Treatment of children with uncomplicated severe acute malnutrition (SAM) is based on ready-to-use therapeutic foods (RUTF) prescribed based on body weight and administered at home. Treatment performance is typically monitored through weight gain. We previously reported that a reduced dose of RUTF resulted in weight gain velocity similar to standard dose. Here we investigate the change in body composition of children treated for SAM and compare it to community controls, and describe the effect of a reduced RUTF dose on body composition at recovery. Body composition was measured via bio-electrical impedance analysis at admission and recovery among a sub-group of children with SAM participating in a clinical trial and receiving a reduced or a standard dose of RUTF. Non-malnourished children were measured to represent community controls. Linear mixed regression models were fitted. We obtained body composition data from 452 children at admission, 259 at recovery and 97 community controls. During SAM treatment the average weight increased by 1.20 kg of which 0.55 kg (45%) was fat-free mass (FFM) and 0.67 kg (55%) was fat mass (FM). At recovery, children treated for SAM had 1.27 kg lower weight, 0.38 kg lower FFM, and 0.90 kg lower FM compared to community controls. However, their fat-free mass index (FFMI) was not different from community controls (Δ0.2 kg/m²; 95% CI -0.1, 0.4). No differences were observed in FFM, FM or fat mass index (FMI) between the study arms at recovery. However, FFMI was 0.35 kg/m² higher at recovery with the reduced compared to standard dose (p = 0.007) due to slightly lower height (Δ0.22 cm; p = 0.25) and higher FFM (Δ0.11 kg; p = 0.078) in the reduced dose group. Almost half of the weight gain during SAM treatment was FFM. Compared to community controls, children recovered from SAM had a lower FM while their height-adjusted FFM was similar. There was no evidence of a differential effect of a reduced RUTF dose on the tissue accretion of treated children when compared to standard treatment.

Ready-to-use-therapeutic-foods (RUTF) was designed for the nutritional management of children with uncomplicated severe acute malnutrition (SAM) treated as outpatients. However, to our knowledge, no study has evaluated the availability, use and consumption of RUTF within the beneficiary household in programs and in the context of a reduction in the dose of RUTF. This study, assessed the effect of a reduction in RUTF dose on the availability, use, consumption, and perceptions of caregivers on RUTF prescribed to 516 children treated for SAM, aged 6-59 months in Burkina Faso. Children received a weekly dose of RUTF according to their treatment arm until recovery. Data were collected by structured individual in-depth interviews, with caregivers one month and two months post-admission. Differences between children receiving reduced RUTF (intervention arm) and those receiving standard RUTF (control arm) were assessed by Poisson, logistic, and ordered logistic regression model. RUTF was available for the whole week in 95% in intervention arm compared to about 98% in control arm (p > 0.05). Starting from week 3 onwards, children in intervention arm consumed an average of 9 sachets of RUTF per week compared to 15 sachets in control arm (p < 0.001) and 5% of children in intervention arm reported leftover compared to 11% in control arm (p < 0.05). About 40% of children in intervention arm consumed RUTF at least 3-times per day compared to 82% in control arm (p < 0.001). The amount of RUTF prescribed was perceived as sufficient in 93% by caregivers in intervention arm against 97% in control arm (p > 0.05). In conclusion, reducing the dose of RUTF did not affect the availability of RUTF during treatment but did reduce leftover and the frequency of consumption of RUTF.

Ready-to-use therapeutic foods (RUTF) are designed to cover the daily nutrient requirements of children with severe acute malnutrition (SAM). However, with the transfer of uncomplicated SAM care from the hospital environment to the community level, children will be able to consume complementary and family foods (CFF) in addition to RUTF, and this might decrease the quantity of RUTF needed for recovery. Using an individually randomized clinical trial, we investigated the effects of a reduced RUTF dose on the daily energy and macronutrient intakes, the proportion of energy coming from CFF, and the mean probability of adequacy (MPA) of intake in 11 micronutrients of 516 children aged 6–59 mo who were treated for SAM in Burkina Faso. The data were collected using a single 24-h multipass dietary recall, 1 mo after starting treatment, from December 2016 to August 2018, repeated on a subsample of 66 children. Differences between children receiving the reduced RUTF (intervention arm) and those receiving standard RUTF (control arm) were assessed by linear mixed models. Daily energy intake was lower (P < 0.01) in the intervention arm (mean ± SD 1321 ± 339 kcal) than in the control arm (1467 ± 319 kcal). CFF contributed to 40% of the daily energy intake in the intervention and 35% in the control arm. The MPA for 11 micronutrients was 0.89 ± 0.1 in the intervention arm and 0.95 ± 0.07 in the control arm (P = 0.06). Reducing the dose of RUTF during SAM treatment had a negative impact on daily energy intake of the children. Despite this, children covered their recommended energy intake. The energy intake coming from CFF was similar between arms, suggesting that children's feeding practices did not change due to the reduction in RUTF in this context. This trial was registered at the IRSCTN registry as ISRCTN50039021.

Severe acute malnutrition (SAM) is treated with ready-to-use therapeutic foods (RUTF) containing a vitamin–mineral premix. Yet little is known about micronutrient status in children with SAM before and after treatment. We aimed to investigate vitamin B12 status in children with uncomplicated SAM, aged 6–59 months in Burkina Faso, before and after treatment with a standard or a reduced dose of RUTF. Blood samples were collected at admission and discharge. Serum B12 was determined with microbiological assay and serum methylmalonic acid (MMA) and total homocysteine (tHcy) were analyzed with gas chromatography-tandem mass spectrometry. B12 status was classified using the combined indicator (3cB12). Among 374 children, the median [interquartile range] age was 11.0 [7.7–16.9] months, and 85.8% were breastfed. Marked or severe B12 deficiency, as judged by 3cB12, decreased from 32% to 9% between admission and discharge (p < 0.05). No differences in B12 status following treatment with either standard (n = 194) or reduced (n = 180) doses of RUTF were observed. Breastfed children showed a lower B12 status (3cB12) than non-breastfed ones (−1.10 vs −0.18, p < 0.001 at admission; −0.44 vs 0.19; p < 0.001 at discharge). In conclusion, treatment of SAM with RUTF improved children’s B12 status but did not fully correct B12 deficiency.

Nutritional treatment of children with uncomplicated severe acute malnutrition (SAM) is based on ready‐to‐use therapeutic foods (RUTF). With treatment provided at community level, children could have access to other foods, and a reduction in the dose of RUTF could further increase dietary diversity during treatment. We assessed the dietary diversity score (DDS), the minimum dietary diversity (MDD), the minimum meal frequency (MMF) and the minimum acceptable diet (MAD) of 459 infants and young children aged 6–23 months being treated for SAM with different doses of RUTF. We also investigated the factors associated with DDS. Dietary intake was estimated using a single 24‐h multipass dietary recall, 1 month after starting treatment, from December 2016 to August 2018. The DDS was calculated on the basis of eight food groups. Differences between children receiving the reduced RUTF and the standard RUTF dose and factors associated with DDS were assessed by Poisson and logistic regression models. RUTF dose was not associated with DDS (4.07 ± 1.25 for reduced RUTF and 4.01 ± 1.26 for standard RUTF;P = 0.77). Food groups most consumed by children were grains, roots or tubers (96%) and legumes and nuts (72%). Eggs consumption was low (3%). DDS was positively associated with child's age, mother's education, household wealth index, urban residence and rainy season. The present findings show that children with SAM consumed a variety of foods during treatment in addition to the RUTF ration prescribed to them. Reducing the dose of RUTF during SAM treatment did not impact DDS.

Treatment of acute malnutrition requires novel approaches to improve coverage, reduce costs and improve the efficiency of standard protocols that separate the management of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). The use of simplified, combined protocols to treat both MAM and SAM has drawn research and policy interest among global, regional and national stakeholders. However, the perspectives of local communities and health care workers regarding the use of protocols to treat acute malnutrition in a routine health care system are generally lacking. This was a cross‐sectional mixed‐methods study aimed at assessing the perceptions of different stakeholders on the use of a simplified, combined protocol in two districts in the Central African Republic. Most of the respondents preferred the simplified, combined protocol over the standard protocol. They generally agreed that the protocol was easy to understand, allowed more children to receive treatment and was effective in treating acute malnutrition. The protocol modifications were well received, including the expanded admission criteria, use of mid‐upper arm circumference (MUAC) only for admission and discharge criteria and reduced and simplified ready‐to‐use therapeutic food quantity to treat MAM and SAM. Some caregivers expressed concern with the use of MUAC only to declare recovery, flagging that underlying illnesses could still be present. The caregivers recommended the provision of other food basket interventions to improve the treatment. The support by caregivers and health care workers on the idea of training community health volunteers to treat acute malnutrition points to the potential of scaling up decentralized treatment to increase coverage in remote areas.