1

Evaluation of three standard dietary regimes in the

treatment of

Severe Malnutrition; The “TranSAM study”

An interim analysis

Report written by Sara van Vliet (s2255685) under supervision of Dr R.H. J. Bandsma,

Pediatric Gastroenterologist at the University of Groningen and University Medical Center

Groningen (UMCG) and Dr W.P. Voskuijl, Paediatrician and Senior Lecturer at the

Department of Paediatrics, College of Medicine, Queen Elisabeth Central Hospital (QECH)

2

Summary

Malnutrition is still one of the most devastating co-morbidities in young children. Despite

following treatment protocols for children suffering from severe acute malnutrition (SAM)

based on World Health Organisation (WHO) management guidelines case-fatality rate during

rehabilitation, even in specialized centers, remain up to 30%. The rise in co-morbidities such

as HIV has dramatically altered the epidemiology, case-presentation, pathophysiology, case-

management and outcome of childhood malnutrition. In addition, clinical impression and

recent published and unpublished data from the study Unit, MOYO House, at Department of

Paediatrics & Child Health, Queen Elisabeth Central Hospital (QECH), Blantyre, Malawi,

suggest that case-fatality during rehabilitation of HIV (non-) infected severely malnourished

children has been increasing over time and could be related to a specific phase of treatment,

namely the Transition Phase. There is data from the laboratory in Groningen, studies in

MOYO House, and others that severe malnutrition is associated with a severe impairment in

gut function, leading to deficient uptake of nutrients, especially carbohydrates. This impaired

function can be associated with watery diarrhoea and can ultimately lead to the child’s

demise. There is a lack of data evaluating gut function and optimal nutritional regimen

needed during the Transition Phase in rehabilitating severely, especially HIV infected,

malnourished children. This study aims to evaluate three different, commonly used and well

established WHO/ United Nations International Children's Emergency Fund (UNICEF)

(1999; 2009) dietary treatment protocols in severely malnourished children while admitted to

MOYO house. The Therapeutic Diets either consists of F75 (WHOs low energy, low protein

therapeutic milk) + Ready-to-Use-Therapeutic Food (RUTF), RUTF only, or F100 (WHOs

high energy and high protein therapeutic milk). The design was a randomised controlled

clinical trial.

This report serves as an interim analysis of the first 30 recruitments, looking at stool

frequency, stool consistency, frequency of vomiting, electrolyte disturbances, mortality and

changes in weight to look at the effect of the three different diets. Hypothesised was that the

(too) high carbohydrate content of F75 + RUTF would cause more frequent electrolyte

disturbances and would induce more frequent diarrhoea in a still recovering gastro intestinal

system compared to RUTF only or F100. The analysed results cannot describe a trend. In

addition, no major differences are found between the different diets to break off the study or

change the study design. A bigger sample size will be recruited to use for further analyses.

These outcomes could possibly provide answers in relation to the effect of the different diets.

Ondervoeding is nog steeds een van de meest heftige co-morbiditeiten in jonge kinderen.

Ondanks het volgen van behandelingsprotocollen voor kinderen die lijden aan Severe Acute

Malnutriton (SAM) volgens de richtlijnen van de Wereldgezondheidsorganisatie (WHO)

blijft het sterftecijfer tijdens revalidatie, zelfs in gespecialiseerde centra, nog zo’n 30%. Het

stijgen van co-morbiditeiten zoals HIV heeft de epidemiologie, casus presentatie,

pathofysiologie, beleid en prognose van ondervoeding in kinderen drastisch veranderd.

Bovendien geven ervaringen uit de kliniek en recente gepubliceerde en ongepubliceerde

gegevens uit onze studie locatie, MOYO ward, op de afdeling Pediatric & Child Health in het

Queen Elisabeth Central Hospital (QECH), Blantyre, Malawi, de indruk dat sterfte tijdens

revalidatie van HIV (niet-) besmette ondervoede kinderen na verloop van tijd is toegenomen

en gerelateerd is aan een specifieke fase van de behandeling, de zogenaamde overgangsfase.

Gegevens uit het laboratorium in Groningen en studies uit MOYO ward en andere centra

wijzen erop dat ernstige ondervoeding geassocieerd is met een ernstig verminderd

functioneren van de darm en dysfunctie in de opname van voedingsstoffen, met name van

3

koolhydraten. Deze verminderde functie uit zich in waterige diarree en kan uiteindelijk leiden

tot het sterven van het kind. Er is een gebrek aan kennis over de darm functie en over een

optimaal dieet tijdens de overgangsfase in de behandeling van ernstig, met name HIV

geïnfecteerd, ondervoede kinderen. Deze studie richt zich op het evalueren van drie

verschillende therapeutische diëten, volgens de protocollen van WHO/ United Nations

International Children's Emergency Fund (UNICEF) (1999; 2009), ook in gebruik op MOYO

ward. De diëten bestaan uit het geven van; F75 (een lage energie densiteit, laag eiwitgehalte

therapeutische melk) + Ready-to-Use-Therapeutic-Food (RUTF), alleen RUTF of F100 (hoge

energie densiteit en eiwitrijk therapeutische melk). Het ontwerp van de studie is een

randomised controlled clinical trial.

Dit verslag dient als een interim analyse van de eerste 30 inclusies, kijkend naar stoelgang

(frequentie en consistentie van de ontlasting), braken, elektrolytenstoornissen, mortaliteit en

gewichtsveranderingen om het effect van de drie verschillende diëten te beoordelen. De

hypothese was dat het (te) hoge koolhydraatgehalte van F75 + RUTF, in vergelijking met

alleen RUTF of F100, zou leiden tot meer frequente elektrolytenstoornissen en zou zorgen

voor meer frequente diarree in een nog steeds herstellend gastro-intestinaal systeem. De

geanalyseerde resultaten kunnen geen trend beschrijven. Er zijn geen grote verschillen

gevonden tussen de verschillende diëten die zouden kunnen leiden tot het vroegtijdig

afbreken van de studie of de methodes te veranderen. Een grotere inclusie groep zal worden

gebruikt voor verdere analyses. Deze resultaten zouden inzicht kunnen geven over het effect

van de verschillende diëten.

4

Contents list

Summary 2

1. Introduction 5

1.1 Malawi

1.2 The signs, symptoms and outcome of children with Severe Acute

Malnutrition

1.3 Managing severe malnutrition in children

1.3.1 WHO therapeutic guidelines

1.3.2 Managing severe malnutrition in MOYO nutrition ward,

QECH, Malawi

1.4 The aetiology behind the experienced morbidity and case-fatality

during the rehabilitation of severely malnourished children

1.4.1 Malabsorption/osmotic diarrhoea

1.4.2 Bacteraemia

1.5 Current study

2. Methodology 10

2.1 Preparation

2.1.1 Protocol

2.1.2 Set-up

2.2 Subjects

2.3 Design

2.3.1 Randomisation

2.3.2 Blinding

2.4 Intervention

2.5 Variables, Sampling and Storage

2.6 Analyses

2.7 Outcome variables

2.8 Statistics

3. Results 15

4. Discussion 17

5. Conclusion 19

Acknowledgements 19

References 19

Appendices 23

5

1. Introduction

Severe Acute Malnutrition (SAM) is still one of the most devastating conditions in young

children, affecting nearly 20 million worldwide and causes an estimated 2 million to die

every year [1,2,3]. What is more, undernutrition is estimated to be indirectly responsible for

over a third (35%) of the global child mortality [4]. Despite WHO’s Therapeutic Guideline,

case-fatality rates (CFR) during rehabilitation, even in specialized centres, remain high, up to

30% [5,6,7,8]. This exceeds targets such as those based on WHO treatment guidelines which

claim that CFRs should be as low as 5% [9].

1.1 Malawi

Malawi is one of the world’s poorest countries ranking 170 out of 187 countries with

comparable data on the Human Development Index (HDI) [10]. This index represents a

combined measure of three basic dimensions of human development; health, education and

income. Malawi’s health system is frequently hit by crises in the delivery of essential

medicines, understaffed clinics and erratic drug supplies. The UK charity Oxfam reported

that only 9% of local health facilities (54 out of 585) had the full Essential Health Package

list of drugs for treating 11 common diseases in 2012. Additionally, they reported that clinics

often run out of basic antibiotics, HIV test kits and insecticide-treated mosquito nets, and

many facilities have very low stocks of vaccines [11].

50.7 % of the country’s population live under the poverty line with the poorest residing in the

rural northern and southern parts of the country [12]. The agriculture sector, the most

important sector in the economy, is often hit by crises (e.g. crop failure, increase of prices)

causing Malawi to experience frequent food shortages. The Malawi Vulnerability Assessment

Committee (MVAC), based on their results of a post-harvest food security assessment,

predicted that in the April 2012 to March 2013 consumption period, 1.63 million people in 15

mainly southern districts would be unable to adequately access food in order to meet their

basic food needs [13]. The latest estimation of malnutrition (weight/age) in % of children

under five in Malawi is 13.8. The prevalence of undernourishment in the population is 27.0%

[14].

1.2 The signs, symptoms and outcome of children with Severe Acute Malnutrition

Malnutrition can be classified as mild, moderate and severe based on anthropometry,

biochemistry and clinical assessment [15]. Clinically, SAM in children aged 6-60 months

presents itself into different forms. Firstly, the meagre child is wasted (Marasmus), as defined

by low weight-for-height ≤ -3 Z-scores or a mid-upper-arm circumference of <11.5 cm

(WHO growth standards) [16]. Quite different is the clinical manifestation of kwashiorkor,

as defined by low-weight-for-age (60 to 80 % of expected weight) and nutritionally induced

bilateral oedema. Accompanying features include a fatty liver and hepatomegaly, sparse and

discoloured hair, “flaky paint” rash over the skin, anorexia and metabolic disturbances [9].

SAM impairs the immune system causing children suffering from SAM to have a lower

immune response. Children with SAM have a tripled risk of dying from pneumonia, measles,

or diarrhoea [4,17]. They also have a higher risk of acquiring tuberculosis [18]. There are

several studies investigating underlying mechanisms in the development of the immune

system in children suffering from SAM. Protein and zinc deficiency in young infants

contributes to thymus atrophy and dysfunction. Impaired T-cell maturation is associated with

6

a poor nutritional status of the child [19,20,21]. Children with SAM are also more prone to

get severely ill from more common and ‘harmless’ childhood diseases. Frequent illness in a

child with SAM further demises their nutritional status and locks the child in a vicious circle

of recurring illness and discordant growth. Another important co-morbidity in children with

SAM is the human immunodeficiency virus (HIV). HIV has had a major impact on the

epidemiology, case-presentation, pathophysiology, case-management and outcome of

childhood malnutrition [22]. It is estimated that 2.1 million children worldwide are living

with HIV of which 90% live in sub-Saharan Africa [23]. The HIV infection can compromise

the nutritional status of these children early on in their lives [24]. In a systematic review and

meta-analysis of HIV prevalence and mortality among children treated for SAM in sub-

Saharan Africa in which 17 studies (4891 children) were included, the average prevalence of

HIV infection was 29.2%. Children with HIV and SAM were significantly more likely to die

than those children who were HIV sero-negative (HIV–ve) [25].

1.3 Managing severe malnutrition in children

1.3.1 WHO therapeutic guidelines

Inpatient treatment of severely malnourished children are based on WHO’s Therapeutic

Guidelines [9,26,27] and is staged into three phases, instructed by the WHO 10-step plan

(figure X); firstly the Stabilisation and Resuscitation 1st Phase, in which children are

resuscitated and metabolically stabilised on a maintenance diet of F75 (WHOs low energy,

low protein therapeutic milk of 75 kcal/kg/day) (step 1-7). This phase will usually last 2-7

days and is focussed on stabilising the child by carefully re-feeding and treating and

identifying life-threatening problems e.g. to avoid the child acquiring the so-called ‘refeeding

syndrome’; a critical state in which the child suffers from electrolyte disturbances and cardiac

failure If appetite is regained and, in the case of kwashiorkor, oedema is starting to resolve,

children are put on a diet containing a higher energy and protein concentration (F100) in what

is called the Transition or 2nd

Phase. Finally, if the child remains well and its appetite allows

ad-libitum feeding the rehabilitation is concluded in the 3rd

Rehabilitation Phase of Rapid

Catch-up Growth with high-energy diet of RUTF (Ready-to-Use-Therapeutic Food). This

stage of the treatment can be done at home.

Table 1: WHO 10-step plan for the management of SAM, adapted from WHO [15].

7

1.3.2 Managing severe malnutrition in MOYO nutrition ward, QECH, Malawi

MOYO nutrition ward treats their inpatients using the above mentioned WHO guidelines and

according to National Malawi guidelines [28]. Clinical experience applying National Malawi

guidelines and annually treating between 1250-2500 severely malnourished children on the

ward point towards a number of unresolved issues regarding peak case fatality rates found.

The mortality rate is high [29] and appears to be increasing over time [30,31]. This could be

associated with several changes of the inpatient feeding protocols on MOYO ward:

- From 2002-5, guidelines for initial care followed WHO 1999 relatively closely with an

‘stabilization phase’ using ‘F75’ milk followed by a minimum of 2 days ‘transition phase

feeding’ using ‘F100’ milk.

- From 2005, ready-to-use therapeutic foods (RUTF) began to be introduced into the diet

during and after transition phase.

- From 2006, the transition phase diet was standardised following guidelines elsewhere: F100

milk was replaced by introduction of RUTF.

- From 2008, the transition phase diet reverted to a more traditional F100-based regime. This

however took time to implement [32], with audit showing that many patients from 2008-10

were still being managed following 2006 guidelines [33].

Retrospective analyses of ward data revealed an increased mortality in children who

transitioned to RUTF (15%) compared to F100 (11%) odds ratio 1.38 (95% CI 1.04 to 1.82)

p<0.00113 (unpublished observations).

However, this increased mortality can also be associated with the increasing clinical

complexity of the patients admitted to the ward [34]. It is difficult to separate the contribution

of changing patient profile from the clinical/feeding interventions which have also changed

over time. Furthermore, watery diarrhoea is observed and appears to be associated with a

substantially higher mortality [33,35]. Cases of circulatory failure are also observed resulting

from either hypo-volaemia induced by the above diarrhoea, or fluid overload following

therapeutic correction; both are presently not very well guided by therapeutic guidelines.

What is more, several nutritional units in the region have experienced a peak in mortality in

the transitional phase (from a F75 stabilization diet to a higher energy diet) [31, unpublished

observations]. All these contributing factors need to be disentangled. Up to date, there is no

published data available prospectively evaluating the different strategies in the transition

phase for inpatient treatment of severely malnourished children.

1.4 The aetiology behind the experienced morbidity and case-fatality during the

rehabilitation of severely malnourished children

1.4.1 Malabsorption/osmotic diarrhoea

Previous studies have shown that severe malnutrition is associated with a severe impairment

in gut function, leading to deficient uptake of nutrients, especially carbohydrates. The

carbohydrate sources of RUTF and F100 consist of a mixture of malto-dextrin, sucrose and

lactose. Sucrose, consisting of glucose and fructose, is a disaccharide, which needs to be

hydrolysed by a disaccharidase before intestinal absorption is possible. Older studies from

Jamaica [36] and South-Africa [37] as well as, limited histological evidence [38,39,40] has

shown impaired absorption of disaccharides and various degrees of villous atrophy in

children with kwashiorkor which could account for the decreased disaccharide absorption

found in these children. Whereas absorption of glucose across the apical membrane is

mediated by the sodium-dependent glucose transporter (SGLT-1), the absorption of fructose

mainly takes place through GLUT-5 [41]. The maximum capacity of healthy intestine to

absorb fructose is limited [42]. Recent human studies have indicated that its absorption can

be improved if glucose and fructose are consumed simultaneously [43,44]. In children with

8

severe malnutrition, villous atrophy and limited disaccharidase activity, the intake of

carbohydrates could exceed the intestinal carbohydrate absorptive capacity. Severe glucose

malabsorption was also found in kwashiorkor and hypo-albuminaemic marasmus patients

using a double label glucose technique. In addition, children who showed most severe

glucose malabsorption appeared to develop diarrhoea and/or vomiting [45].

Water absorption in the intestine is dependent on the absorption of solutes. Unabsorbed

nutrients, in this case carbohydrates, will cause osmotic diarrhoea in the malnourished child.

This watery diarrhoea can lead to electrolyte disturbances, dehydration (child becomes

hypovolaemic) and ultimately death. There is local evidence from MOYO house and other

studies supporting this hypothesis [45,46,47]. A study from Nigeria electrolyte disturbances

in children with protein energy malnutrition suffering from diarrhoea showed especially a

high rate of metabolic acidosis (low serum pH and high serum HCO3-) and hypokalaemia

[48].

1.4.2 Bacteraemia

The bacterial infection in severely malnourished children related to immunosuppression can

also be associated with the gut through loss of the protective mucosal barrier [49]. Children

with severe malnutrition are shown to have a higher prevalence of gut barrier dysfunction

[50] and Escherichia coli bacteraemia [51]. What is more, in the severely malnourished a

higher mortality rate from invasive bacterial infection was found than in well- nourished

children with bacteraemia (39% versus 12%) [52]. A recent study investigated the role of the

gut microbiome as a causal factor in kwashiorkor patients and identified that the combination

of Malawian diet and kwashiorkor microbiome in recipient mice produced marked weight

loss, accompanied by distress in amino acid, carbohydrate, and intermediary metabolism that

were only transiently improved with administering RUTF [53].

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1.5 Current study

To date, there is a lack of data evaluating gut function, intestinal microbial flora, and optimal

nutritional regimen needed during the Transition Phase in rehabilitating severely, especially

HIV infected, malnourished children. New insights could have important implications for the

development of new dietary protocols in the treatment of malnutrition, potentially decreasing

the occurrence of the often fatal diarrhoea during rehabilitation and greatly benefit this

patient group.

This research, set up as a randomised controlled clinical trial, aims to evaluate the outcome,

especially in relation to a child’s gut function, of three different, commonly used dietary

treatment protocols during the Transition Phase (consisting either of F75 + RUTF, RUTF

only, or F100). F75 consists of 65 energy % carbohydrates compared to F100 40% and RUTF

32%. As caloric intake is increased during the transition phase we hypothesize that the (too)

high carbohydrate content of F75 + RUTF is associated with more frequent electrolyte

disturbances and will induce more frequent diarrhoea in a still recovering gastro intestinal

system compared to RUTF only or F100.

In this research, I was responsible for set-up of the study and an interim analysis. This report

will show the interim analysis on the first 30 study inclusions, looking at the effect of the

different diets through analysis of stool consistency, frequency, electrolyte disturbances and

weight loss and/or gain. Any great significant differences found between the diets could lead

to breaking off or changing the study design. Any trends described could provide more

insight.

Research Question: What is the effect of three commonly used transition-phase diets on

clinical outcomes in children being treated for severe acute malnutrition?

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2. Methodology

2.1 Preparation

Given the nature of the research and research setting, ample time was allocated for

preparation and on-the-ground set-up of workspace, including training of staff and a proof

run of the study. These activities were performed under supervision and aided by my local

supervisor, Dr. Voskuijl.

2.1.1 Protocol

Firstly, the protocol needed to be re-written as change in ward practice and practices in the

international community became apparent; a third arm was added, the “RUTF only” arm, as

was learned that multiple other institutions provide RUTF as the basal nutritional source

during the transition phase and only add F75 if children don’t take enough calories from

RUTF. Providing F75 while adding RUTF had been a common practice at MOYO, the

nutrition rehabilitation unit of Queen Elisabeth Central Hospital during the transition phase.

Both diets are in theory consistent with the recommended WHO protocol but are essentially

different; adding a third arm would greatly strengthen the clinical relevance of the study.

Furthermore, the non-malnourished control group was dropped so as to simplify the protocol

and reduce the need for blood sampling. Though these controls would have been ideal given

the scarcity of normal range reference data, the advantage was outweighed by the

disadvantage in terms of extra blood sampling for control-children. In addition, involving

healthy controls in a study remains an issue in receiving consent from the ethical committee.

Lastly, the protocol was updated with new case definitions of severe acute malnutrition in

accordance with WHO guidelines. For this, I performed a small survey in the paediatric

Accident and Emergency department, assessing the children admitted on their weight, height

and MUAC (mid-upper arm circumference) and found that children were easier diagnosed

with malnutrition using the WHO standard than when using the (older) National Center for

Health Statistics (NCHS)references.

This was in accordance with the literature comparing these standards on a larger scale and

concluding that definition of malnutrition using WHO standards would lead to a higher

disease burden, particularly for severe wasting, than using the NHCS references [54].

2.1.2 Set-up

I investigated practice on the ward and ensured that the study protocol and interventions were

in line with current practices and that these practices were carried out in a similar manner by

all the staff and caregivers. For this, we introduced the use of the ‘MOYO slide chart’ on the

ward to assess children’s nutritional status [55].

Secondly, I certified my workspace, creating space on the ward and finding a lab and

adequate equipment to process and analyse my samples. I gathered all the materials needed

for sampling, processing and storage (including arranging a dependable -80o C freezer to

store samples until shipment to the Netherlands).

Lastly, I had to recruit and instruct staff to help with patient recruitment and sampling. I

recruited five MOYO staff nurses.

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2.2 Subjects

Inclusion criteria

Children, aged between 6 and 60 months, admitted to MOYO House and diagnosed as

kwashiorkor, and/or marasmus were included after informed consent was given by their

guardian (for consent form in English see appendix A). Both HIV positive and negative

children were included in the study.

Exclusion criteria

Severely malnourished HIV infected children who were MOYO readmissions within the past

year or who were already on anti-retroviral-therapy were excluded. Children that presented

with a PCV of less than 15%, severe hemodynamic instability or severe neurological

symptoms were also excluded. Children whose HIV status was unknown due to their carer

declining the routinely offered test were also excluded.

Subjects were screened for eligibility on admission to MOYO House and written informed

consent was requested soon after.

Study children who developed persisting diarrhoea during their transition phase and/or

hypovolaemia were monitored more closely. After reversing to their initial therapeutic diet

F75, these patients were checked frequently for fluid & electrolyte balance. Furthermore,

their circulatory state was carefully documented: if compromised they received standard

clinical care.

2.3 Design

This is an open label randomized controlled trial of three standard dietary regimes which are

already in widespread clinical use: two of which are currently in use on MOYO; the third of

which is a variation of how to eat the same basic diet (see 2.4).

2.3.1 Randomisation

Patients were randomised on HIV status and were randomly allocated a feed. The

randomization sequence was computer generated by a colleague from the Malawi Liverpool

Welcome trust (MLW) who was not involved in front line fieldwork.

Allocation concealment was achieved by inserting group labels/feeding instructions into

sealed, sequentially numbered opaque envelopes. At the moment when patients were ready to

begin a transition phase diet, they were asked to draw the next numbered envelope from the

assigned pile; the envelope was opened to show their assigned group. The feed was also

written on the patient’s ‘food ticket’ to help both the carer to remember the correct group and

also to help the MOYO ward kitchen to give the correct feed at all times.

2.3.2 Blinding

This was an open label trial – given the nature of the intervention, it was not be possible to

blind the subjects to their group. For the same reason, it was not possible to blind staff doing

clinical assessment. The investigators analysing samples in the Netherlands will however be

blind to a patient’s group.

2.4 Intervention

Patients began the study once they achieved standard criteria to move from phase 1 to the

transition phase, according to the WHO guidelines [20]. This was after return of their appetite

and, in case of children with kwashiorkor, improvement of oedema.

12

The three therapeutic diets to be tested during the transition phase were:

1. A High Energy Therapeutic Regime based on F100 milk: in an iso-volumetric amount to

F75 phase 1 milk.

2. A High Energy Therapeutic Regime of RUTF supplemented with F75 milk. Caregivers

started a feed by giving ready-to-use therapeutic foods as much as was tolerated by the child

(up to a maximum of 135 kcal/kg/d) and then followed by giving F75 - to ensure a minimum

intake of 100 kcal/kg/d. The amount of ready-to-use therapeutic foods was increased over 2-3

days until the full requirement of ready-to-use therapeutic foods was taken by the child. F75

was then stopped.

3. A High Energy Therapeutic Regime of RUTF only. Caregivers started a feed by giving

ready-to-use therapeutic foods as much as was tolerated by the child (up to a maximum of

135 kcal/kg/d) but with water and not routinely followed with F75. The amount of ready-to-

use therapeutic foods was increased over 2-3 days until the full requirement of ready-to-use

therapeutic foods was taken by the child. If a child was unable to eat his/her RUTF, they were

moved back a phase to f75 milk alone.

Table 2: Different carbohydrate loads for every diet

CHOa (g)

provided by:

135 kcal F100 135 kcal RUTF 100 kcal F75 + 35 kcal

RUTF

Sucrose 2.34 6.50 2.58

Lactose 8.83 3.25 3.31

Dextrine maltose 2.34 0.00 13.00

Other CHO 0.00 0.88 0.23

Total 13.5 10.6 19.1 aCHO: Carbohydrates

As noted, diet 1 and 2 were both already in use in MOYO House; diet 2 was a variation of

diet 3.

The duration of the study, commencing when at the end of phase 1 the child was transitioned

to the high energy diet, was for the full duration of transition phase. Case fatality, catch-up

growth and failure was recorded for every child until the child was found fit for discharge

from MOYO House.

2.5 Variables, Sampling and Storage

Diets and appetite

Amount and route of administration of feeding was recorded daily. Appetite was recorded

with every feed (by asking caregiver), as was refusal to complete any feed. Patients were

allowed to change from the transition phase to phase 2 if they had been clinically well during

the transition phase and continued to have a good appetite.

Anthropometry and clinical signs of malnutrition

Twice daily weights were taken, and daily assessment of the measure of oedema, hydration

state and capillary refill time, and other routinely collected clinical signs related to

malnutrition. For full list of variables see the questionnaires in appendix B.

Blood sampling

A total of 3 blood samples was taken throughout the study. The first sample was taken on

admission to MOYO House. A second sample was taken while the child was still receiving

F75, just before entering the transition phase. The third sample was taken on day 3 in the

transition phase. Blood was centrifuged and plasma was used to perform electrolyte and

13

bloodgas testing and analyses. A fraction was stored at -80o C until further analysis.

Electrolytes were determined immediately; if there were of therapeutic value they were used

to adjust therapy. Per sample 2.5 ml of blood was drawn keeping the total volume over the

child’s entire test period below 8 ml.

Excreta sampling

A faecal and urine sample, to asses (mal) absorption of the nutrients, were taken on the same

days as the analytic blood sampling. Part of the faecal sample was stored at -80o C until

analysis. Stool frequency and consistency were noted daily.

See appendix C for a case report form (CRF).

2.6 Analyses

As recruitment is on-going and the data set is not completed interim analyses were done on

the first 30 recruitment (of which 25 received the intervention).

The change in weight between the day before and after the diet (day 3) and the weight at the

end of the diet (day 3) were analysed. Weight, amount of feeding, anorexia, route of feeding,

duration on phase 1 and on the transition phase, duration until time of discharge (and death)

and other clinical signs related to malnutrition were entered into a database. The majority of

these other variables will be analysed on the complete sample group.

Plasma electrolytes (glucose/lactate, sodium, potassium, bicarbonate- concentrations), and pH

were determined locally for all time points. This report looked at plasma disturbances in

potassium, bicarbonate and pH, by looking at the difference between the day before and after

(day 3) of the diet, and the end values of the diet (day 3). The other electrolytes will be

analysed for the complete sample group.

Future analyses of the plasma, stool and urine samples that were collected and stored in the

freezer will be performed at the end of the recruitment, when all the samples have been

shipped to the Netherlands. Plasma and urine will be used to measure excretion of 8-

hydroxydeoxyguanosine (8-OhdG) corrected for creatinine excretion as a measure of DNA

oxidative damage. In addition, plasma citrulline concentrations will be determined as a

reflection of enterocyte mass. These analyses will be performed in the Netherlands since

these analyses cannot be conducted in Malawi. Albumin concentration will be determined in

Groningen as well. Faeces pH was determined locally. Faeces will be analysed to determine

alpha 1-antitrypsin and elastase content as a measure of protein loss and pancreatic function,

respectively. In addition, microbiomal analyses of the faecal flora will be performed using

16S rRNA pyrosequencing. These last two faecal samples will be analysed in the Netherlands

since these analyses cannot be conducted in Malawi.

After analysis, all biochemical parameters will be entered in a database.

2.7 Outcome variables

The outcome variables of this report were:

1. Frequency of diarrhoea

2. Frequency of vomiting

3. Electrolyte disturbances (in potassium, bicarbonate and blood pH)

14

4. Recovery rate expressed in incremental weight/kg bodyweight/per day.

5. Mortality

Variables of the complete sample load will be divided into primary and secondary variables

and will include:

Primary Outcome Variable:

1.Fecal pH (on fresh material; determined in Blantyre, BLZ).

Secondary Outcome Variables:

1.Electrolyte disturbances

2.Recovery rate expressed in incremental weight/kg bodyweight/per day

3.Morbidity and clinical signs; assessed every day by a standardized form during the entire

admission period

4.Urinary excretion of 8-hydroxydeoxyguanosine (8-OhdG) corrected for creatinine

excretion, as a measure of DNA oxidative damage (determined in Groningen)

5.Plasma 8-hydroxydeoxyguanosine (8-OhdG) (determined in Groningen)

6.Plasma citrulline concentrations, as a reflection of enterocyte mass (determined in

Groningen)

7.Fecal excretion of elastase and alpha 1-antitrypsin (determined in Groningen)

8.Analysis of fecal microbiota (determined in Groningen).

2.8 Statistics

The calculated sample size is 15 participants per group. An additional 3 participants per

group will be included to account for loss of follow up, inability to obtain blood samples and

other technical issues. Since HIV positive and negative children are to be analysed separately,

a total of 18 (patients) x 3 (groups) x 2 (HIV groups) = 108 patients will be recruited. The

sample size was calculated for faecal pH and reducing substances, which is the most

important primary outcome measure as it most directly reflects carbohydrate malabsorption.

Based on recent glucose absorption data, 45% of malnourished patients suffered from severe

glucose malabsorption that is expected to be associated with osmotic diarrhoea. RUTF in

combination with F75 was the most often used practice during the period this study was

performed. We aim for an improvement of 30% in carbohydrate malabsorption of treatment

1 (F100) compared to 2 (F75+ RUTF) in this pilot study. Using α=0.05 and 80% power, with

an expected sigma of 13% an N of 15 per arm was calculated.

This report will conduct an interim analysis of the first 30 recruitments (of which 27 received

the intervention). Since patients are randomly recruited, HIV positive and negative children

were not balanced between the different groups. The differences between the HIV positive

and negative children will therefore not be incorporated in this interim analysis. Furthermore,

the results of this analysis will not be considered conclusive but serve as indicator for

possible trends and/or significant differences in outcome between the groups to amend or

discontinue the study.

15

3. Results

At their time of transition, the first 30 patients were randomly allocated a diet. This resulted

in a F100 N=11, F75+ RUTF N=7 and RUTF only N=9 group. The demographic

characteristics of the study sample are summarised in the table below.

Table 3: Demographic characteristics of study sample divided by diet F100 F75+ RUTF RUTF only

Count Column N %

Count Column N %

Count Column N %

Male gender freqa (%) 3(27.3) 2(28.6) 4(44.4)

Age (months), mean (SDb) 28(18.74) 22(7.07) 21(10.83)

Weight, mean(SD) 7.77(2.01) 8.04(2.14) 6.86(1.60)

pH serum beforec diet, mean(SD) 7.39(0.10) 7.42(0.15) 7.47(0.11)

Potassiumd before diet, mean(SD) 4.5(0.59) 4.62(0.68) 4.16(0.28)

Bicarbonated before diet, mean(SD) 22.3(3.74) 23.2(6.98) 23.4(2.18)

Breastfeeding (months), mean(SD) 16.3(6.65) 17.1(8.40) 12.6(4.58)

HIV test positive, freq (%) 3(27.3) 2(28.6) 1(11.1)

Bilateral oedema, freq (%)

8(72.7) 5(71.4) 7(77.8)

MUACe

(cm) freq (%) 12.0(1.84) 12.2(2.12) 11.8(1.90)

afreq: frequency

bSD: standard deviation

cbefore: day before start transition feed

delectrolytes were measured in serum in mmol/L

eMUAC: mid-upper-arm circumference

The study sample was dominantly female. The mean age across the groups did not differ

greatly, with a mean age of 28, 22 and 21 months. The mean pH at the start of the diet was

lowest in the F100 group and highest in the RUTF only group. The mean starting potassium

levels were similar across the groups and the lowest in the RUTF only group. The mean

HCO3- levels were also similar across the groups with the greatest variance within the F75+

RUTF group. In total there were 6 HIV positive children, of which most (N=3) in the F100

group. Most of the study sample (N=20) had bilateral oedema. In each group the majority of

patients had bilateral oedema.

16

Because of the small sample size, no normal distribution was expected. This was later

verified by testing one of the variables. A non-parametric test (the Kruskal-Wallis) was used

to give the following results;

Table 4: Outcome variables of study sample divided by diet

aHCO3-: Bicarbonate

No differences were found between the different groups as the results shown above were not

significant. I will describe them nevertheless, so I can refer to them in the discussion

following.

With the therapeutic diet of F75+RUTF children there was a tendency to have less diarrhoea

than the other two diets. However, this is not significant (p=.176). In addition this group also

had the highest rate of normal stool (p=.664). Most diarrhoea was seen in the F100 group, in

which the maximum frequency was also the highest. There was no significant difference

between the groups in vomiting frequency (p=.339). Most vomiting was seen in the RUTF

only group. The least vomiting was seen in the F100. The weight difference across all the

groups was very little, but most gain was seen in the F75+ RUTF group. The RUTF group

showed the highest rate of overall weight loss and the least weight gain. The weight of the

F100 group showed the least weight change. These results are not significant (p=.562). The

pH difference in the F100 group was the highest and showed the most gain compared to the

other groups. The F75+ RUTF group showed the most overall loss in pH compared to the

other groups. This is not significant (p=.507). The highest potassium difference was seen in

the F75+ RUTF group with no loss across the whole group. The RUTF only group had the

highest rate of overall potassium loss. These results are not significant (p= .179). The HCO3-

difference was the highest in the F75+ RUTF group, with the most loss overall compared to

the other groups. In the F100 group there was only loss of HCO3-. This is not significant

(p=.634). The pH after the diet was overall highest in the F100 group and lowest in the RUTF

only group. These results are not significant (p=.688). The average potassium levels after diet

were in the normal range. The mean was highest in the F75+ RUTF group. The lowest

Therapeutic diets

F100 F75+ RUTF RUTF only p value

Mean (Min-Max)SD Mean (Min-Max)SD Mean (Min-Max)SD

Clinical data

Freq watery/loose stool

7.89(0.00-19.00)5.49 3.14(0.00-7.00)3.08 4.78(0.00-17.00)5.74 .176

Freq normal stool 3.11(0.00-10.00)3.89 4.57(0.00-11.00)4.61 2.33(0.00-7.00)2.69 .664

Freq vomiting 0.11(0.00-1.00)0.33 0.43(0.00-1.00)0.53 2.56(0.00-11.00)4.10 .339

Weight difference after diet

0.00(-0.28-0.18)0.16 0.01(-0.30-0.32)0.19 -0.10(-0.38-0.11)0.17 .562

Biochemical data

pH difference after diet 0.06(-0.02-0.20)0.10 -0.03(-0.17-0.19)0.15 -0.02(-0.35-0.10)0.17 .507

Potassium difference after diet

0.68(0.00-1.00)0.47 0.75(0.00-1.20)0.57 -0.06(-1.40-0.70)0.81 .179

HCO3-a difference

after diet -1.13(-2.30--0.50)0.81 -2.58(-6.90-3.00)4.22 -0.76(-3.00-2.20)2.17 .634

pH after diet 7.47(7.30-7.72)0.16 7.41(7.31-7.62)0.13 7.41(7.22-7.51)0.09 .688

Potassium after diet 4.76(2.90-7.00)1.46 5.04(4.00-5.70)0.70 4.17(2.60-4.90)0.82 .279

HCO3-a after diet 21.98(15.60-30.00)4.53 19.68(17.10-22.80)2.33 18.98(11.70-23.90)3.61 .407

17

average potassium was found in the RUTF only group, where the minimum was also lowest.

These results are not significant (p=.279). Lastly, the HCO3- after the diet was highest in the

F100 group and lowest in the RUTF only group. This is not significant (p= .407).

Mortality in all the groups was 0. No data are yet available for the duration of the transition

phase and the time of recovery.

4. Discussion

For this report we analysed stool frequency, stool consistency, frequency of vomiting,

electrolyte disturbances, mortality and changes in weight to study the effect of three

commonly used transition-phase diets on clinical outcomes in children being treated for

severe acute malnutrition. We hypothesised that children receiving the F75+ RUTF diet

would experience the highest rate of diarrhoea, electrolyte disturbances and weight loss. In

this interim analysis, no large differences were found between the groups that would lead to

breaking off the study or changing the study design.

There were no significant differences between the diets. This can most likely be explained by

the fact that this study sample (N=27) - namely, the children that received the diet - was much

smaller than the calculated sample size (N=108). In this sample size an individual difference

within a group was more likely to be responsible for the differences seen between the three

groups, more so than the difference of the group as whole.

Taking these individual differences into account, we can first take a look at the frequency of

watery diarrhoea. This variable had a trend to be higher in the F100 group. This group had a

patient with a frequency of 19. This individual will greatly increase the mean of the small

group as a whole, compared to the other groups. In a greater sample size, we expect these

children to be distributed across the groups. In addition, the F100 group had more

recruitments than the other groups; a higher frequency of stool could already be expected. It

is therefore difficult to attribute the high frequency to the diet alone. Useful in the analysis of

diarrhoea frequency would be to take into account the carbohydrate absorption and /or losses

through analysing stool and blood samples on reducing substances and carbohydrate

absorption, respectively. These analyses will be included in the next report.

The impact of an individual can also be seen in the frequency of vomiting. In the RUTF only

group one child vomited 11 times. As these results are not significant, no relation can be

defined between the diet and the vomiting. However, one could suggest that carbohydrate

malbsorption in the diets explained the vomiting seen in the children. Nausea and vomiting

have been described in fructose malabsorption [56] and the RUTF only group had the highest

sucrose load compared to the other diets. But the symptoms could also be attributed to the

taste and/or consistency of the feed. RUTF is a dry, sweet paste that can be difficult to

swallow for small children, especially those who are HIV positive and suffer from

oesophageal thrush [57].

Looking at changes in weight across the groups from before and three days into the diet, we

can see they did not differ much from each other. The RUTF only group experienced a slight

more overall weight loss compared to the other two groups, although this was not significant.

Children are expected to recover lost weight in the transition phase and ‘catch- up growth’

until they are ready for discharge [15]. The weight losses seen in our results could be

18

explained by the losses through stool/vomiting but they don’t have to be alarming as the

children with bilateral oedema could still be losing weight as their oedema resolves. After all,

in all the groups a majority of children started out with bilateral oedema. Moreover, great

weight gain could not be expected in the course of three days. In terms of overall weight

gain1, more weight gain could be expected for the RUTF diet. RUTF has a > 5 energy density

compared to F100 but it has a similar ratio of nutrients to energy (in RUTF the skim milk

used in F100 is replaced by peanut butter) [58]. The higher energy density of RUTF could

have consequences for the duration of stay (or recovery rate) of a child as protocols advise

that discharge in most instances is based on a percentage weight gain (after loss of oedema)

of 15% and this can be adjusted up to 20% weight gain depending on the local situation [16].

Lastly, the electrolyte disturbances seen between the different groups; again, these results

were not significant. Looking at individual cases (minimums), low bicarbonate and potassium

levels at the end of the intervention were seen in all groups. All the groups regained a pH

within normal range (7.35-7.45) at the end of the diet. The F100 group started out with the

lowest mean blood pH (most acidotic) and overall gained the most in pH after the diet. The

mechanism behind hypokalaemia in malnourished patients is still unclear but it is associated

with diarrhoea. According to Agarwal et all [59] the diarrhoea does not necessary disturb the

absorptive mechanisms of potassium but fecal potassium losses are increased in diarrhoeal

diseases by unabsorbed anions (which obligate potassium), by electrochemical gradients

secondary to active chloride secretion, and probably by secondary hyperaldosteronism2. The

same study argues that it’s the potassium losses through this reduced net absorption of

potassium in diarrhoea rather than loss of muscle mass because of malnutrition that causes

hypokalaemia. If this is true, one would expect the diet with the highest rates of diarrhoea to

have the lowest potassium levels. This is the case in our results; F100 and RUTF had the

lowest potassium levels. Due to no significance, it is difficult to be firm on the case.

The results of this interim analysis are not significant enough to describe a trend, give definite

answers or provide informed recommendations on which diet to use during the transition

phase in the treatment of children with SAM. A bigger sample size and more samples that

reflect carbohydrate (mal)absorption are needed for this, as the powercalculation advised.

In addition, in analyses to come, being able to differentiate between the HIV positive and

HIV negative children in the bigger sample would be interesting, as HIV is known to

complicate the child’s recovery. What is more, up till now, no patients were seen to perish

during the different transition diets. If this trend continues, important will be to look at the

rate of recovery of the patients; how are they faring on the different diets? How long is their

duration of stay? For this, including the other (clinical questionnaire) variables in the analyses

will be essential. The outcome of these analyses could not only provide more definite

answers in relation to the effect of the different diets and inform the team in MOYO House

(and WHO) but also formulate further collaborative studies to possibly change (the current as

observed inadequate) rehabilitation regimes.

Alternatively, one could decide to take a closer look at the phase I (F75) diet; all the children

that passed away in this study sample died during this phase. Or the timing of transition;

1 This was difficult to record for this study sample because they were put on a different diet after the last

samples were taken, if clinically preferred. 2 Hyperaldosteronism is a medical condition in which the adrenal gland produces too much aldosterone, a

steroid hormone responsible for the secretion of potassium in the distal tubule and collecting duct of the kidneys.

19

perhaps patients are transitioned too early because they ‘cry’ for more food although their

body cannot yet take the food. Maybe even consider including a (protocolised) phase in

between phase I and II; this is already informal practice on MOYO ward by the slow

introduction of RUTF.

Overall, more recruitment is needed to determine the effect of the different transition diets.

But interesting is to think about possible implications for inpatient care in the case that the

hypothesis of F75+RUTF causing the most complications would be true. As stated before, the

high energy density of RUTF could also provide higher recovery rates and decrease patients’

duration of stay. In an underdeveloped country like Malawi, where health centres and staff

are scarce, these are important issues to consider. The rapid deterioration of a child with

SAM in any phase does not have to be fatal if they are closely monitored. But this issue

cannot be fully dealt with without facing the vast problems of a third world hospital setting.

5. Conclusion

No major differences came out of the interim analysis to suggest changing or breaking off the

study. No trends could yet be described to provide more insight. Recommended is to wait till

recruitment and sampling is finalised and perform analyses on a bigger sample size. These

results could possibly provide more definite answers in relation to the effect of the three

different diets used in the transition phase.

Acknowledgements

I want to thank both my supervisors, Dr. Robert Bandsma, from Groningen and Dr. Wieger

Voskuijl, on the ground, for sharing their knowledge and giving me unconditional support,

guidance and responsibility while conducting a study in a challenging research setting. In

addition, I want to thank the head of department of the paediatric department at QECH, Dr

Neil Kennedy, for allowing us to perform our study in the department. I also thank the Moyo

staff nurses for their hard work, sharing of experience and support throughout. This also goes

for George Fudzulani, lab technician at the department and Praise Kafulatila, lab archiver at

the MLW. Lastly, I want to thank the children and their guardians in Moyo ward for their

patience, strength and invaluable cooperation.

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[56] Shepherd S.J. et all. Fructose Malabsorption and Symptoms of Irritable Bowel Syndrome: Guidelines for

Effective Dietary Management. J Am Diet Assoc. 2006;106:1631-1639.

[57] Management of Malnutrition in Children Under Five Years. Mother and Child Nutrtion 2013. Available:

http://motherchildnutrition.org/malnutrition-management/info/rutf-plumpy-nut.html. Accessed: 2013,12 April.

[58] Diop E.H.I. et all. Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for

the rehabilitation of severely malnourished children: a randomized trial. Am J Clin Nutr 2003;78:302-307.

[59] Agarwall R. et all. Pathophysiology of potassium absorption and secretion by the human intestine.

Gastroenterology 1994;107(2):548-571.

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Appendix A: Consent form English

Appendix Consent Form Parent or Guardian

Research Topic: The effect of different nutritional regimens in the treatment of severe acute malnutrition Malnutrition makes the body weaker and less able to fight infections. Malnutrition also causes the gut to work less well. The gut is where food is taken up by the body. We are conducting a study to compare the results of three different diets in malnourished children.

To obtain the answers to our questions, your child will receive one of three possible diets after we have seen some improvement on the diet the child is receiving at this moment. These diets are the same as we already use to treat malnutrition in children. To obtain a better idea on what diet is better for children with malnutrition, we need to take 3 times some blood from your child. Taking the blood will give some mild pain for the child and the parent should not worry. The total amount of blood we will take is less than two teaspoons and will not have any effect on your child. We will also take some urine and feces to analyse what the effects are of the two different diets. All this information will help us to give even better care to children with malnutrition in the future. You are free to participate or not, and this will not influence the way your child is cared for here at the hospital. If you do not understand any part of this consent form, please inform the investigator so that further explanation can be given. Please feel free to call Dr Wieger Voskuijl: Department of Paediatrics & Child Health QECH; cell 09966 04638, Sara van Vliet, Department of Paediatrics & Child Health QECH; cell 09968613 19. If you have any issues regarding your rights to participate in this study, please contact the chairman of Ethics Committee whose contact are as follows: Lucinda Manda-Taylor College of Medicine, P/Bag 360, Blantyre, University of Malawi 01871911

____________________________ I have understood the above information and I voluntarily agree/disagree to participate in this research. Name of Child Date Signature OR Right Thumbprint Name of Interviewer Signature

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Appendix B: Questionnaires for clinical assessment

INFORMATION TO BE TAKEN ON ADMISSION - Enrollment in TranSAM

General information

Patient study number:

Patient’s name:

Patient DOB (d -mm-yyyy):

HIMS:

Guardian’s (preferably Mom’s) name:

Guardian (preferably Mom’s) DOB (d-mm-yyyy):

Patient’s Address:

Date of admission (d-m-y):

Nutritional diagnosis on admission

Weight (in kg)

MUAC (in cm))

Length (in cm)

Weight/Height (in SD below the mean)

Presence of oedema (0/+/++/+++)

For how long has the child been breastfed?

Which complementary diet is the child taking

presently?

Anorexia (nr. days):

Co-Morbidity:

Reactive/non-Reactive (R/NR):

Duration of illness before admission (in weeks):

Main complaint:

Duration, if any, of oedema before admission

(in weeks):

Diarrhoea in preceding days (nr. days):

Nr. of diarrhoea (‘episodes’) in last 3 months:

Vomiting (nr. of days):

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CLINICAL ASSESMENT TO BE TAKEN DAILY (8:00 AM and 4:00 PM)

-Clinical assessment in TranSAM DAY date: DAY date: DAY date: AM PM AM PM AM PM

Weight (kg)

Appetite (Poor/Fair/Good/Excellent)

Finishing feeds (Y/N)

Stool consistency (Normal/Loose/ Watery/Bloody)

Stool frequency AM = Since sunrise/last 24 hours

PM = Since midday

Number of vomits (last 24 hours)

Losses compensated (Good/Fair/Poor/Absent)

Presence of oedema 0/+/++/+++

Hydration status (Dehydrated N=0, mild=1, moderate=2, severe=3)

IV rehydration Y/N (if Y, specify)

Capillary Refill Time (in seconds)

Temperature (in degrees Celsius)

Chest auscultation (Crepitations Y/N)

Saturation (%)

Respiratory rate (per minute)

Heart rate (per minute)

Liver size (in cm) (Enlarged = > 2cm, Y/N)

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Appendix C: Case report form (sample 1)

SAMPLE 1

Code Parameter Tube Fluid Tube Cupjes Total

Glucose NA

whole blood

0,5 ml

Lactate NA

whole blood

Sodium NA

whole blood

Potassium NA

whole blood

Chloric acid NA

whole blood

Ph NA

whole blood

A1 8-OhdG serum (rood) plasma 0,5 ml 200 microliter 0,5 ml

8-OhdG serum (rood) plasma 0,5 ml

200 microliter 0,5 ml

Citrulline serum (rood) plasma 0,5 ml

200 microliter 0,5 ml

B1 Albumin EDTA (paars) plasma 0,25 ml 200 microliter 0,25 ml

2,25 ml

U1 8-OhdG Eppendorf cup urine 0,5 ml 0,5 ml 0,5 ml

F1 Elastase Eppendorf cup faeces 1 g 1 g 1 g

Elastase Eppendorf cup faeces 1 g 1 g 1 g

Microbioma Eppendorf cup faeces

250 mg 250 mg 250 mg

Alpha 1 antitrypsine pot faeces 5 g 5 g 5 g

Ph Eppendorf cup faeces 1 g 1 g 1 g

Total amount blood: 2,25 ml

Total amount urine: 0,5 ml

Total amount faeces 8,25 g