Survival and Recovery in Severely Wasted Under-five Children Without Community Management of Acute Malnutrition Programme

The recent WHO guideline on acute malnutrition overestimates therapeutic energy requirement

The World Health Organization has recently updated the guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. Apart from differences with regard to the nutritional framework that defines the quantity of energy required as Ready-to-Use Therapeutic Food (RUTF) for the outpatient treatment of severe wasting and/or nutritional oedema, there are also important gaps in the practical guidance. Instead of the recommended energy intake of 150-185 kcal/kg/day, our alternative calculations indicate the requirement to be only 105-120 kcal/kg/day. If true, the implementation of such caloric overfeeding can have adverse consequences. Gaps in practical guidance also need to be addressed, including the timing of transition to home-based diets, maximal duration of therapeutic feeding, especially in non-responders (∼50% in South Asia), and the role of augmented home foods as the primary therapeutic food option.

Determinants of the food insecurity at household level in Pakistan: A multilevel model approach

Food insecurity is a major concern for the developing world and around 37% of the population of Pakistan is food insecure. This paper utilizes the Food Insecurity Experience Scale (FIES) to assess the population prevalence of food insecurity and to identify their risk factors and determinants at the household level in Pakistan. This study employs a multi-level random coefficient model, using the Pakistan Panel Household Survey (PPHS-2010) dataset; representative data from 4,130 households. Factors like; income of the household, gender, education, household size, land ownership, and shocks of food insecurity allow the incidence of idiosyncratic shocks (injuries and/or casualties) at the community level, which affects the food insecurity situation of the community, rather differently were included. The study confirms a statistically significant inverse relationship between household income, household size, and household head education with food insecurity and a positive association of shocks and inflation with food insecurity at the household level. Specifically, with increasing per capita income of the household, food insecurity declines (coefficient: -0.083, statistically significant at 1%) and food insecurity increases with shocks (coefficient: 0.058, statistically significant at 1% significance level). The study also reveals a significant heterogeneity at a one percent significance level in the determinants of food insecurity at the district, community, and household levels. The income of the household, household head gender and education level, household size, household assets, shocks, injuries, and inflationary pressure are important determinants of food insecurity in Pakistan.

Evaluation of the Health and Nutritional Status of Discharged Children From Malnutrition Treatment Centres Using Mobile Phone Calls During the COVID-19 Lockdown in Jharkhand, India

Background The Indian state of Jharkhand has the highest rate of wasting (29%) among young children. Mobile audio call follow-up can be used to assess such children with severe acute malnutrition (SAM). Aim This study evaluated SAM children during the COVID-19 outbreak and learn more about the status of their home/community care, and caregivers' awareness of integrated child development services (ICDS) and COVID-19 prevention. Methods Contact numbers of caregivers for discharged children were obtained from 54 malnutrition treatment centers (MTCs). In April and June 2020, mentors conducted follow-up interviews using mobile phone calls. Results Seven children (1.72%) were reported dead and 400 were alive, mostly girls (59.5%). Only a few caregivers observed post-discharge ailments (15.4%) and weight loss (7.7%) in their children. Children aged six to 24 months were characterized by continued breastfeeding (88.0%) at most five to six times a day (45.8%). Most of the children were not fed as per maternal infant and young child feeding protocols. Age in months with an adjusted odds ratio (OR) of 0.55 (1.00-1.11) as a 95% confidence interval (CI), age category, with an adjusted OR of 4.32 (1.71- 10.94) as 95% CI, and breastfeeding with adjusted OR 1.85 (1.07- 3.21) as 95% CI were three major predictors for a well-fed child. Conclusion Community involvement is crucial in the follow-up of children with SAM for effective rehabilitation. Mobile phone audio call follow-up is a relatively cost-effective approach to tackle geographic barriers and COVID-19 lockdown-induced situations. There are major gaps mainly in informing caregivers on how to manage COVID-19 with breastfeeding.

Effectiveness of community-based treatment programs for treatment of uncomplicated severe acute malnourished children aged 6-59 months using locally produced nutrient dense foods: protocol for a multicentric longitudinal quasi-experimental study

BACKGROUND

Severe acute malnutrition (SAM) is a major underlying cause of mortality among children. Around one third of the world's acutely malnourished children live in India. The WHO recommends community-based management of acute malnutrition (CMAM) for managing children with SAM. In India, different states are implementing community-based SAM treatment programme, hereinafter called CSAM, using varieties of locally produced nutrient dense food items with different nutrient compositions. The study will assess the effectiveness of these state specific CSAM interventions.

METHODS

The longitudinal quasi-experimental study will be undertaken in two purposively selected blocks of one district each in the four intervention states and one comparison state. From each state, 200 SAM children identified using weight-for-length/height z-score (WHZ) < - 3 criteria will be enrolled in the study. Their anthropometric data and skinfold thickness will be taken on admission, at sixth week and at discharge by trained field investigators. Other child details, incidence of morbidity and socio-economic details will be collected on admission. To assess food consumption pattern including consumption of locally produced nutrient dense food supplements, dietary assessment, using 24-h dietary recall will be conducted on admission, at sixth week and at discharge. In addition, body composition parameters will be assessed for a sub-set of children using bio-electrical impedance analysis on admission and at discharge to analyse changes in total body water, fat-free mass, and fat mass. Post discharge, all study participants will be followed up monthly until 6 months. Atleast 10% of the sample will be checked for quality assessment. The study's primary outcome is cure rate defined as children attaining WHZ ≥ -2. Secondary outcomes include mean weight gain, mean length of stay, body composition parameters, relapse and mortality rates. Additionally, process evaluation and cost effectiveness analysis will be conducted.

DISCUSSION

There is a shortage of robust evidence regarding the effectiveness of locally produced nutrient dense food supplements provided as part of the CSAM intervention in India. This study will contribute to evidence on effective strategies to manage children with uncomplicated SAM in India. The study protocol has all necessary ethical approvals. Written informed consent will be obtained from caregivers of the children.

TRIAL REGISTRATION

The study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 ) Date of registration 24/09/2020.

A mathematical model to estimate the incidence of child wasting in Yemen

INTRODUCTION

The ongoing civil war in Yemen has severely restricted imports of food and fuel, disrupted livelihoods and displaced millions, worsening already high pre-war levels of food insecurity. Paired with frequent outbreaks of disease and a collapsed health system, this has brought rates of wasting in children under five to the country's highest recorded levels, which continue to increase as the crisis worsens and aid becomes increasingly limited. In their planning of services to treat and prevent wasting in children, humanitarian agencies rely on a standard calculation to estimate the expected number of cases for the coming year, where incidence is estimated from prevalence and the average duration of an episode of wasting. The average duration of an episode of moderate and severe wasting is currently estimated at 7.5 months-a globally-used value derived from historical cohort studies. Given that incidence varies considerably by context-where food production and availability, treatment coverage and disease rates all vary-a single estimate cannot be applied to all contexts, and especially not a highly unstable crisis setting such as Yemen. While recent studies have aimed to derive context-specific incidence estimates in several countries, little has been done to estimate the incidence of both moderate and severe wasting in Yemen.

METHODS

In order to provide context-specific estimates of the average duration of an episode, and resultingly, incidence correction factors for moderate and severe wasting, we have developed a Markov model. Model inputs were estimated using a combination of treatment admission and outcome records compiled by the Yemen Nutrition Cluster, 2018 and 2019 SMART surveys, and other estimates from the literature. The model derived estimates for the governorate of Lahj, Yemen; it was initialized using August 2018 SMART survey prevalence data and run until October 2019-the date of the subsequent SMART survey. Using a process of repeated model calibration, the incidence correction factors for severe wasting and moderate wasting were found, validating the resulting prevalence against the recorded value from the 2019 SMART survey.

RESULTS

The average durations of an episode of moderate and severe wasting were estimated at 4.86 months, for an incidence correction factor k of 2.59, and 3.86 months, for an incidence correction factor k of 3.11, respectively. It was found that the annual caseload of moderate wasting was 36% higher and the annual caseload of severe wasting 58% higher than the originally-assumed values, estimated with k = 1.6.

CONCLUSION

The model-derived incidence rates, consistent with findings from other contexts that a global incidence correction factor cannot be sufficient, allow for improved, context-specific estimates of the burden of wasting in Yemen. In crisis settings such as Yemen where funding and resources are extremely limited, the model's outputs holistically capture the burden of wasting in a way that may guide effective decision-making and may help ensure that limited resources are allocated most effectively.

Mortality and recovery following moderate and severe acute malnutrition in children aged 6-18 months in rural Jharkhand and Odisha, eastern India: A cohort study

BACKGROUND

Recent data suggest that case fatality from severe acute malnutrition (SAM) in India may be lower than the 10%-20% estimated by the World Health Organization (WHO). A contemporary quantification of mortality and recovery from acute malnutrition in Indian community settings is essential to inform policy regarding the benefits of scaling up prevention and treatment programmes.

METHODS AND FINDINGS

We conducted a cohort study using data collected during a recently completed cluster-randomised controlled trial in 120 geographical clusters with a total population of 121,531 in rural Jharkhand and Odisha, eastern India. Children born between October 1, 2013, and February 10, 2015, and alive at 6 months of age were followed up at 9, 12, and 18 months. We measured the children's anthropometry and asked caregivers whether children had been referred to services for malnutrition in the past 3 months. We determined the incidence and prevalence of moderate acute malnutrition (MAM) and SAM, as well as mortality and recovery at each follow-up. We then used Cox-proportional models to estimate mortality hazard ratios (HRs) for MAM and SAM. In total, 2,869 children were eligible for follow-up at 6 months of age. We knew the vital status of 93% of children (2,669/2,869) at 18 months. There were 2,704 children-years of follow-up time. The incidence of MAM by weight-for-length z score (WLZ) and/or mid-upper arm circumference (MUAC) was 406 (1,098/2,704) per 1,000 children-years. The incidence of SAM by WLZ, MUAC, or oedema was 190 (513/2,704) per 1,000 children-years. There were 36 deaths: 12 among children with MAM and six among children with SAM. Case fatality rates were 1.1% (12/1,098) for MAM and 1.2% (6/513) for SAM. In total, 99% of all children with SAM at 6 months of age (227/230) were alive 3 months later, 40% (92/230) were still SAM, and 18% (41/230) had recovered (WLZ ≥ -2 standard deviation [SD]; MUAC ≥ 12.5; no oedema). The adjusted HRs using all anthropometric indicators were 1.43 (95% CI 0.53-3.87, p = 0.480) for MAM and 2.56 (95% CI 0.99-6.70, p = 0.052) for SAM. Both WLZ < -3 and MUAC ≥ 11.5 and < 12.5 were associated with increased mortality risk (HR: 3.33, 95% CI 1.23-8.99, p = 0.018 and HR: 3.87, 95% CI 1.63-9.18, p = 0.002, respectively). A key limitation of our analysis was missing WLZ or MUAC data at all time points for 2.5% of children, including for two of the 36 children who died.

CONCLUSIONS

In rural eastern India, the incidence of acute malnutrition among children older than 6 months was high, but case fatality following SAM was 1.2%, much lower than the 10%-20% estimated by WHO. Case fatality rates below 6% have now been recorded in three other Indian studies. Community treatment using ready-to-use therapeutic food may not avert a substantial number of SAM-related deaths in children aged over 6 months, as mortality in this group is lower than expected. Our findings strengthen the case for prioritising prevention through known health, nutrition, and multisectoral interventions in the first 1,000 days of life, while ensuring access to treatment when prevention fails.

Nutrition rehabilitation of children with severe acute malnutrition: Revisiting studies undertaken by the National Institute of Nutrition

Severe acute malnutrition (SAM) in children under five years is an important public health problem due to associated high mortality and long-term health consequences. Research on the dietary causes of SAM, especially the role and relative importance of dietary protein, in the aetiology of oedematous malnutrition, has led to considerable debates and controversies. The present article revisits some of the debates in this field, where the researchers at the National Institute of Nutrition (NIN), Hyderabad, India, with their pioneering work, have contributed to the global literature on the various facets of the disease. Highlighting the importance of energy as a bigger problem than protein malnutrition is a noteworthy contribution of NIN's research. It is, however, important to examine the protein quality of the diets in light of the new information on the lysine requirements. The article argues that the currently dominating hypothesis of free radical theory requires a critical review of the supporting evidence. Over the past few decades, the research has focused on low-cost diets using locally available foods. The article also argues that solutions based on local foods, being acceptable and sustainable, need to be strengthened for their effective delivery through the existing nutrition programmes. Recent evidence shows that the use of ready-to-use therapeutic foods (RUTF) with high micronutrient density may be linked with higher mortality possibly due to the high iron content, which could be counterproductive. There are several unaddressed concerns regarding the potential long-term impact of consumption of RUTF in children with SAM. More evidence and a cautious approach are, therefore, needed before implementing these solutions.

Progress of children with severe acute malnutrition in the malnutrition treatment centre rehabilitation program: evidence from a prospective study in Jharkhand, India

BACKGROUND

In Jharkhand, Malnutrition Treatment Centres (MTCs) have been established to provide care to children with severe acute malnutrition (SAM). The study examined the effects of facility- and community based care provided as part the MTC program on children with severe acute malnutrition.

METHOD

A cohort of 150 children were enrolled and interviewed by trained investigators at admission, discharge, and after two months on the completion of the community-based phase of the MTC program. Trained investigators collected data on diet, morbidity, anthropometry, and utilization of health and nutrition services.

RESULTS

We found no deaths among children attending the MTC program. Recovery was poor, and the majority of children demonstrated poor weight gain, with severe wasting and underweight reported in 52 and 83% of the children respectively at the completion of the community-based phase of the MTC program. The average weight gain in the MTC facility (3.8 ± 5.9 g/kg body weight/d) and after discharge (0.6 ± 2.1 g/kg body weight/d) was below recommended standards. 67% of the children consumed food that met less than 50% of the recommended energy and protein requirement. Children experienced high number of illness episodes after discharge: 68% children had coughs and cold, 40% had fever and 35% had diarrhoea. Multiple morbidities were common: 50% of children had two or more episodes of illness. Caregiver's exposure to MTC's health and nutrition education sessions and meetings with frontline workers did not improve feeding practices at home. The take-home ration amount distributed to children through the supplementary food program was inadequate to achieve growth benefits.

CONCLUSIONS

Recovery of children during and after the MTC program was suboptimal. This highlights the need for additional support to strengthen MTC program so that effective care to children can be provided.