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Bahwere P, James P, Abdissa A, Getu Y, Getnet Y, Sadler K, Girma T. Use of tuberculin skin test for assessment of immune recovery among previously malnourished children in Ethiopia. BMC Res Notes 2017; 10:570. [PMID: 29115985 PMCID: PMC5688824 DOI: 10.1186/s13104-017-2909-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 11/01/2017] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To compare levels of immunity in children recovering from severe acute malnutrition (cases) against those of community controls (controls). RESULTS At baseline children recovering from severe acute malnutrition had lower, mid upper arm circumference (122 mm for cases and 135 mm for controls; p < 0.001), weight-for-height Z-score (- 1.0 for cases and - 0.5 for controls; p < 0.001), weight-for-age Z-score (- 2.8 for cases and - 1.1 for controls; p < 0.001) and height/length-for-age Z-score (- 3.6 for cases and - 1.4 for controls; p < 0.001), than controls. Age and gender matched community controls. At baseline, prevalence of a positive tuberculin skin test, assessed by cutaneous delayed-type hypersensitivity reaction skin test, was very low in both cases (3/93 = 3.2%) and controls (2/94 = 2.1%) and did not significantly increase at 6 months follow up (6/86 = 7.0% in cases and 3/84 = 3.4% in controls). The incidences of common childhood morbidities, namely fever, diarrhoea and cough, were 1.7-1.8 times higher among cases than controls. In conclusion, these results show that tuberculin skin test does not enable any conclusive statements regarding the immune status of patients following treatment for severe acute malnutrition. The increased incidence of infection in cases compared to controls suggests persistence of lower resistance to infection even after anthropometric recovery is achieved.
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Affiliation(s)
- Paluku Bahwere
- Valid International, 35, Leopold Street, Oxford, OX4 1TW UK
- Research Centre in Epidemiology, Biostatistics and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
| | - Philip James
- Valid International, 35, Leopold Street, Oxford, OX4 1TW UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Alemseged Abdissa
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Oromia Ethiopia
| | - Yesufe Getu
- Save Children Federation, Addis Ababa, Ethiopia
| | | | - Kate Sadler
- Valid International, 35, Leopold Street, Oxford, OX4 1TW UK
| | - Tsinuel Girma
- Department of Paediatrics and Child Health, Jimma University, Jimma, Oromia Ethiopia
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Hossain MI, Ahmed T, Arifeen SE, Billah SM, Faruque A, Islam MM, Jackson AA. Comparison of midupper arm circumference and weight-for-height z score for assessing acute malnutrition in Bangladeshi children aged 6-60 mo: an analytical study. Am J Clin Nutr 2017; 106:1232-1237. [PMID: 28978541 DOI: 10.3945/ajcn.116.139881] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/06/2017] [Indexed: 11/14/2022] Open
Abstract
Background: In clinical settings, wasting in childhood has primarily been assessed with the use of a weight-for-height z score (WHZ), and in community settings, it has been assessed via the midupper arm circumference (MUAC) with a cutoff <115 mm for severe wasting and <115-125 mm for moderate wasting. Our recent experience indicates that many wasted children were not identified when these cutoffs for MUAC were used.Objective: We determined the cutoffs for MUAC to detect wasting in Bangladeshi children aged 6-60 mo.Design: A secondary analysis was carried out on data from 27,767 children aged 6-59 mo. This analysis comprised 1) 9131 children across Bangladesh and 2) 18,636 children enrolled in a surveillance study in the Dhaka Hospital of icddr,b during 1996-2014. The area under the receiver operating curve was used to indicate the most appropriate choice for cutoffs that related MUAC with WHZ.Results: The mean ± SD age for the entire group was 21 ± 14 mo, WHZ was -1.18 ± 1.23, height-for-age z score was -1.63 ± 1.39, MUAC was 136 ± 14 mm, and 45% of subjects were girls. MUAC correlated with the WHZ (r: 0.618, P < 0.001). Age-stratified analyses revealed that, for ages 6-24 mo, MUAC cutoffs were <120 mm for a WHZ <-3 and <125 mm for a WHZ <-2 with a sensitivity of 72.9% and 63.2%, respectively, and a specificity of 84.7% and 85.3%, respectively; for ages 25-36 mo, MUAC cutoffs were <125 mm for a WHZ <-3 and <135 mm for a WHZ <-2 with a sensitivity of 55.0% and 71.7%, respectively, and a specificity of 92.8% and 78.7% respectively; and for ages 37-60 mo, MUAC cutoffs were <135 mm for a WHZ <-3 and <140 mm for a WHZ <-2 with a sensitivity of 71.4% and 70.4%, respectively, and a specificity of 84.6% and 80.3%, respectively.Conclusion: The respective cutoffs for MUAC to better capture the vulnerability and risk of severe (WHZ <-3) and moderate (WHZ <-2) wasting would be <120 and <125 mm for ages 6-24 mo, <125 and <135 mm for ages 25-36 mo, and <135 and <140 mm for ages 37-60 mo.
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Affiliation(s)
- Md Iqbal Hossain
- Nutrition and Clinical Services Division and .,James P Grant School of Public Health, Brac University, Mohakhali, Dhaka, Bangladesh; and
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division and.,James P Grant School of Public Health, Brac University, Mohakhali, Dhaka, Bangladesh; and
| | - Shams El Arifeen
- Maternal and Child Health Division, icddr,b, Mohakhali, Dhaka, Bangladesh.,James P Grant School of Public Health, Brac University, Mohakhali, Dhaka, Bangladesh; and
| | - Sk Masum Billah
- Maternal and Child Health Division, icddr,b, Mohakhali, Dhaka, Bangladesh
| | - Asg Faruque
- Nutrition and Clinical Services Division and
| | | | - Alan A Jackson
- Human Nutrition, International Malnutrition Task Force, Southampton General Hospital, Southampton, United Kingdom
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Bahwere P, Akomo P, Mwale M, Murakami H, Banda C, Kathumba S, Banda C, Jere S, Sadler K, Collins S. Soya, maize, and sorghum-based ready-to-use therapeutic food with amino acid is as efficacious as the standard milk and peanut paste-based formulation for the treatment of severe acute malnutrition in children: a noninferiority individually randomized controlled efficacy clinical trial in Malawi. Am J Clin Nutr 2017; 106:1100-1112. [PMID: 28814393 DOI: 10.3945/ajcn.117.156653] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/19/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Development of more cost-effective ready-to-use therapeutic food (RUTF) is a global public health priority. To date, previous lower-cost recipes have been less effective than the standard peanut and milk (PM)-based RUTF, particularly in children aged <24 mo.Objective: We aimed to compare the efficacy of the PM-RUTF to a milk-free soya, maize, and sorghum (FSMS)-RUTF enriched with crystalline amino acids without cow milk powder and a milk, soya, maize, and sorghum (MSMS)-RUTF containing 9.3% skim cow milk powder.Design: This nonblinded, 3-arm, parallel-group, simple randomized controlled trial enrolled Malawian children with severe acute malnutrition.Results: In intention-to-treat analyses, FSMS-RUTF showed noninferiority for recovery rates in children aged 24-59 mo (Δ: -1.9%; 95% CI: -9.5%, 5.6%) and 6-23 mo (Δ: -0.2%; 95% CI: -7.5%, 7.1%) compared with PM-RUTF. MSMS-RUTF also showed noninferiority for recovery rates in children aged 24-59 mo (Δ: 0.0%; 95% CI: -7.3%, 7.4%) and 6-23 mo (Δ: 0.6%; 95% CI: -4.3%, 5.5%). Noninferiority in recovery rates was also observed in per-protocol analyses. For length of stay in the program (time to cure), both FSMS-RUTF in children aged 24-59 mo (Δ: 2.8 d; 95% CI: -0.8, 6.5 d) and 6-23 mo (Δ: 3.4 d; 95% CI: -1.2, 8.0 d) and MSMS-RUTF in children aged 24-59 mo (Δ: 0.2 d; 95% CI: -3.1, 3.6 d) and 6-23 mo (Δ: 1.2 d; 95% CI: -3.4, 5.8 d) were not inferior to PM-RUTF. FSMS-RUTF was also significantly better than PM-RUTF at increasing hemoglobin and body iron stores in anemic children, with mean hemoglobin increases of 2.1 (95% CI: 1.6, 2.6) and 1.3 (95% CI: 0.9, 1.8) and mean body iron store increases of 2.0 (95% CI: 0.8, 3.3) and 0.1 (95% CI: -1.1, 1.3) for FSMS-RUTF and PM-RUTF, respectively.Conclusions: FSMS-RUTF without milk is efficacious in the treatment of severe acute malnutrition in children aged 6-23 and 24-59 mo. It is also better at correcting iron deficiency anemia than PM-RUTF. This trial was registered at www.pactr.org as PACTR201505001101224.
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Affiliation(s)
- Paluku Bahwere
- Valid International, Oxford, United Kingdom;
- Center for Epidemiology, Biostatistics, and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
| | | | | | | | | | | | | | | | | | - Steve Collins
- Valid International, Oxford, United Kingdom
- Valid Nutrition, Cork, Republic of Ireland
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Burrell A, Kerac M, Nabwera H. Monitoring and discharging children being treated for severe acute malnutrition using mid-upper arm circumference: secondary data analysis from rural Gambia. Int Health 2017; 9:226-233. [PMID: 28810666 PMCID: PMC5881269 DOI: 10.1093/inthealth/ihx022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 06/13/2017] [Indexed: 11/14/2022] Open
Abstract
Background Severe acute malnutrition (SAM) is a major public health problem. Mid-upper arm circumference (MUAC) is widely used to admit children to treatment programmes. However, insufficient data supporting MUAC discharge criterion limits its use as a stand-alone tool. Our aim was to evaluate MUAC for monitoring nutritional recovery and discharge. Methods This was a secondary analysis of clinical data from children 6-59 months-old treated for SAM from January 2003 to December 2013 at the Nutritional Rehabilitation Unit in rural Gambia. Weight, weight-for-height z-score (WHZ) and MUAC response to treatment were assessed. Treatment indicators and regression models controlled for admission measurement and age were compared by discharge MUAC and WHZ. Results Four hundred and sixty-three children with marasmus were included. MUAC, WHZ and weight showed parallel responses to treatment. MUAC≥125 mm as a discharge criterion performed well, showing good prediction of default and referral to hospital, acceptable duration of stay, and a higher absolute MUAC measure compared to WHZ≥-2.00, closely related to lower risk of mortality. Conclusions MUAC can be used as a standalone tool for monitoring nutritional recovery. MUAC≥125 mm performs well as a discharge criterion; however, follow-up data is needed to assess its safety. Further research is needed on children meeting MUAC discharge criterion but with WHZ≤2.0.
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Affiliation(s)
- Alice Burrell
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
| | - Marko Kerac
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.,Leonard Cheshire Disability & Inclusive Development Centre, Department of Epidemiology & Child Health, University College London, London, UK
| | - Helen Nabwera
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.,The MRC Gambia Unit, Keneba, The Gambia
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Amadi B, Besa E, Zyambo K, Kaonga P, Louis-Auguste J, Chandwe K, Tarr PI, Denno DM, Nataro JP, Faubion W, Sailer A, Yeruva S, Brantner T, Murray J, Prendergast AJ, Turner JR, Kelly P. Impaired Barrier Function and Autoantibody Generation in Malnutrition Enteropathy in Zambia. EBioMedicine 2017; 22:191-199. [PMID: 28750860 PMCID: PMC5552244 DOI: 10.1016/j.ebiom.2017.07.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/15/2017] [Accepted: 07/17/2017] [Indexed: 12/24/2022] Open
Abstract
Intestinal damage in malnutrition constitutes a threat to the survival of many thousands of children globally. We studied children in Lusaka, Zambia, with severe acute malnutrition (SAM) and persistent diarrhea using endoscopy, biopsy and analysis of markers and protective proteins in blood and intestinal secretions. We carried out parallel investigations in apparently healthy adults, and analyzed biomarkers only in apparently healthy children. Villus height and crypt depth did not differ in children with SAM and adult controls, but epithelial surface was reduced in children with SAM (median 445, interquartile range (IQR) 388, 562 μm per 100 μm muscularis mucosae) compared to adults (578, IQR 465,709; P = 0.004). Histological lesions and disruptions of claudin-4 and E-cadherin were most pronounced in children with SAM. Circulating lipopolysaccharide, a marker of bacterial translocation, was higher in malnourished children (251, IQR 110,460 EU/ml) than in healthy children (51, IQR 0,111; P = 0.0001). Other translocation markers showed similar patterns. Anti-Deamidated Gliadin Peptide IgG concentrations, although within the normal range, were higher in children with SAM (median 2.7 U/ml, IQR 1.5–8.6) than in adults (1.6, 1.4–2.1; P = 0.005), and were inversely correlated with villus height (ρ = − 0.79, n = 13, P = 0.001). Malnutrition enteropathy is associated with intestinal barrier failure and immune dysregulation. Enteropathy in children with severe acute malnutrition is characterized by variable villus blunting and epithelial disruption. Biomarkers indicate very high levels of microbial translocation from intestinal lumen to systemic circulation. Coeliac-type autoantibodies were associated with villus blunting, microbial translocation markers and mortality.
There is abundant evidence that childhood malnutrition is a major contributor to mortality in many low and middle income countries. Mortality remains unacceptably high. Here we show that severe acute malnutrition was characterized by very high levels of microbial translocation and inflammation, and severe mucosal damage with disturbed tight junction protein expression. Antibodies to tissue transglutaminase and deamidated gliadin peptides, although within the normal range, correlated with villus morphology, translocation markers and death. Malnutrition enteropathy permits mucosal inflammation, microbial translocation and immune dysregulation.
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Affiliation(s)
- Beatrice Amadi
- Department of Paediatrics, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Patrick Kaonga
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - John Louis-Auguste
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Kanta Chandwe
- Department of Paediatrics, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Phillip I Tarr
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Donna M Denno
- Department of Pediatrics, University of Washington, Seattle, USA
| | - James P Nataro
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, USA
| | | | - Anne Sailer
- Departments of Pathology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sunil Yeruva
- Departments of Pathology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Andrew J Prendergast
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Jerrold R Turner
- Departments of Pathology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK.
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56
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Cuneo CN, Dansereau E, Habib AR, Davies M, Ware S, Kornetsky K. Treating Childhood Malnutrition in Rural Haiti: Program Outcomes and Obstacles. Ann Glob Health 2017; 83:300-310. [PMID: 28619405 DOI: 10.1016/j.aogh.2017.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Haiti has the worst malnutrition rate in the Western hemisphere. In October 2010, a cholera epidemic erupted and spread rapidly throughout the country, straining Haiti's already fragile health infrastructure across all levels of care. This study reviews data from an outpatient therapeutic feeding program (OTP) for acute childhood malnutrition at a clinic in rural Haiti with a focus on the effect of the 2010 cholera epidemic on program operations. METHODS A retrospective chart review was conducted for the complete set of patients who were enrolled in the OTP from its inception in March 2009 through January 2014. FINDINGS A total of 187 charts were retrieved representing 176 unique patients, of whom 5 were currently enrolled in care. At admission, 96 (51.3%) met criteria for severe acute malnutrition, 88 (47.1%) met criteria for moderate acute malnutrition, and 3 (1.6%) did not meet criteria for acute malnutrition. Of the 182 completed charts, 119 (65.4%) reached their target weight (≥-1 weight-for-height z-score) by discharge (ie, were "cured"), 43 (23.6%) defaulted, 11 (6.0%) were discharged prematurely, 8 (4.4%) died, and 1 (0.5%) was hospitalized. A total of 11 patients (6.3%) who were initially admitted relapsed after discharge and were later readmitted. Data from 170 complete records (93.4%) were included in a multivariate logistic regression. Severe (vs moderate) acute malnutrition was negatively associated with likelihood of being cured when controlling for other patient- and care-related factors (OR = 0.261, P = .002). Average cholera burden was negatively correlated with likelihood of OTP treatment cure when controlling for patient- and care-related variables (OR = 0.859, P = .002) but was insignificant when controlling for year. CONCLUSIONS Results from the study have been used to inform a restructuring of the clinic's acute malnutrition program toward a more community-centered model of management, the context and implications of which are discussed in relation to the existing literature.
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Affiliation(s)
- C Nicholas Cuneo
- Department of Global Health and Social Medicine, Brigham and Women's Hospital, Boston, MA; Department of Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Emily Dansereau
- Institute for Health Metrics and Evaluation, The University of Washington, Seattle, WA
| | | | - Mary Davies
- Columbia University College of Physicians and Surgeons, New York, NY; St. Joseph's Clinic, Thomassique, Haiti
| | | | - Kenneth Kornetsky
- St. Joseph's Clinic, Thomassique, Haiti; Medical Missionaries, Manassas, VA
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Isanaka S, Kodish SR, Berthé F, Alley I, Nackers F, Hanson KE, Grais RF. Outpatient treatment of severe acute malnutrition: response to treatment with a reduced schedule of therapeutic food distribution. Am J Clin Nutr 2017; 105:1191-1197. [PMID: 28404577 DOI: 10.3945/ajcn.116.148064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Community-based management of severe acute malnutrition (SAM) has been shown to be safe and cost-effective, but program coverage remains low. Treatment models that maintain high levels of clinical effectiveness but allow for increased coverage are still needed. A reduced schedule of follow-up, in which children receive clinical follow-up and therapeutic foods on a monthly rather than weekly basis, may be one alternative.Objective: We aimed to describe the safety and feasibility of a monthly distribution of ready-to-use therapeutic food (RUTF) in the treatment of uncomplicated SAM, in terms of clinical response to treatment and household RUTF use.Design: We conducted a nonrandomized pilot intervention study in which 115 children eligible for outpatient treatment of SAM were provided a monthly ration of RUTF. Anthropometric measurements were taken weekly for 4 wk to monitor treatment response. Unannounced household spot checks were conducted over 4 wk to assess household use of RUTF and storage practices.Results: Adequate weight and midupper arm circumference (MUAC) gain were found throughout the 4-wk follow-up period. Observed mean ± SD weight gain from admission was 9.8 ± 6.8 g · kg-1 · d-1 in week 1 and 4.2 ± 2.1 g · kg-1 · d-1 by week 4. Unplanned household spot checks found an average surplus of RUTF sachets compared with the number expected based on the date of distribution and recommended dosing throughout the 4 wk of follow-up. The frequency at which more than the recommended dose was used (i.e., deviance of >2 sachets between available and expected stocks) was 4% and 22% of households visited in week 1 and week 4, respectively.Conclusion: Adequate treatment response and RUTF use in the outpatient treatment of SAM was maintained over 4 wk of follow-up with a monthly schedule of RUTF distribution. This study was registered at clinicaltrials.gov as NCT02994212.
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Affiliation(s)
- Sheila Isanaka
- Departments of Nutrition and .,Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
| | | | | | | | | | - Kerstin E Hanson
- Médecins Sans Frontières, Operational Center Paris, Paris, France
| | - Rebecca F Grais
- Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and.,Epicentre and
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Comparison of Mid-Upper Arm Circumference and Weight-for-Height to Diagnose Severe Acute Malnutrition: A Study in Southern Ethiopia. Nutrients 2017; 9:nu9030267. [PMID: 28287482 PMCID: PMC5372930 DOI: 10.3390/nu9030267] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/01/2017] [Accepted: 03/08/2017] [Indexed: 11/23/2022] Open
Abstract
Weight-for-height Z-score (WHZ) and mid-upper arm circumference (MUAC) are two independent anthropometric indicators for diagnosing and admitting children with severe acute malnutrition (SAM) for treatment. While severely wasted children are at high risk of mortality, MUAC and WHZ do not always identify the same population of children as having SAM. Understanding how this discrepancy relates to age and sex may provide valuable information for care programmes for children with SAM. Age and sex distribution for differences between children identified as SAM by MUAC and WHZ were examined and the degree of agreement calculated. Children (n = 4297) aged 6–59 months with validated anthropometric measures were recruited from a population-based survey conducted in rural southern Ethiopia. MUAC < 115 mm and WHZ < −3 were used to define severe wasting as per the World Health Organization (WHO) classification. The kappa coefficient (κ) was calculated. There was fair agreement between the MUAC and WHZ definitions of severe wasting in boys (κ = 0.37) and children younger than 24 months (κ = 0.32) but poor agreement in girls (κ = 0.15) and children aged 24 months and above (κ = 0.13). More research is needed on response to treatment and prediction of mortality using different anthropometric measurements in relation to ages and sex of children.
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Abstract
Malnutrition continues to be a major public health challenge especially in South Asian developing countries. The aim of the present review is to spotlight the magnitude of the prevalence of malnutrition and its dynamics in South Asian region and to suggest potential approaches for the prevention and control of this issue of public health significance. An extensive review of literature, covering malnutrition and its determinants, health and economic consequences and pragmatic preventive strategies was performed on computer based bibliographic databases (PubMed, Google Scholar, Scopus, Medline and Sciencedirect.com ) to retrieve abstracts and full texts for India, Pakistan, Bangladesh, Sri Lanka and Nepal. All relevant titles and abstracts were examined and evaluated for malnutrition and its prevalence in South Asia. The results revealed malnutrition to be a major public health problem and a potential cause of high disease burden and mortality in South Asia. Compelling evidence suggests malnutrition to be the leading cause of stunting, wasting and underweight with drastic economic consequences among vulnerable populations. Reduced cognitive performance and low productivity have also been associated with micronutrients malnutrition. Suboptimal breastfeeding, inadequate food supply, micronutrient deficiencies, low household income, poor health care system, increased healthcare costs, illiteracy, unhygienic and substandard living, inappropriate child's care and the caregiver, food insecurity and on top of that vicious cycle of poverty, have been recognized as principal indicators for growing malnutrition prevalence in South Asia. Global organizations, local governments, program managers, NGOs, academia, industry in particular and the society at large need to take up the challenge to completely confiscate malnutrition from the region for economic prosperity and a healthier future.
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Affiliation(s)
- Saeed Akhtar
- a Department of Food Science and Nutrition , Bahauddin Zakariya University , Multan , Pakistan
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60
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Frison S, Kerac M, Checchi F, Prudhon C. Anthropometric indices and measures to assess change in the nutritional status of a population: a systematic literature review. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0104-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Briend A, Prudhon C, Prinzo ZW, Daelmans BMEG, Mason JB. Putting the Management of Severe Malnutrition Back on the International Health Agenda. Food Nutr Bull 2016; 27:S3-6. [PMID: 17076210 DOI: 10.1177/15648265060273s301] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- André Briend
- Department of Child and Adolescent Health, World Health Organization, 20, avenue Appia, CH-1211 Geneva 27, Switzerland.
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62
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Mwanza M, Okop KJ, Puoane T. Evaluation of outpatient therapeutic programme for management of severe acute malnutrition in three districts of the eastern province, Zambia. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0102-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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63
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Panda S, Sadhu C, Pramanik G, Pahari S, Hossain J. Concerning public health situation of under-nutrition in children and anemia in women in Indian Sundarbans delta: a community based cross-sectional investigation. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0105-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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64
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Somassè YE, Dramaix M, Bahwere P, Donnen P. Relapses from acute malnutrition and related factors in a community-based management programme in Burkina Faso. MATERNAL & CHILD NUTRITION 2016; 12:908-17. [PMID: 26059267 PMCID: PMC6860074 DOI: 10.1111/mcn.12197] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Community-based management of acute malnutrition (CMAM) is effective in treating acute malnutrition. However, post-discharge follow-up often lacks. We aimed at assessing the relapse rate and the associated factors in a CMAM programme in Burkina Faso. Discharged children from the community nutrition centre were requested to return at least every 3 months for follow-up. The data of recovered children (weight-for-height z-score ≥-2) who were discharged between July 2010 and June 2011 were collected in 45 villages, randomly selected out of 210 in January 2012. Sociodemographic data, economic variables, information on household food availability and the child's food consumption in the last 24 h were collected from the parents. A multivariate Cox proportional hazards regression was used to identify the factors associated to relapse. Of the 637 children, 14 (2.2%) died and 218 (34.2%) were lost to follow-up. The relapse rate [95% confidence interval] among the children who returned for follow-up was 15.4 [11.8-19.0] per 100 children-years. The associated factors to relapses in multivariate Cox regression model were mid-upper arm circumference (MUAC) at discharge below 125 mm, no oil/fat consumption during the last 24 h and incomplete vaccination. To limit relapses, CMAM programmes should avoid premature discharge before a MUAC of at least 125 mm. Nutrition education should emphasize fat/oil as inexpensive energy source for children. Promoting immunization is essential to promote child growth. Periodic monitoring of discharged children should be organized to detect earlier those who are at risk of relapse. The relapse rate should be a CMAM effectiveness indicator.
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Affiliation(s)
| | - Michèle Dramaix
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Paluku Bahwere
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Donnen
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
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Mengesha MM, Deyessa N, Tegegne BS, Dessie Y. Treatment outcome and factors affecting time to recovery in children with severe acute malnutrition treated at outpatient therapeutic care program. Glob Health Action 2016; 9:30704. [PMID: 27396484 PMCID: PMC4939403 DOI: 10.3402/gha.v9.30704] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 04/28/2016] [Accepted: 05/27/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The outpatient therapeutic care program (OTP) of children with severe acute malnutrition (SAM) has been decentralized to health post level in Ethiopia since 2008-2009. However, there is a lack of evidence regarding treatment outcomes and factors related to the duration of stay on treatment after its decentralization to health post level. OBJECTIVE This study was aimed to assess treatment outcome and factors affecting time to recovery in children with SAM treated at OTP. DESIGN Health facility-based retrospective cohort study was conducted using data from 348 patient cards. The outcome variable was time to recovery. Descriptive analysis was done using percentages for categorical data and mean/median for continuous variables. A robust method of analyzing time to event data, the Cox proportional-hazard regression, was used. All statistical tests in this study are declared significant at p<0.05. RESULT 89.1% of children with kwashiorkor and 69.4% of children with marasmus were recovered. Of the total children studied, 22% were readmitted cases. The median time of recovery was 35 days for children with kwashiorkor and 49 days for children with marasmus. Children older than 3 years were 33% less likely to achieve nutritional recovery [adjusted hazard ratio, AHR=0.67, 95% confidence interval, CI (0.46, 0.97)]. Similarly, marasmic children stayed longer on treatment [AHR=0.42, 95% CI (0.32, 0.56)]. However, children who gained Mid-Upper Arm Circumference (MUAC) ≥ 0.24 mm/day were 59% more likely to recover faster [AHR=1.59, 95% CI (1.23, 2.06)]. CONCLUSIONS Close monitoring of weight and MUAC gain to assess nutritional improvement with due emphasis given to children with lower admission weight, children of age 3 years and above and marasmic children will have a positive effect on treatment duration and outcome.
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Affiliation(s)
- Melkamu Merid Mengesha
- Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia;
| | - Negussie Deyessa
- Department of Preventive Medicine, School of Public health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Balewgizie Sileshi Tegegne
- Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Yadeta Dessie
- Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Chanani S, Wacksman J, Deshmukh D, Pantvaidya S, Fernandez A, Jayaraman A. M-Health for Improving Screening Accuracy of Acute Malnutrition in a Community-Based Management of Acute Malnutrition Program in Mumbai Informal Settlements. Food Nutr Bull 2016; 37:504-516. [PMID: 27370976 DOI: 10.1177/0379572116657241] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute malnutrition is linked to child mortality and morbidity. Community-Based Management of Acute Malnutrition (CMAM) programs can be instrumental in large-scale detection and treatment of undernutrition. The World Health Organization (WHO) 2006 weight-for-height/length tables are diagnostic tools available to screen for acute malnutrition. Frontline workers (FWs) in a CMAM program in Dharavi, Mumbai, were using CommCare, a mobile application, for monitoring and case management of children in combination with the paper-based WHO simplified tables. A strategy was undertaken to digitize the WHO tables into the CommCare application. OBJECTIVE To measure differences in diagnostic accuracy in community-based screening for acute malnutrition, by FWs, using a mobile-based solution. METHODS Twenty-seven FWs initially used the paper-based tables and then switched to an updated mobile application that included a nutritional grade calculator. Human error rates specifically associated with grade classification were calculated by comparison of the grade assigned by the FW to the grade each child should have received based on the same WHO tables. Cohen kappa coefficient, sensitivity and specificity rates were also calculated and compared for paper-based grade assignments and calculator grade assignments. RESULTS Comparing FWs (N = 14) who completed at least 40 screenings without and 40 with the calculator, the error rates were 5.5% and 0.7%, respectively (p < .0001). Interrater reliability (κ) increased to an almost perfect level (>.90), from .79 to .97, after switching to the mobile calculator. Sensitivity and specificity also improved significantly. CONCLUSION The mobile calculator significantly reduces an important component of human error in using the WHO tables to assess acute malnutrition at the community level.
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Affiliation(s)
- Sheila Chanani
- Society for Nutrition, Education and Health Action, Mumbai, India
| | | | - Devika Deshmukh
- UNICEF, State Consultant for Tribal Development, Mumbai, India
| | | | - Armida Fernandez
- Society for Nutrition, Education and Health Action, Mumbai, India
| | - Anuja Jayaraman
- Society for Nutrition, Education and Health Action, Mumbai, India
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Binns PJ, Dale NM, Banda T, Banda C, Shaba B, Myatt M. Safety and practicability of using mid-upper arm circumference as a discharge criterion in community based management of severe acute malnutrition in children aged 6 to 59 months programmes. Arch Public Health 2016; 74:24. [PMID: 27307989 PMCID: PMC4908708 DOI: 10.1186/s13690-016-0136-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 04/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of proportional weight gain as a discharge criterion for MUAC admissions to programs treating severe acute malnutrition (SAM) is no longer recommended by WHO. The critical limitation with the proportional weight gain criterion was that children who are most severely malnourished tended to receive shorter treatment compared to less severely malnourished children. Studies have shown that using a discharge criterion of MUAC ≥ 125 mm eliminates this problem but concerns remain over the duration of treatment required to reach this criterion and whether this discharge criterion is safe. This study assessed the safety and practicability of using MUAC ≥ 125 mm as a discharge criterion for community based management of SAM in children aged 6 to 59 months. METHODS A standards-based trial was undertaken in health facilities for the outpatient treatment of SAM in Lilongwe District, Malawi. 258 children aged 6 to 51 months were enrolled with uncomplicated SAM as defined by a MUAC equal or less than 115 mm without serious medical complications. Children were discharged from treatment as 'cured' when they achieved a MUAC of 125 mm or greater for two consecutive visits. After discharge, children were followed-up at home every two weeks for three months. RESULTS This study confirms that a MUAC discharge criterion of 125 mm or greater is a safe discharge criterion and is associated with low levels of relapse to SAM (1.9 %) and mortality (1.3 %) with long durations of treatment seen only in the most severe SAM cases. The proportion of children experiencing a negative outcome was 3.2 % and significantly below the 10 % standard (p = 0.0013) established for the study. All children with negative outcomes had achieved weight-for-height z-score (WHZ) above -1 z-scores at discharge. Children admitted with lower MUAC had higher proportional weight gains (p < 0.001) and longer lengths of stay (p < 0.0001). MUAC at admission and attendance were both independently associated with cure (p < 0.0001). There was no association with negative outcomes at three months post discharge for children with heights at admission below 65 cm than for taller children (p = 0.5798). CONCLUSIONS These results are consistent with MUAC ≥ 125 mm for two consecutive visits being a safe and practicable discharge criterion. Use of a MUAC threshold of 125 mm for discharge achieves reasonable lengths of stay and was also found to be appropriate for children aged six months or older who are less than 65 cm in height at admission. Early detection and recruitment of SAM cases using MUAC in the community and compliance with the CMAM treatment protocols should reduce lengths of stay and associated treatment costs.
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Affiliation(s)
| | - Nancy M. Dale
- />Department for International Health, University of Tampere, Tampere, Finland
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Tadesse E, Ekström EC, Berhane Y. Challenges in Implementing the Integrated Community-Based Outpatient Therapeutic Program for Severely Malnourished Children in Rural Southern Ethiopia. Nutrients 2016; 8:nu8050251. [PMID: 27128936 PMCID: PMC4882664 DOI: 10.3390/nu8050251] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/06/2016] [Accepted: 04/22/2016] [Indexed: 11/16/2022] Open
Abstract
Currently, treatment of uncomplicated severe acute malnutrition is managed in the integrated Community based Outpatient Therapeutic Program (C-OTP) using ready-to-use therapeutic foods (RUTFs). The aim of this study was to determine challenges in implementing the critical steps in C-OTP and caregivers’ perceptions of service provision in southern Ethiopia. A total of 1048 caregivers of children admitted to the OTP and 175 Health Extension Workers (HEWs) from 94 selected health posts were included in the study. Program admission, follow-up and exit information was collected from caregivers during home visits. HEWs were interviewed at their respective health posts. Only 46.6% (481/1032) were given the recommended amount of RUTF and 19.3% (196/1015) were given antibiotics on admission. During C-OTP participation 34.9% (316/905) had uninterrupted provision of the recommended amount of RUTF. Of the children who left the program, 220/554 (39.7%) exited the program in line with the national recommendation. Caregivers (42.9% (394/918) and HEWs (37.1%, 62/167) perceive that RUTFs were being sold as a commodity. Inadequate provision and unintended usage of RUTFs, lack of antibiotics and inappropriate exit from the program were major constraints. For successful saving of lives, adequate resources must be allocated, and providers must be trained regularly, and supervised properly.
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Affiliation(s)
- Elazar Tadesse
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala SE-75185, Sweden.
- Addis Continental Institute of Public Health, P.O. Box 26751/1000, Addis Ababa, Ethiopia.
| | - Eva-Charlotte Ekström
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala SE-75185, Sweden.
| | - Yemane Berhane
- Addis Continental Institute of Public Health, P.O. Box 26751/1000, Addis Ababa, Ethiopia.
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James P, Sadler K, Wondafrash M, Argaw A, Luo H, Geleta B, Kedir K, Getnet Y, Belachew T, Bahwere P. Children with Moderate Acute Malnutrition with No Access to Supplementary Feeding Programmes Experience High Rates of Deterioration and No Improvement: Results from a Prospective Cohort Study in Rural Ethiopia. PLoS One 2016; 11:e0153530. [PMID: 27100177 PMCID: PMC4839581 DOI: 10.1371/journal.pone.0153530] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 03/30/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children with moderate acute malnutrition (MAM) have an increased risk of mortality, infections and impaired physical and cognitive development compared to well-nourished children. In parts of Ethiopia not considered chronically food insecure there are no supplementary feeding programmes (SFPs) for treating MAM. The short-term outcomes of children who have MAM in such areas are not currently described, and there remains an urgent need for evidence-based policy recommendations. METHODS We defined MAM as mid-upper arm circumference (MUAC) of ≥11.0 cm and <12.5 cm with no bilateral pitting oedema to include Ethiopian government and World Health Organisation cut-offs. We prospectively surveyed 884 children aged 6-59 months living with MAM in a rural area of Ethiopia not eligible for a supplementary feeding programme. Weekly home visits were made for seven months (28 weeks), covering the end of peak malnutrition through to the post-harvest period (the most food secure window), collecting anthropometric, socio-demographic and food security data. RESULTS By the end of the study follow up, 32.5% (287/884) remained with MAM, 9.3% (82/884) experienced at least one episode of SAM (MUAC <11 cm and/or bilateral pitting oedema), and 0.9% (8/884) died. Only 54.2% of the children recovered with no episode of SAM by the end of the study. Of those who developed SAM half still had MAM at the end of the follow up period. The median (interquartile range) time to recovery was 9 (4-15) weeks. Children with the lowest MUAC at enrolment had a significantly higher risk of remaining with MAM and a lower chance of recovering. CONCLUSIONS Children with MAM during the post-harvest season in an area not eligible for SFP experience an extremely high incidence of SAM and a low recovery rate. Not having a targeted nutrition-specific intervention to address MAM in this context places children with MAM at excessive risk of adverse outcomes. Further preventive and curative approaches should urgently be considered.
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Affiliation(s)
| | | | - Mekitie Wondafrash
- Population and Family Health Department, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
- Department of Food Safety and Food Quality, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Alemayehu Argaw
- Population and Family Health Department, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
- Department of Food Safety and Food Quality, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Hanqi Luo
- Valid International, Oxford, United Kingdom
| | - Benti Geleta
- Save the Children International, Addis Ababa, Ethiopia
| | - Kiya Kedir
- Save the Children International, Addis Ababa, Ethiopia
| | - Yilak Getnet
- Save the Children International, Addis Ababa, Ethiopia
| | - Tefera Belachew
- Population and Family Health Department, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
| | - Paluku Bahwere
- Valid International, Oxford, United Kingdom
- Research Center in Epidemiology, Biostatistics and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
- * E-mail:
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Bahwere P, Balaluka B, Wells JCK, Mbiribindi CN, Sadler K, Akomo P, Dramaix-Wilmet M, Collins S. Cereals and pulse-based ready-to-use therapeutic food as an alternative to the standard milk- and peanut paste-based formulation for treating severe acute malnutrition: a noninferiority, individually randomized controlled efficacy clinical trial. Am J Clin Nutr 2016; 103:1145-61. [PMID: 26984485 DOI: 10.3945/ajcn.115.119537] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 01/26/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The cost of current standard ready-to-use therapeutic food (RUTF) is among the major obstacles to scaling up community-based management of acute malnutrition (CMAM), an important child survival strategy. Identifying a cheaper alternative is a global public health priority. OBJECTIVE We sought to compare the efficacy of soya-maize-sorghum RUTF (SMS-RUTF) with that of standard peanut paste-based RUTF (P-RUTF). DESIGN We used a nonblinded, parallel-group, simple randomized controlled trial along with a day care approach that enrolled 2 groups of children aged 6-23 and 24-59 mo, respectively, with severe acute malnutrition (SAM). RESULTS Intention-to-treat (ITT) and per-protocol (PP) analyses showed noninferiority of SMS-RUTF compared with P-RUTF for the recovery rate [ITT: Δ = -2.0% (95% CI: -7.6%, 3.6%); PP: -1.9% (95% CI: -5.3%, 1.4%)], weight gain [Δ = -0.7 g · kg(-1)· d(-1)(95% CI: -1.3, 0.0 g · kg(-1)· d(-1))], and length of stay [Δ = 2.0 d (95% CI: -1.7, 5.8 d)] in children ≥24 mo of age. In children ≤23 mo of age, the recovery rate of SMS-RUTF was inferior to that of P-RUTF [ITT: Δ = -20.8% (95% CI: -29.9%, -11.7%); PP: -17.2% (95% CI: -25.6%, -8.7%)]. Treatment with SMS-RUTF resulted in a greater increase in hemoglobin [0.670 g/dL (95% CI: 0.420, 0.921 g/dL);P< 0.001]. Treatment with both RUTFs resulted in the replenishment of all of the amino acids tested except for methionine. There were no differences at discharge between RUTF groups in fat mass [Δ = 0.3 kg (95% CI: -0.6, 1.6 kg);P= 0.341] or fat mass index [Δ = 0.4 kg/m(2)(95% CI: -0.3, 1.1 kg/m(2));P= 0.262]. By contrast, comparisons of fat-free mass indicated lower concentrations than the community controls after treatment with either of the 2 RUTFs [Δ = -1.3 kg (95% CI: -2.4, -0.1 kg) andP= 0.034 for comparison between community controls and the SMS-RUTF group; Δ = -1.8 kg (95% CI: -2.9, -0.6 kg) andP= 0.003 for comparison between community controls and the P-RUTF group]. CONCLUSION SMS-RUTF can be used to treat SAM in children aged ≥24 mo to reduce the costs of CMAM programs. More research is required to optimize SMS-RUTF for younger children. This trial was registered in the Pan African Clinical Trial Registry as PACTR201303000475166.
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Affiliation(s)
- Paluku Bahwere
- Valid International, Oxford, United Kingdom; Centre for Research in Epidemiology, Biostatistics and Clinical Research, School of Public Health, University of Brussels, Brussels, Belgium;
| | - Bisimwa Balaluka
- Lwiro Natural Science Research Centre, South Kivu, Democratic Republic of Congo; College of Medicine, Catholic University of Bukavu, South Kivu, Democratic Republic of Congo
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, University College London Institute of Child Health, London, United Kingdom; and
| | | | | | | | - Michèle Dramaix-Wilmet
- Centre for Research in Epidemiology, Biostatistics and Clinical Research, School of Public Health, University of Brussels, Brussels, Belgium
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Nyeko R, Calbi V, Ssegujja BO, Ayot GF. Treatment outcome among children under-five years hospitalized with severe acute malnutrition in St. Mary’s hospital Lacor, Northern Uganda. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0058-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Amadi B, Imikendu M, Sakala M, Banda R, Kelly P. Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Retrospective Analysis of Three Years of a Programme in Lusaka. PLoS One 2016; 11:e0149218. [PMID: 26943124 PMCID: PMC4778761 DOI: 10.1371/journal.pone.0149218] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/28/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka. PROGRAMME ACTIVITIES AND ANALYSIS Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression. FINDINGS 1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM (RR of SAM 10.9; 95%CI 3.4,34.8; P<0.0001), and higher in children with HIV infection (RR 5.2, 95%CI 2.9, 9.0; P<0.0001). In multivariate analysis, HIV (OR 5.2; 95%CI 2.6, 10.1; P<0.0001), MUAC <11.5 cm (OR 4.1; 95%CI 2.2, 7.4; P<0.0001) and the first year of the programme (OR 1.9; 95%CI 1.0, 3.4; P = 0.04) all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality (RR 0.23; 95%CI 0.10, 0.57; P = 0.0008). INTERPRETATION Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.
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Affiliation(s)
- Beatrice Amadi
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
- * E-mail:
| | - Mercy Imikendu
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Milika Sakala
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Rosemary Banda
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, 4 Newark Street, London, United Kingdom
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Irena AH, Bahwere P, Owino VO, Diop EI, Bachmann MO, Mbwili-Muleya C, Dibari F, Sadler K, Collins S. Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial. MATERNAL & CHILD NUTRITION 2015; 11 Suppl 4:105-19. [PMID: 23782554 PMCID: PMC6860345 DOI: 10.1111/mcn.12054] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto. This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome. The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group. In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.
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Affiliation(s)
| | - Paluku Bahwere
- Valid International, Oxford, UK
- Centre of research in Epidemiology, biostatistics and clinical research, School of Public Health, Free University of Brussels, Brussels, Belgium
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James PT, Van den Briel N, Rozet A, Israël A, Fenn B, Navarro‐Colorado C. Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar. MATERNAL & CHILD NUTRITION 2015; 11:859-69. [PMID: 25850698 PMCID: PMC4672709 DOI: 10.1111/mcn.12192] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready-to-use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low-dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight-for-Height z-score of ≥-3 and mid-upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low-dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non-responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg(-1) day(-1) [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non-response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67-7.42). Our results indicate that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here.
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Affiliation(s)
- Philip T. James
- Expertise and Advocacy DepartmentAction Contre la Faim (ACF)ParisFrance
- Faculty of Epidemiology & Population HealthLondon School of Hygiene & Tropical MedicineLondonUK
| | | | - Aurélie Rozet
- Expertise and Advocacy DepartmentAction Contre la Faim (ACF)ParisFrance
| | | | - Bridget Fenn
- Faculty of Epidemiology & Population HealthLondon School of Hygiene & Tropical MedicineLondonUK
| | - Carlos Navarro‐Colorado
- Emergency Response and Recovery BranchDivision of Global Disease ProtectionCenter for Global HealthUS Centers for Disease Control and PreventionAtlantaGeorgiaUSA
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Ali E, Zachariah R, Dahmane A, Van den Boogaard W, Shams Z, Akter T, Alders P, Manzi M, Allaouna M, Draguez B, Delchevalerie P, Harries AD. Peanut-based ready-to-use therapeutic food: acceptability among malnourished children and community workers in Bangladesh. Public Health Action 2015; 3:128-35. [PMID: 26393015 DOI: 10.5588/pha.12.0077] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 02/19/2013] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To assess the acceptability of a ready-to-use therapeutic food (Plumpy'nut(®) [PPN]) among 1) care givers of malnourished children and 2) community health workers (CHWs) at a nutrition rehabilitation centre in an urban slum in Dhaka, Bangladesh. METHODS This was a cross-sectional semi-structured questionnaire survey conducted between April and June 2011 as part of a nutritional programme run by Médecins Sans Frontières. The study population included care givers of malnourished children aged 6-59 months who received PPN for at least 3 weeks, and CHWs. RESULTS Of the 149 care givers (93% female) interviewed, 60% expressed problems with PPN acceptability. Overall, 43% perceived the child's dissatisfaction with the taste, 31% with consistency and 64% attributed side effects to PPN (nausea, vomiting, loose motion, diarrhoea, abdominal distension and pain). It is to be noted that 47% of children needed encouragement or were forced to eat PPN, while 5% completely rejected it after 3 weeks. Of the 29 CHWs interviewed, 48% were dissatisfied with PPN's taste and consistency, and 55% with its smell. However, 91% of the care givers and all CHWs still perceived a therapeutic benefit of PPN for malnourished children. CONCLUSION Despite a therapeutic benefit, only 4 in 10 care givers perceived PPN as being acceptable as a food product, which is of concern.
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Affiliation(s)
- E Ali
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - R Zachariah
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - A Dahmane
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - W Van den Boogaard
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | | | | | - P Alders
- Brussels Operational Centre, MSF, Brussels, Belgium
| | - M Manzi
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - M Allaouna
- Brussels Operational Centre, MSF, Brussels, Belgium
| | - B Draguez
- Brussels Operational Centre, MSF, Brussels, Belgium
| | | | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France ; London School of Hygiene & Tropical Medicine, London, UK
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77
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Burza S, Mahajan R, Marino E, Sunyoto T, Shandilya C, Tabrez M, Kumari K, Mathew P, Jha A, Salse N, Mishra KN. Community-based management of severe acute malnutrition in India: new evidence from Bihar. Am J Clin Nutr 2015; 101:847-59. [PMID: 25833981 PMCID: PMC4381773 DOI: 10.3945/ajcn.114.093294] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 02/04/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND An estimated one-third of the world's children who are wasted live in India. In Bihar state, of children <5 y old, 27.1% are wasted and 8.3% have severe acute malnutrition (SAM). In 2009, Médecins Sans Frontières (MSF) initiated a community-based management of acute malnutrition (CMAM) program for children aged 6-59 mo with SAM. OBJECTIVE In this report, we describe the characteristics and outcomes of 8274 children treated between February 2009 and September 2011. DESIGN Between February 2009 and June 2010, the program admitted children with a weight-for-height z score (WHZ) <-3 SD and/or midupper arm circumference (MUAC) <110 mm and discharged those who reached a WHZ >-2 SDs and MUAC >110 mm. These variables changed in July 2010 to admission on the basis of an MUAC <115 mm and discharge at an MUAC ≥120 mm. Uncomplicated SAM cases were treated as outpatients in the community by using a WHO-standard, ready-to-use, therapeutic lipid-based paste produced in India; complicated cases were treated as inpatients by using F75/F100 WHO-standard milk until they could complete treatment in the community. RESULTS A total of 8274 children were admitted including 5149 girls (62.2%), 6613 children aged 6-23 mo (79.9%), and 87.3% children who belonged to Scheduled Caste, Scheduled Tribe, or Other Backward Caste families or households. Of 3873 children admitted under the old criteria, 41 children (1.1%) died, 2069 children (53.4%) were discharged as cured, and 1485 children (38.3%) defaulted. Of 4401 children admitted under the new criteria, 36 children (0.8%) died, 2526 children (57.4%) were discharged as cured, and 1591 children (36.2%) defaulted. For children discharged as cured, the mean (±SD) weight gain and length of stay were 4.7 ± 3.1 and 5.1 ± 3.7 g · kg(-1) · d(-1) and 8.7 ± 6.1 and 7.3 ± 5.6 wk under the old and new criteria, respectively (P < 0.01). After adjustment, significant risk factors for default were as follows: no community referral for admission, more severe wasting on admission, younger age, and a long commute for treatment. CONCLUSIONS To our knowledge, this is the first conventional CMAM program in India and has achieved low mortality and high cure rates in nondefaulting children. The new admission criteria lower the threshold for severity with the result that more children are included who are at lower risk of death and have a smaller WHZ deficit to correct than do children identified by the old criteria. This study was registered as a retrospective observational analysis of routine program data at http://www.isrctn.com as ISRCTN13980582.
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Affiliation(s)
- Sakib Burza
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Raman Mahajan
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Elisa Marino
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Temmy Sunyoto
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Chandra Shandilya
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Mohammad Tabrez
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Kabita Kumari
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Prince Mathew
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Amar Jha
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Nuria Salse
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
| | - Kripa Nath Mishra
- From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM)
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Angood C, McGrath M, Mehta S, Mwangome M, Lung’aho M, Roberfroid D, Perry A, Wilkinson C, Israel AD, Bizouerne C, Haider R, Seal A, Berkley JA, Kerac M. Research priorities to improve the management of acute malnutrition in infants aged less than six months (MAMI). PLoS Med 2015; 12:e1001812. [PMID: 25898252 PMCID: PMC4405387 DOI: 10.1371/journal.pmed.1001812] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
By engaging expert opinion, Marko Kerac and colleagues set research priorities for the management of acute malnutrition in infants.
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Affiliation(s)
- Chloe Angood
- Emergency Nutrition Network, Oxford, United Kingdom
| | | | - Sagar Mehta
- Washington University School of Medicine, St Louis, Missouri, United States of America
| | | | | | - Dominique Roberfroid
- Nutrition and Child Health Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Abigail Perry
- Department for International Development, London, United Kingdom
| | - Caroline Wilkinson
- Public Health Section, Division of Programme Support and Management, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | | | | | - Rukhsana Haider
- Training & Assistance for Health & Nutrition (TAHN) Foundation, Dhaka, Bangladesh
| | - Andrew Seal
- Institute for Global Health, University College London, London, United Kingdom
| | - James A. Berkley
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Marko Kerac
- Leonard Cheshire Disability & Inclusive Development Centre, University College London, London, United Kingdom
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
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79
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Ackatia-Armah RS, McDonald CM, Doumbia S, Erhardt JG, Hamer DH, Brown KH. Malian children with moderate acute malnutrition who are treated with lipid-based dietary supplements have greater weight gains and recovery rates than those treated with locally produced cereal-legume products: a community-based, cluster-randomized trial. Am J Clin Nutr 2015; 101:632-45. [PMID: 25733649 DOI: 10.3945/ajcn.113.069807] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Moderate acute malnutrition (MAM), defined as weight-for-length z score between -3 and -2 or midupper arm circumference between 11.5 and 12.5 cm, affects ∼33 million children aged <5 y worldwide. OBJECTIVE The objective was to compare the effects of 4 dietary supplements for the treatment of MAM. DESIGN Twelve community health centers in rural Mali were randomly assigned to provide to 1264 MAM children aged 6-35 mo one of 4 dietary supplements containing ∼500 kcal/d for 12 wk: 1) ready-to-use, lipid-based supplementary food (RUSF); 2) special corn-soy blend (CSB++); 3) locally processed, fortified flour (Misola); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). RESULTS In total, 1178 children (93.2%) completed the study. The adjusted mean (95% CI) change in weight (kg) from baseline was greater with RUSF than with the locally processed blends and was intermediate with CSB++ [1.16 (1.08, 1.24) for RUSF, 1.04 (0.96, 1.13) for CSB++, 0.91 (0.82, 0.99) for Misola, and 0.83 (0.74, 0.92) for LMF; P < 0.001]. For length change, RUSF and CSB++ differed significantly from LMF. Sustained recovery rates were higher with RUSF (73%) than with Misola (61%) and LMF (58%), P < 0.0001; CSB++ recovery rates (68%) did not differ from any of the other groups. CONCLUSIONS RUSF was more effective, but more costly, than other dietary supplements for the treatment of MAM; CSB++ yielded intermediate results. The benefits of treatment should be considered in relation to product costs and availability.
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Affiliation(s)
- Robert S Ackatia-Armah
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Christine M McDonald
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Seydou Doumbia
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Juergen G Erhardt
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Davidson H Hamer
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
| | - Kenneth H Brown
- From the Program in Nutrition and Metabolism, Boston University School of Medicine, Boston, MA (RSA-A and DHH); Helen Keller International, New York, NY (RSA-A and KHB); the Program in International and Community Nutrition, University of California, Davis, CA (RSA-A and KHB); the Division of GI/Nutrition, Boston Children's Hospital, Boston, MA (CMM); the Department of Public Health, Faculty of Medicine, University of Bamako, Bamako, Mali (SD); the University of Indonesia, Jakarta, Indonesia (JGE); the Center for Global Health and Development, Boston University, Boston, MA (DHH); and the Department of Global Health, Boston University School of Public Health, Boston, MA (DHH)
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80
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Abstract
Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.
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Key Words
- Antibiotics,
- Children,
- Diarrhoea,
- HIV,
- Infection,
- Malaria
- Malnutrition,
- Measles,
- Pneumonia,
- Sepsis,
- Tuberculosis,
- Urinary tract infection,
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81
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Abstract
The scope of this review is partly dictated by the global concern to improve nutrition, starting with proclamation of the Millennium Development Goals, followed by the Scaling-up Nutrition (SUN) project. The global and regional prevalence of child malnutrition is described and discussed in detail. The various and sometimes unexpected effects of recent economic development and urbanisation on nutritional status are described. Preventive intervention, using the post-SUN terminology of nutrition-sensitive and nutrition-specific interventions is reviewed, citing examples of each. Early treatment of malnutrition, e.g. by community therapeutic care, is regarded as preventive. Indirect but nutrition-specific approaches to prevention by immunisation and management of infections such as HIV are also reviewed.
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82
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Lelijveld N, Mahebere‐Chirambo C, Kerac M. Carer and staff perspectives on supplementary suckling for treating infant malnutrition: qualitative findings from Malawi. MATERNAL & CHILD NUTRITION 2014; 10:593-603. [PMID: 23795949 PMCID: PMC6860316 DOI: 10.1111/mcn.12064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Severe acute malnutrition (SAM) in infants aged <6 months is a major global health problem. Supplementary suckling (SS) is widely recommended as an inpatient treatment technique for infant <6 months SAM. Its aim is to re-establish effective exclusive breastfeeding. Despite widespread support in guidelines, research suggests that field use of SS is limited in many settings. In this study, we aimed therefore to describe and understand the barriers and facilitating factors to SS as a treatment technique for infant SAM. We conducted qualitative interviews and focus group discussions in a hospital setting in Blantyre, Malawi, with ward staff and caregivers of infants <2 years. We created a conceptual framework based on five major themes identified from the data: (1) motivation; (2) breastfeeding views; (3) practicalities; (4) understanding; and (5) perceptions of hospital-based medicine. Within each major theme, more setting-specific subthemes can also be developed. Other health facilities considering SS roll-out could consider their own barriers and facilitators using our framework; this will facilitate the implementation of SS, improve staff confidence and therefore give SS a better chance of success. Used to shape and guide discussions and inform action plans for implementing SS, the framework has the potential to facilitate SS roll-out in settings other than Malawi, where this study was conducted. We hope that it will help pave the way to more widespread SS, more research into its use and effectiveness, and a stronger evidence-base on malnutrition in infants aged <6 months.
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Affiliation(s)
| | | | - Marko Kerac
- Leonard Cheshire Disability and Inclusive Development Centre, Department of Epidemiology and Public HealthUniversity College LondonLondonUK
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83
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How do the new WHO discharge criteria for the treatment of severe acute malnutrition affect the performance of therapeutic feeding programmes? New evidence from India. Eur J Clin Nutr 2014; 69:509-13. [PMID: 25226818 PMCID: PMC4387550 DOI: 10.1038/ejcn.2014.197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 07/24/2014] [Accepted: 08/13/2014] [Indexed: 11/30/2022]
Abstract
Background/Objectives: To assesses how the introduction of new WHO discharge criteria for the treatment of severe acute malnutrition (SAM) may affect the performance of therapeutic feeding programmes in India. Subjects/Methods: The analysis concerns 6041 children admitted to Nutrition Rehabilitation Centers (NRCs) in Jharkhand, Madhya Pradesh and Uttar Pradesh between 1 July 2009 and 31 December 2011. Results: A total of 217 children (3.6%) had bilateral pitting oedema, 1803 (29.8%) had severe wasting with medical complications, 4021 (66.6%) had uncomplicated severe wasting and 4810 (79.7%) were in the age group 6–23 months old. The programme has high survival (>99%), default (⩾15%) and discharge (>75%) rates. The use of weight gain ⩾15% as recovery criteria (old criteria) translates into recovery rates in NRCs that range from 33.6% for children admitted with weight-for-height z-score (WHZ) ⩽−3 to 35.2% for children admitted with mid-upper-arm circumference (MUAC) <115 mm. The use of WHZ ⩾−2 as recovery criteria reduces recovery rates by ~2-fold (17.5%) while the use of MUAC ⩾125 mm as recovery criteria reduces recovery rates by 3.5-fold (10%). The new criteria tends to keep longer in the programme children who are younger and/or have poorer anthropometry at admission (that is, more vulnerable). Conclusions: The new WHO discharge criteria reduce the recovery rates currently reported by programmes for the treatment of children with SAM in India. However, their introduction in the programme practice will increase programme impact—particularly if accompanied by a general improvement in the strategy and protocols currently used—as they prioritize the most vulnerable children.
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84
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Abstract
Marko Kerac and Andrew Seal comment on the study by Langendorf and colleagues about the effectiveness of different strategies to prevent malnutrition in young children and discuss the implications of this study for food programs worldwide. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Marko Kerac
- Leonard Cheshire Disability and Inclusive Development Centre, Department of Epidemiology & Public Health, University College London, London, United Kingdom
- * E-mail:
| | - Andrew Seal
- Institute for Global Health, University College London, London, United Kingdom
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85
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Maleta K, Amadi B. Community-based management of acute malnutrition (CMAM) in sub-Saharan Africa: case studies from Ghana, Malawi, and Zambia. Food Nutr Bull 2014; 35:S34-8. [PMID: 25069291 DOI: 10.1177/15648265140352s105] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recent success with community-based management of acute malnutrition (CMAM) has spurred interest on how to improve coverage while maintaining treatment outcomes. OBJECTIVE To document, as case studies, the experience of three African countries, Malawi, Ghana, and Zambia, in scaling up CMAM. METHODS Desk review using published and unpublished data and country programmatic data and key informant interviews. RESULTS All three countries, with different motivations for startup, have successfully integrated CMAM into their essential health packages for children under 5 years of age, at least in their policy and strategic documents. Strong leadership by the ministries of health has been instrumental, complemented by key stakeholders and donor partners. Implementation is at variable stages, depending on when the program rolled out, with Malawi having achieved the most integration, followed by Ghana and Zambia. Using CMAM, the three countries have significantly extended service coverage and improved treatment outcomes, with cure rates ranging from 73% in Ghana to 90% in Malawi, while maintaining very low death rates: 1.7% in Malawi, 2% in Ghana, and 5% in Zambia. CONCLUSIONS CMAM is a viable option to improve service coverage and outcomes in health systems where inpatient therapeutic care alone cannot suffice.
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86
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Bahwere P. Severe Acute Malnutrition during Emergencies: Burden, Management, and Gaps. Food Nutr Bull 2014; 35:S47-51. [DOI: 10.1177/15648265140352s107] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Natural and man-made disasters, including floods, droughts, earthquakes, and armed conflicts, create nutrition crises. Unfortunately, the frequency and severity of such disasters have been increasing since the beginning of the 20th century, and their contribution to the burden of acute malnutrition is increasing every year. However, their contribution to the burden of acute malnutrition is underrecognized due to the ways in which global statistics are built and causes of death are reported. Fortunately, the success of the current protocol for treatment of severe acute malnutrition (SAM) and the integrated approach to treatment has created a momentum allowing expanded coverage of treatment of SAM, especially in humanitarian emergency contexts. For this progress to be maintained and accelerated, changes in nutrition information systems at the national and global levels are needed, and the persisting barriers to the expansion and integration of treatment of SAM into routine health systems need to be removed. Emergency funding approaches and objectives have to include sustaining and amplifying the achievements of the short-term palliative interventions. Nutrition programs implemented in emergency contexts have the capacity to contribute to answering priority research questions, and this capacity should be more optimally utilized.
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87
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Follow-up of post-discharge growth and mortality after treatment for severe acute malnutrition (FuSAM study): a prospective cohort study. PLoS One 2014; 9:e96030. [PMID: 24892281 PMCID: PMC4043484 DOI: 10.1371/journal.pone.0096030] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 04/03/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Management of Severe Acute Malnutrition (SAM) plays a vital role in achieving global child survival targets. Effective treatment programmes are available but little is known about longer term outcomes following programme discharge. METHODS From July 2006 to March 2007, 1024 children (median age 21.5 months, IQR 15-32) contributed 1187 admission episodes to an inpatient-based SAM treatment centre in Blantyre, Malawi. Long term outcomes, were determined in a longitudinal cohort study, a year or more after initial programme discharge. We found information on 88%(899/1024). RESULTS In total, 42%(427/1024) children died during or after treatment. 25%(105/427) of deaths occurred after normal programme discharge, >90 days after admission. Mortality was greatest among HIV seropositive children: 62%(274/445). Other risk factors included age <12 months; severity of malnutrition at admission; and disability. In survivors, weight-for-height and weight-for-age improved but height-for-age remained low, mean -2.97 z-scores (SD 1.3). CONCLUSIONS Although SAM mortality in this setting was unacceptably high, our findings offer important lessons for future programming, policy and research. First is the need for improved programme evaluation: most routine reporting systems would have missed late deaths and underestimated total mortality due to SAM. Second, a more holistic view of SAM is needed: while treatment will always focus on nutritional interventions, it is vital to also identify and manage underlying clinical conditions such as HIV and disability. Finally early identification and treatment of SAM should be emphasised: our results suggest that this could improve longer term as well as short term outcomes. As international policy and programming becomes increasingly focused on stunting and post-malnutrition chronic disease outcomes, SAM should not be forgotten. Proactive prevention and treatment services are essential, not only to reduce mortality in the short term but also because they have potential to impact on longer term morbidity, growth and development of survivors.
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88
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Abstract
Background: Natural and man-made disasters are prevailing in Ethiopia mainly due to drought, floods, landslides, earthquake, volcanic eruptions, and disease epidemics. Few studies so far have critically reviewed about medical responses to disasters and little information exists pertaining to the initiatives being undertaken by health sector from the perspective of basic disaster management cycle. This article aimed to review emergency health responses to disasters and other related interventions which have been undertaken in the health sector.
Methods: Relevant documents were identified by searches in the websites of different sectors in Ethiopian and international non-governmental organizations and United Nations agencies. Using selected keywords, articles were also searched in the data bases of Medline, CINAHL, Scopus, and Google Scholar. In addition, pertinent articles from non-indexed journals were referred to.
Results: Disaster management system in Ethiopia focused on response, recovery, and rehabilitation from 1974 to 1988; while the period between 1988 and 1993 marked the transition phase towards a more comprehensive approach. Theoretically, from 1993 onwards, the disaster management system has fully integrated the mitigation, prevention, and preparedness phases into already existing response and recovery approach, particularly for drought. This policy has changed the emergency response practices and the health sector has taken some initiatives in the area of emergency health care. Hence, drought early warning system, therapeutic feeding program in hospitals, health centers and posts in drought prone areas to manage promptly acute malnutrition cases have all been put in place. In addition, public health disease emergencies have been responded to at all levels of health care system.
Conclusions: Emergency health responses to drought and its ramifications such as acute malnutrition and epidemics have become more comprehensive in the context of basic disaster management phases; and impacts of drought and epidemics seem to be declining. However, the remaining challenge is to address disasters arising from other hazards such as flooding in terms of mitigation, prevention, preparedness and integrating them in the health care system.
Key Words: Disaster, Emergency Health, Health System, Ethiopia
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Kouam CE, Delisle H, Ebbing HJ, Israël AD, Salpéteur C, Aïssa MA, Ridde V. Perspectives for integration into the local health system of community-based management of acute malnutrition in children under 5 years: a qualitative study in Bangladesh. Nutr J 2014; 13:22. [PMID: 24649941 PMCID: PMC3994471 DOI: 10.1186/1475-2891-13-22] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 03/12/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Acute malnutrition is a major cause of death among under-five children in low- and middle-income countries. United Nations agencies recommend the integration of community-based management of acute malnutrition (CMAM) into the local health systems for sustainability. The objective of the study was to assess the preparedness of the health system to implement CMAM targeting children under-five years in two sub-districts of Bangladesh. METHODS The assessment was performed through direct observation of 44 health centres, individual interviews of seven policy makers, three donors, four health and nutrition implementing partners, 29 health workers, and review of secondary data. Assessment themes, derived from the WHO six Building Blocks, were nutrition governance, nutrition financing, health service delivery, human resources, equipment and supply, referral, monitoring and supervision mechanism. They were subdivided into 16 criteria. Findings were compared with CMAM operational recommendations according to WHO, Valid International and Food and Nutrition Technical Assistance guidelines. RESULTS The government of Bangladesh has developed inpatient and outpatient CMAM guidelines, and a policy offering free-of-charge health care for under-five children. Nutrition coordination was not under full government leadership. Most of funds (74%) dedicated to CMAM were provided by donors, for short-term interventions. Of the total 44 health centres assessed, 39 (88.6%) were active, among which 4 (10.2%) delivered inpatient services, 35 (89.8%) outpatient services, and 24 (61.5%) outreach services. These were regarded as opportunities to include CMAM activities. There were 48.9% vacant positions and the health workers were not trained for management of acute malnutrition. Equipment and supplies did not meet the operational recommendations for management of acute malnutrition. CONCLUSION Implementing CMAM through the health centres of both sub-districts would warrant progressive strengthening of the overall health system in the light of identified barriers. A short term strategy would consist of strengthening government coordination of nutrition interventions, exploring additional funding sources, equipping and supplying functional health centres, training health workers and actively involving community health workers to cope with health facility staff shortage. A mid-term strategy would consist of securing permanent funding for CMAM, rehabilitating non-functional health centres, attracting and retaining health workers in rural areas.
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Affiliation(s)
- Camille Eric Kouam
- TRANSNUT - (WHO Collaborating Centre on Nutrition Changes and Development), Department of Nutrition, Faculty of Medicine, University of Montreal, 2405 Chemin de la Côte Sainte-Catherine, Montreal, Quebec H3T 1A8, Canada
| | - Hélène Delisle
- TRANSNUT - (WHO Collaborating Centre on Nutrition Changes and Development), Department of Nutrition, Faculty of Medicine, University of Montreal, 2405 Chemin de la Côte Sainte-Catherine, Montreal, Quebec H3T 1A8, Canada
| | - Hans J Ebbing
- Nutrition & Health Service, Action Against Hunger France (ACF-France), House - 20, Rd- 117, Gulshan 2, Dhaka 1212, Bangladesh
| | - Anne Dominique Israël
- Nutrition & Health Service, Action Against Hunger France (ACF-France), 4 rue Niepce - 75662 PARIS CEDEX 14, Paris, France
| | - Cécile Salpéteur
- Nutrition & Health Service, Action Against Hunger France (ACF-France), 4 rue Niepce - 75662 PARIS CEDEX 14, Paris, France
| | - Myriam Aït Aïssa
- Nutrition & Health Service, Action Against Hunger France (ACF-France), 4 rue Niepce - 75662 PARIS CEDEX 14, Paris, France
| | - Valery Ridde
- School of Public Health, CRCHUM, Faculty of Medicine, University of Montreal, Saint-Antoine Tower, 850 Saint-Denis, 3rd Floor, Room S03-462, Montreal, Quebec H2X 0A9, Canada
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Walzer S, Droeschel D, Nuijten M, Chevrou-Séverac H. Health economic analyses in medical nutrition: a systematic literature review. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:109-24. [PMID: 24648747 PMCID: PMC3956482 DOI: 10.2147/ceor.s53601] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Medical nutrition is a specific nutrition category either covering specific dietary needs and/or nutrient deficiency in patients or feeding patients unable to eat normally. Medical nutrition is regulated by a specific bill in Europe and in the US, with specific legislation and guidelines, and is provided to patients with special nutritional needs and indications for nutrition support. Therefore, medical nutrition products are delivered by medical prescription and supervised by health care professionals. Although these products have existed for more than 2 decades, health economic evidence of medical nutrition interventions is scarce. This research assesses the current published health economic evidence for medical nutrition by performing a systematic literature review related to health economic analysis of medical nutrition. Methods A systematic literature search was done using standard literature databases, including PubMed, the Health Technology Assessment Database, and the National Health Service Economic Evaluation Database. Additionally, a free web-based search was conducted using the same search terms utilized in the systematic database search. The clinical background and basis of the analysis, health economic design, and results were extracted from the papers finally selected. The Drummond checklist was used to validate the quality of health economic modeling studies and the AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklist was used for published systematic reviews. Results Fifty-three papers were identified and obtained via PubMed, or directly via journal webpages for further assessment. Thirty-two papers were finally included in a thorough data extraction procedure, including those identified by a “gray literature search” utilizing the Google search engine and cross-reference searches. Results regarding content of the studies showed that malnutrition was the underlying clinical condition in most cases (32%). In addition, gastrointestinal disorders (eg, surgery, cancer) were often analyzed. In terms of settings, 56% of papers covered inpatients, whereas 14 papers (44%) captured outpatients, including patients in community centers. Interestingly, in comparison with the papers identified overall, very few health economic models were found. Most of the articles were modeling analyses and economic trials in different design settings. Overall, only eight health economic models were published and were validated applying the Drummond checklist. In summary, most of the models included were carried out to quite a high standard, although some areas were identified for further improvement. Of the two systematic health economic reviews identified, one achieved the highest quality score when applying the AMSTAR checklist. Conclusion The reasons for finding only a few modeling studies but quite a large number of clinical trials with health economic endpoints, might be different. Until recently, health economics has not been required for reimbursement or coverage decisions concerning medical nutrition interventions. Further, there might be specifics of medical nutrition which might not allow easy modeling and consequently explain the limited uptake so far. The health economic data on medical nutrition generated and published is quite ample. However, it has been primarily based on database analysis and clinical studies. Only a few modeling analyses have been carried out, indicating a need for further research to understand the specifics of medical nutrition and their applicability for health economic modeling.
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Affiliation(s)
- Stefan Walzer
- MArS Market Access and Pricing Strategy GmbH, Weil am Rhein, Germany ; State University Baden-Wuerttemberg, Loerrach, Germany
| | - Daniel Droeschel
- MArS Market Access and Pricing Strategy GmbH, Weil am Rhein, Germany ; Riedlingen University, SRH FernHochschule, Riedlingen, Germany
| | - Mark Nuijten
- Ars Accessus Medica BV, Amsterdam, the Netherlands
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Bahwere P, Banda T, Sadler K, Nyirenda G, Owino V, Shaba B, Dibari F, Collins S. Effectiveness of milk whey protein-based ready-to-use therapeutic food in treatment of severe acute malnutrition in Malawian under-5 children: a randomised, double-blind, controlled non-inferiority clinical trial. MATERNAL AND CHILD NUTRITION 2014; 10:436-51. [PMID: 24521353 PMCID: PMC6860310 DOI: 10.1111/mcn.12112] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The cost of ready‐to‐use therapeutic food (RUTF) used in community‐based management of acute malnutrition has been a major obstacle to the scale up of this important child survival strategy. The current standard recipe for RUTF [peanut‐based RUTF (P‐RUTF)] is made from peanut paste, milk powder, oil, sugar, and minerals and vitamins. Milk powder forms about 30% of the ingredients and may represent over half the cost of the final product. The quality of whey protein concentrates 34% (WPC34) is similar to that of dried skimmed milk (DSM) used in the standard recipe and can be 25–33% cheaper. This blinded, parallel group, randomised, controlled non‐inferiority clinical trial tested the effectiveness in treating severe acute malnutrition (SAM) of a new RUTF formulation WPC‐RUTF in which WPC34 was used to replace DSM. Average weight gain (non‐inferiority margin Δ = −1.2 g kg−1 day−1) and recovery rate (Δ = −10%) were the primary outcomes, and length of stay (LOS) was the secondary outcome (Δ = +14 days). Both per‐protocol (PP) and intention‐to‐treat (ITT) analyses showed that WPC‐RUTF was not inferior to P‐RUTF for recovery rate [difference and its 95% confidence interval (CI) of 0.5% (95% CI –2.7, 3.7) in PP analysis and 0.6% (95% CI –5.2, 6.3) in ITT analysis] for average weight gain [0.2 (−0.5; 0.9) for both analyses] and LOS [−1.6 days (95% CI, −4.6, 1.4 days) in PP analysis and −1.9 days (95% CI, −4.6, 0.8 days) for ITT analysis]. In conclusion, whey protein‐based RUTF is an effective cheaper alternative to the standard milk‐based RUTF for the treatment of SAM.
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Affiliation(s)
- Paluku Bahwere
- Valid International, Oxford, UK; Centre of Research in Epidemiology, Biostatistics and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
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Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health 2014; 35:399-421. [PMID: 24387091 DOI: 10.1146/annurev-publhealth-032013-182354] [Citation(s) in RCA: 488] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past half-century, community health workers (CHWs) have been a growing force for extending health care and improving the health of populations. Following their introduction in the 1970s, many large-scale CHW programs declined during the 1980s, but CHW programs throughout the world more recently have seen marked growth. Research and evaluations conducted predominantly during the past two decades offer compelling evidence that CHWs are critical for helping health systems achieve their potential, regardless of a country's level of development. In low-income countries, CHWs can make major improvements in health priority areas, including reducing childhood undernutrition, improving maternal and child health, expanding access to family-planning services, and contributing to the control of HIV, malaria, and tuberculosis infections. In many middle-income countries, most notably Brazil, CHWs are key members of the health team and essential for the provision of primary health care and health promotion. In the United States, evidence indicates that CHWs can contribute to reducing the disease burden by participating in the management of hypertension, in the reduction of cardiovascular risk factors, in diabetes control, in the management of HIV infection, and in cancer screening, particularly with hard-to-reach subpopulations. This review highlights the history of CHW programs around the world and their growing importance in achieving health for all.
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93
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Abdul-Latif AMC, Nonvignon J. Economic Cost of Community-Based Management of Severe Acute Malnutrition in a Rural District in Ghana. Health (London) 2014. [DOI: 10.4236/health.2014.610112] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Vir SC. Community based maternal and child health nutrition project, uttar pradesh: an innovative strategy focusing on "at risk" families. Indian J Community Med 2013; 38:234-9. [PMID: 24302825 PMCID: PMC3831694 DOI: 10.4103/0970-0218.120159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 08/10/2012] [Indexed: 11/04/2022] Open
Abstract
RESEARCH QUESTION Use of community based volunteers, frequently reaching and counseling a selected group of prioritized families, can make a substantial difference in improving maternal and child care practices and in reducing child undernutrition. SETTING Program Rural Uttar Pradesh, India. STUDY DESIGN A comparison of baseline and endline surveys following 4 years of community based project intervention. PARTICIPANTS "At risk" undernutrition families comprising mothers of under twos, newlyweds, and severely undernourished children below 6 years. INTERVENTION Mapping and counseling of "at risk" families. Measuring impact on maternal-child care practices, underweight status. RESULTS Trained community mobilizers identified and counseled selected "at risk" families. Following 4 years of implementation in 907 villages of 8 blocks of four districts, significant improvement was noted in practices of early initiation of breastfeeding, feeding colostrum, timely introduction of complementary feeding, and washing the hands after defecation. Percentage of mothers exclusively breastfeeding at 6 months was only 2.1% with 78% receiving prelacteal feeds. A small increase in normal and mild malnutrition and a significant reduction of 43% in severe malnutrition was noted. CONCLUSION Frequently counseling by accredited social health activists by focusing on selected defined "at risk" families of under twos and those with severe malnourished children could result in increasing acceptability of correct child health, feeding, and care practices and in contributing to improving nutritional status scenario.
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Affiliation(s)
- Sheila C Vir
- Director, Public Health Nutrition and Development Center, New Delhi, India
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95
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Somassé YE, Bahwere P, Laokri S, Elmoussaoui N, Donnen P. Sustainability and scaling-up analysis of community-based management of acute malnutrition: lessons learned from Burkina Faso. Food Nutr Bull 2013; 34:338-48. [PMID: 24167914 DOI: 10.1177/156482651303400306] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Community-based management of acute malnutrition (CMAM) is an effective strategy frequently implemented by nongovernmental organizations, but handing CMAM over to national health systems and scaling it up remains a great challenge. OBJECTIVE To highlight the challenges to sustainability and scalability of a CMAM program in Burkina Faso. METHODS We conducted a review of program reports to evaluate program performance and conducted individual interviews with key informants (health system fieldworkers and officials and program staff members) and focus group discussions with beneficiaries (mothers whose children were attending the program, community volunteers, and village leaders) to analyze the required conditions for scaling up using ExpandNet recommendations. RESULTS The program coverage rate was 90% among children under 5 years of age in the 180 intervention villages. Between June 2007 and December 2010, 19,009 cases of acute malnutrition (AM) among children under 5 years of age were treated, of which 4,308 (22.7%) were cases of severe acute malnutrition (SAM). The recovery rate was 89.4% for moderate acute malnutrition (MAM) and 86.5% for SAM. The case-fatality rate was 2.8% for MAM and 4.2% for SAM. The default rate was 7% for all cases. The prevalence of SAM decreased between 2008 and 2009 from 5.4% to 1.8%. Barriers to sustainability and scaling up were underlined: management by external personnel from the health system, no financial support for the scaling-up process, insufficient national advocacy, and nonsustainable activities (e.g., free care). CONCLUSIONS The CMAM program was effective, but the handover conditions and scaling-up requirements were unsatisfactory. We identified poor integration into the health system, lack of resources, and insufficient advocacy.
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Affiliation(s)
- Yassimè Elysée Somassé
- Centre de Recherche en Politiques et Systèmes de Santé - Santé Internationale Ecole de Santé de Publique, Université Libre de Bruxelles, CP 594, Route de Lennik 808, 1070 Brussels, Belgium.
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Aguayo VM, Agarwal V, Agnani M, Das Agrawal D, Bhambhal S, Rawat AK, Gaur A, Garg A, Badgaiyan N, Singh K. Integrated program achieves good survival but moderate recovery rates among children with severe acute malnutrition in India. Am J Clin Nutr 2013; 98:1335-42. [PMID: 24067666 DOI: 10.3945/ajcn.112.054080] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND At any point in time, an average 8 million Indian children suffer from severe acute malnutrition (SAM). OBJECTIVE This article assesses the effectiveness of an integrated model for the management of SAM (IM-SAM) in India comprising facility- and community-based care and using locally adapted protocols. DESIGN Children (n = 2740) were randomly sampled from the 44,017 children aged 6-59 mo admitted to 199 Nutrition Rehabilitation Centers in the state of Madhya Pradesh (1 January to 31 December 2010). RESULTS On admission, 2.2% of children had edema, 23.4% had medical complications, 56% were girls, 79% were in the age group 6-23 mo, and 64% belonged to scheduled tribe or scheduled caste families. Fifty-six children (2.0%) with severe congenital or pathological conditions were transferred to the district hospital. Of the 2684 program exits, 10 children (0.4%) died, 860 (32.0%) did not complete treatment (defaulted), and 1814 (67.6%) were discharged after a mean (±SD) stay of 75.8 ± 9.4 d. The mean weight gain among discharged children was 2.7 ± 1.9 g · kg body wt(-1) · d(-1); on discharge, 1179 (65%) of the children had recovered (weight gain ≥15% of initial weight). CONCLUSIONS The survival rates in the IM-SAM program were very high. However, the moderate recovery rates documented seem to indicate that the protocols currently in use need to be improved. This trial was registered at clinicaltrials.gov as NCT01917734.
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Affiliation(s)
- Víctor M Aguayo
- Government of Madhya Pradesh, Atal Bal State Nutrition Mission and Integrated Child Development Services Program and National Rural Health Mission, Bhopal, India (MA and DDA); Gandhi Medical College, Bhopal, Madhya Pradesh, India (SB); Bundelkhand Medical College, Sagar, Madhya Pradesh, India (AKR); Gwalior Medical College, Gwalior, Madhya Pradesh, India (A Gaur); and UNICEF, Delhi, India (VMA, VA, A Garg, NB, and KS)
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97
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Shewade HD, Patro BK, Bharti B, Soundappan K, Kaur A, Taneja N. Effectiveness of indigenous ready-to-use therapeutic food in community-based management of uncomplicated severe acute malnutrition: a randomized controlled trial from India. J Trop Pediatr 2013; 59:393-8. [PMID: 23751252 DOI: 10.1093/tropej/fmt039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
A randomized controlled trial was conducted in Chandigarh, India (2011), to determine the effectiveness of indigenous ready-to-use therapeutic food (RUTF) in community-based management of uncomplicated severe acute malnutrition (SAM). Intervention was through outpatient therapeutic program site (OTP). Study and control group children (6 months-5 years) were followed up weekly for 12 weeks, in OTP and at home. All children received supplementary nutrition through anganwadis under integrated child development scheme. Study children, in addition, received therapeutic dose of RUTF in OTP. Primary outcome, 115% of baseline weight, was attained in 6 of 13 (46.2%) and 1 of 13 (7.7%) children among study and control group, respectively [odds ratio: 10.28, 95% confidence interval (CI): 1.02-103.95]. Compared with control group, addition of RUTF in study group resulted in average additional increase in weight by 13 g/kg of baseline weight/week/child (95% CI: 2-23). Indigenous RUTF was effective in community-based management of uncomplicated SAM.
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Affiliation(s)
- Hemant D Shewade
- Department of Community Medicine, School of Public Health, PGIMER, Chandigarh 160012. India
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98
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Lenters LM, Wazny K, Webb P, Ahmed T, Bhutta ZA. Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health 2013; 13 Suppl 3:S23. [PMID: 24564235 PMCID: PMC3847503 DOI: 10.1186/1471-2458-13-s3-s23] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Globally, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) affect approximately 52 million children under five. This systematic review evaluates the effectiveness of interventions for SAM including the World Health Organization (WHO) protocol for inpatient management and community-based management with ready-to-use-therapeutic food (RUTF), as well as interventions for MAM in children under five years in low- and middle-income countries. METHODS We systematically searched the literature and included 14 studies in the meta-analysis. Study quality was assessed using CHERG adaptation of GRADE criteria. A Delphi process was undertaken to complement the systematic review in estimating case fatality and recovery rates that were necessary for modelling in the Lives Saved Tool (LiST). RESULTS Case fatality rates for inpatient treatment of SAM using the WHO protocol ranged from 3.4% to 35%. For community-based treatment of SAM, children given RUTF were 51% more likely to achieve nutritional recovery than the standard care group. For the treatment of MAM, children in the RUSF group were significantly more likely to recover and less likely to be non-responders than in the CSB group. In both meta-analyses, weight gain in the intervention group was higher, and although statistically significant, these differences were small. Overall limitations in our analysis include considerable heterogeneity in many outcomes and an inability to evaluate intervention effects separate from commodity effect. The Delphi process indicated that adherence to standardized protocols for the treatment of SAM and MAM should have a marked positive impact on mortality and recovery rates; yet, true consensus was not achieved. CONCLUSIONS Gaps in our ability to estimate effectiveness of overall treatment approaches for SAM and MAM persist. In addition to further impact studies conducted in a wider range of settings, more high quality program evaluations need to be conducted and the results disseminated.
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Affiliation(s)
- Lindsey M Lenters
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kerri Wazny
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Tahmeed Ahmed
- Centre for Nutrition and Food Security, ICDDR,B, Dhaka, Bangladesh
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Woman and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
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Forsén E, Tadesse E, Berhane Y, Ekström EC. Predicted implications of using percentage weight gain as single discharge criterion in management of acute malnutrition in rural southern Ethiopia. MATERNAL AND CHILD NUTRITION 2013; 11:962-72. [PMID: 23941395 DOI: 10.1111/mcn.12076] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Mid-upper arm circumference (MUAC) is increasingly used in identifying and admitting children with acute malnutrition for treatment. It is easy to use because it does not involve height assessment, but its use calls for alternative discharge criteria. This study examined how use of percentage weight gain as discharge criterion would affect the nutritional status of children admitted into a community-based management programme for acute malnutrition in rural southern Ethiopia. Non-oedematous children (n = 631) aged 6-59 months and having a MUAC of <125 mm were studied. By simulation, 10%, 15% and 20% weight was added to admission weight and their nutritional status by weight-for-height z-score (WHZ) was determined at each target. Moderate and severe wasting according to World Health Organization WHZ definitions was used as outcome. Applying the most commonly recommended target of 15% weight gain resulted in 9% of children with admission MUAC <115 mm still being moderately or severely wasted at theoretical discharge. In children with admission MUAC 115-124 mm, 10% of weight gain was sufficient to generate a similar result. Children failing to recover were the ones with the poorest nutritional status at admission. Increasing the percentage weight gain targets in the two groups to 20% and 15%, respectively, would largely resolve wasting but likely lead to increased programme costs by keeping already recovered children in the programme. Further research is needed on appropriate discharge procedures in programmes using MUAC for screening and admission.
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Affiliation(s)
- Emmanuel Forsén
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Elazar Tadesse
- Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb P, Lartey A, Black RE. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 2013; 382:452-477. [PMID: 23746776 DOI: 10.1016/s0140-6736(13)60996-4] [Citation(s) in RCA: 1555] [Impact Index Per Article: 141.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Maternal undernutrition contributes to 800,000 neonatal deaths annually through small for gestational age births; stunting, wasting, and micronutrient deficiencies are estimated to underlie nearly 3·1 million child deaths annually. Progress has been made with many interventions implemented at scale and the evidence for effectiveness of nutrition interventions and delivery strategies has grown since The Lancet Series on Maternal and Child Undernutrition in 2008. We did a comprehensive update of interventions to address undernutrition and micronutrient deficiencies in women and children and used standard methods to assess emerging new evidence for delivery platforms. We modelled the effect on lives saved and cost of these interventions in the 34 countries that have 90% of the world's children with stunted growth. We also examined the effect of various delivery platforms and delivery options using community health workers to engage poor populations and promote behaviour change, access and uptake of interventions. Our analysis suggests the current total of deaths in children younger than 5 years can be reduced by 15% if populations can access ten evidence-based nutrition interventions at 90% coverage. Additionally, access to and uptake of iodised salt can alleviate iodine deficiency and improve health outcomes. Accelerated gains are possible and about a fifth of the existing burden of stunting can be averted using these approaches, if access is improved in this way. The estimated total additional annual cost involved for scaling up access to these ten direct nutrition interventions in the 34 focus countries is Int$9·6 billion per year. Continued investments in nutrition-specific interventions to avert maternal and child undernutrition and micronutrient deficiencies through community engagement and delivery strategies that can reach poor segments of the population at greatest risk can make a great difference. If this improved access is linked to nutrition-sensitive approaches--ie, women's empowerment, agriculture, food systems, education, employment, social protection, and safety nets--they can greatly accelerate progress in countries with the highest burden of maternal and child undernutrition and mortality.
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Affiliation(s)
| | - Jai K Das
- Aga Khan University, Karachi, Pakistan
| | | | | | - Neff Walker
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Robert E Black
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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