested. Overall, we judged six studies to be at high risk of bias, three studies to be at unclear risk of bias, and six studies to be at low risk of bias. (With 'risk of bias', we mean the extent to which the methods used in a study enable it to determine the truth.) All the studies lasted between 8 and 16 weeks. Only five studies followed up children after the study (for a maximum of six months), and generally reported on a limited number of outcomes.

Of our 15 included studies, six were linked to funding or donations from industry, one did not report the source of funding, and eight studies reported funding where sponsors did not include industry.

Key findings

Compared to alternative dietary approaches, standard RUTF probably improves recovery (moderate‐quality evidence) and may increase the rate of weight gain slightly (low‐quality evidence), but the effects on relapse and death are unknown (very low‐quality evidence). With 'quality of evidence' we mean how confident we are that the particular finding represents the true effect. For example, 'very low‐quality' means we are very uncertain about the finding, 'low‐quality evidence' means the future research is very likely to change the finding, 'moderate‐quality evidence' means that future studies may change this finding, and 'high‐quality evidence' means that it is unlikely that future studies will change the finding.

Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given supplementary to the usual diet (low‐quality evidence), but for death and the rate of weight gain, the effects are not known (very low‐quality evidence).

When comparing RUTFs of different formulations, it makes little or no difference for recovery whether a standard or alternative formulation RUTF is used (high‐quality evidence). For relapse, using standard RUTF decreases relapse (high‐quality evidence). It probably makes little or no difference to death (moderate‐quality evidence) and to the rate of weight gain (low‐quality evidence) whether standard or alternative formulation RUTF is used.

Well‐designed, randomised controlled trials (experimental studies where participants meeting the inclusion criteria have an equal chance of being allocated to any of the intervention or control groups) in which analyses have been performed separately for children with and without HIV, and that also measure and report on diarrhoea occurrence, are needed.