Addition of a probiotic/prebiotic* mix to the conventional high-energy ready-to-use therapeutic foods used in feeding programmes does not improve severe malnutrition outcomes for African children. However an observation of reduced outpatient mortality in children given the additional supplement warrants further investigation. These are the conclusions of an Article published in this week's edition of The Lancet, written by Dr Marko Kerac, of Valid International UK, College of Medicine Malawi & UCL Centre for International Health and Development, London, UK, and colleagues.
Probiotic and prebiotic functional foods are claimed to provide health benefits beyond the provision of essential nutrients. In some patients, these supplements reduce diarrhoea, promote healthy gut bacteria, reduce bad gut bacteria, and directly or indirectly affect the immune system. Thus they should also be beneficial in severe acute malnutrition when impaired gut function is a problem, manifested in conditions such as diarrhoea, small bowel overgrowth, increased intestinal permeability, and inflammation of the small intestine (enteropathy). However, probiotics also have a small risk of causing invasive infection—therefore, caution is sometimes recommended in immuno-compromised patients, eg, those with HIV. Improved risk-benefit data are vital in this respect; the most vulnerable, immunosuppressed children who are severely malnourished, and have HIV, are the ones needing therapeutic improvement. In this study, the authors assessed the efficacy of a probiotic and prebiotic functional food for the treatment of severe acute malnutrition in an HIV-prevalent setting.
The randomised controlled trial studied 795 Malawian children aged five months to 16 years. After stabilisation with milk feeds, children were assigned to ready-to-use therapeutic food either with (399) or without (396) Synbiotic2000 Forte—a probiotic/prebiotic blend—for the duration of treatment (median 33 days). The primary outcome was nutritional cure (reaching 80% or more of the median weight-for-height value). Secondary outcomes included death, weight gain, time to cure, and prevalence of clinical symptoms such as diarrhoea and fever.
The researchers found that nutritional cure rates were similar in both groups – 54% Synbiotic versus 51% control. Children who were HIV positive had worse outcomes, but again with little difference between the groups. Subgroup analyses showed a observation of reduced outpatient mortality in the Synbiotic group. Possible reasons for this include known probiotic effects taking time to manifest, and some causes of early inpatient death (e.g. electrolyte imbalance and re-feeding syndrome) being unaffected by known probiotic actions. The authors conclude: "Synbiotic2000 Forte did not improve severe acute malnutrition outcomes. The observation of reduced outpatient mortality might be caused by bias, confounding, or chance, but is biologically plausible, has potential for public health impact, and should be explored in future studies."
In an accompanying Comment, Professor Zulfiqar A Bhutta, Aga Khan University, Karachi, Pakistan, says: "These data underscore the difficulties that plague rolling out effective interventions at scale in the wake of weak health systems and policy environments. Successful management of severe acute malnutrition in community settings depends on three crucial factors. First, the need for horizontal integration of programmes for community management of acute malnutrition with existing health-system interventions, so that moderately and severely malnourished children are promptly recognised and triaged for care and receive essential lifesaving interventions in addition to food. There is little to gain from supply of RUTF alone if effective and timely treatment for malaria, pneumonia, and diarrhoea is not available. Second, in HIV-endemic populations, rapid and continued access to antiretrovirals and ancillary support strategies for children with severe acute malnutrition is key to ensuring that children survive and benefit from nutrition interventions. Third and perhaps most important, although community mobilisation and creation of demand is a cornerstone of community management of acute malnutrition, this aspect is often ignored in large-scale programmes that manage severe acute malnutrition. The experience of such communitybased approaches in other parts of the world with maternal and newborn interventions indicates that community mobilisation and engagement is indeed possible."
Dr Marko Kerac, Valid International, College of Medicine Malawi, & UCL Centre for International Health and Development, London, UK T) +44 (0)207 905 2262 marko.kerac@gmail.com
Professor Zulfiqar A Bhutta, Aga Khan University, Karachi, Pakistan. Please contact Professor Bhutta by e-mail to arrange interviews. E) zulfiqar.bhutta@aku.edu
Note to editors: *Probiotics are dietary supplements of live microorganisms which have a health benefit when eaten in suffient quantities. Prebiotics are non-digestible food ingredients that stimulate the growth or activity of bacteria in the digestive system which are beneficial to the health of the host organism
Journal
The Lancet