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Bahwere P, Funnell G, Qarizada AN, Woodhead S, Bengnwi W, Le MT. Effectiveness of a nonweight-based daily dosage of ready-to-use therapeutic food in children suffering from uncomplicated severe acute malnutrition: A nonrandomized, noninferiority analysis of programme data in Afghanistan. MATERNAL & CHILD NUTRITION 2024; 20:e13641. [PMID: 38627974 PMCID: PMC11168373 DOI: 10.1111/mcn.13641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 06/13/2024]
Abstract
Severe acute malnutrition (SAM) remains a major global public health problem. SAM cases are treated using ready-to-use therapeutic food (RUTF) at a dosage of ∼200 kcal/kg/day per the standard treatment protocol (STD). Emerging evidence on simplifications to the standard protocol, which among other adaptations, includes reducing the daily RUTF dosage, indicates that it is effective and safe for treating children with SAM. In response to a foreseen stock shortage of RUTF, the government of Afghanistan endorsed the temporary use of a modified treatment protocol in which the daily RUTF dosage was prescribed at 1000 kcal/day (irrespective of body weight) until the child achieved moderate acute malnutrition status (weight-for-height z-score ≥ -3 or mid-upper arm circumference [MUAC] ≥ 115 mm), at which point 500 kcal/day was prescribed until cured (modified treatment protocol [MTP]). In this paper, we report the results of this nonweight-based daily RUTF dosage experience. Data of 2042 children with SAM, treated using either the STD protocol (n = 269) or the MTP protocol (n = 1773) from August 2019 to March 2021 in five provinces, were analyzed. The per-protocol analyses confirmed noninferiority of MTP protocol when compared to STD protocol for recovery rate [93.3% vs. 90.2%; ∆ (95% confidence interval, CI) = 3.1 (-0.9; 7.2) %] and length-of-stay [82.6 vs. 75.6 days; ∆ (95% CI) = 6.9 (3.3; 10.5) days], considering the margin of noninferiority of -10% and +14 days, respectively. Weight gain velocity was smaller in the MTP protocol group than in the STD protocol group [3.7 (1.7) vs. 5.2 (2.9) g/kg/day; ∆ (95% CI) = -1.5 (-1.8, -1.2); p < 0.001]. The STD group had a significantly higher mean than the MTP group for absolute MUAC gain [∆ (95% CI) = 1.7 (1.0; 2.3) mm; p < 0.001] and the MUAC velocity [∆ (95% CI) = 0.29 (0.20; 0.37) mm/week; p < 0.001]. Our results confirm the noninferiority of a nonweight-based daily dosage and support the endorsement of this modification as an alternative to the standard protocol in resource-constrained contexts.
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Affiliation(s)
- Paluku Bahwere
- Center for Epidemiology, Biostatistics and Clinical Research (CR2), School of Public HealthUniversité Libre de BruxellesBrusselsBelgium
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Kiguli S, Olupot-Olupot P, Hamaluba M, Giallongo E, Thomas K, Alaroker F, Opoka RO, Tagoola A, Oyella S, Nalwanga D, Nabawanuka E, Okiror W, Nakuya M, Amorut D, Muhindo R, Ayub Mpoya, Mnjalla H, Oguda E, Williams TN, Harrison DA, Rowan K, Briend A, Maitland K. Nutritional supplementation in children with severe pneumonia in Uganda and Kenya (COAST-Nutrition): a phase 2 randomised controlled trial. EClinicalMedicine 2024; 72:102640. [PMID: 38774673 PMCID: PMC11106534 DOI: 10.1016/j.eclinm.2024.102640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/24/2024] Open
Abstract
Background Severe pneumonia in African children results in poor long-term outcomes (deaths/readmissions) with undernutrition as a key risk factor. We hypothesised additional energy/protein-rich Ready-to-Use Therapeutic Foods (RUTF) would meet additional nutritional requirements and improve outcomes. Methods COAST-Nutrition was an open-label Phase 2 randomised controlled trial in children (aged 6 months-12 years) hospitalised with severe pneumonia (and hypoxaemia, SpO2 <92%) in Mbale, Soroti, Jinja, Masaka Regional Referral Hospitals, Uganda and Kilifi County Hospital, Kenya (ISRCTN10829073 (registered 6th June 2018) PACTR202106635355751 (registered 2nd June 2021)). Children were randomised (ratio 1:1) to enhanced nutritional supplementation with RUTF (plus usual diet) for 56 days vs usual diet (control). The primary outcome was change in mid-upper arm circumference (MUAC) at 90 days as a composite with mortality. Secondary outcomes include anthropometric status, mortality, and readmissions at Days 28, 90 and 180. Findings Between 12 August 2018 and 22 April 2022, 846 eligible children were randomised, 424 to RUTF and 422 to usual diet, and followed for 180-days [12 (1%) lost-to-follow-up]. RUTF supplement was initiated in 417/419 (>99%). By Day 90, there was no significant difference in the composite endpoint (probabilistic index 0.49, 95% CI 0.45-0.53, p = 0.74). Respective 90-day mortality (13/420 3.1% vs 14/421 3.3%) and MUAC increment (0.54 (SD 0.85) vs 0.55 (SD 0.81)) were similar between arms. There was no difference in any anthropometric secondary endpoints to Day 28, 90 or 180 except skinfold thickness at Day 28 and Day 90 was greater in the RUTF arm. Serious adverse events were higher in the RUTF arm (n = 164 vs 108), mainly due to hospital readmission for acute illness (54/387 (14%) vs 37/375 (10%). Interpretation Our study suggested that nutritional supplementation with RUTF did not improve outcomes to 180 days in children with severe pneumonia. Funding This trial is part of the EDCTP2 programme (grant number RIA-2016S-1636-COAST-Nutrition) supported by the European Union, and UK Joint Global Health Trials scheme: Medical Research Council, Department for International Development, Wellcome Trust (grant number MR/L004364/1, UK).
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Affiliation(s)
- Sarah Kiguli
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
| | - Peter Olupot-Olupot
- Busitema University Faculty of Health Sciences, Mbale Campus, Uganda
- Mbale Regional Referral Hospital Mbale, Uganda
| | - Mainga Hamaluba
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elisa Giallongo
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | | | - Robert O. Opoka
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
- Jinja Regional Referral Hospital Jinja, Uganda
| | | | - Shela Oyella
- Masaka Regional Referral Hospital Masaka, Uganda
| | - Damalie Nalwanga
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
| | - Eva Nabawanuka
- Department of Paediatrics, School of Medicine, Makerere University and Mulago Hospital Kampala, Uganda
- Department of Radiology, School of Medicine, Makerere University, P.O Box 7072, Kampala, Uganda
| | - William Okiror
- Busitema University Faculty of Health Sciences, Mbale Campus, Uganda
- Mbale Regional Referral Hospital Mbale, Uganda
| | | | - Denis Amorut
- Soroti Regional Referral Hospital, Soroti, Uganda
| | | | - Ayub Mpoya
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Hellen Mnjalla
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Emmanuel Oguda
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - Thomas N. Williams
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
| | - David A. Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Kathy Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, UK
| | - Andre Briend
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Kathryn Maitland
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Imperial College London, London, UK
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Maru Y, Tamiru D, Baye K, Chitekwe S, Lailou A, Darsene H, Abdulai R, Worku M, Belachew T. Effect of a simplified approach on recovery of children 6-59 months with wasting in Ethiopia: A noninferiority, cluster randomized controlled trial. MATERNAL & CHILD NUTRITION 2024:e13670. [PMID: 38800892 DOI: 10.1111/mcn.13670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
Worldwide, nearly 45 million children under the age of 5 years were affected by wasting in 2022. Ethiopia has been challenged by disasters increasing the caseload of children with wasting. This study aimed to determine the effect of a simplified approach on recovery of children with acute malnutrition as compared with the standard protocol. A cluster randomized, controlled, noninferiority trial was carried out in three regions of Ethiopia from December 4, 2021, to July 30, 2022. A total of 58 clusters (health posts) were randomized into intervention and control groups. Children with SAM in the intervention groups received two sachets of Ready-to-Use Therapeutic Food (RUTF), whereas children in the control groups received RUTF based on their body weight. Children with moderate acute malnutrition (MAM) received one sachet of RUTF and one sachet of Ready-to-Use Supplementary Food (RUSF) daily in the intervention and control groups, respectively. Per protocol (PP) and intention-to-treat analysis were used to compare recovery at a noninferiority margin of 15%. Data were collected from 55 health posts and 1032 children. In the PP analysis, the recovery rate of children with wasting among the simplified group (97.8%) was noninferior to the standard protocol group (97.7%), p = 0.399. The RUTF cost per treatment of child with SAM was 56.55 USD for the standard versus 42.78 USD for the simplified approach. The simplified approach is noninferior to the standard protocol in terms of recovery and has a lower cost of RUTF. Further study is recommended to assess the effectiveness of the simplified approach in emergency contexts.
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Affiliation(s)
- Yetayesh Maru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Arnaud Lailou
- UNICEF West and Central Africa Regional Office, Nutrition Section, Dakar, Senegal
| | - Hiwot Darsene
- Nutrition Coordination Office, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | - Rashid Abdulai
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Mesfin Worku
- Nutrition Section, UNICEF Ethiopia, Addis Ababa, Ethiopia
| | - Tefera Belachew
- Nutrition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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Maru Y, Tamiru D, Baye K, Chitekwe S, Kifle YG, Lailou A, Belachew T. Comparing time to recovery in wasting treatment: simplified approach vs. standard protocol among children aged 6-59 months in Ethiopia-a cluster-randomized, controlled, non-inferiority trial. Front Pediatr 2024; 12:1337370. [PMID: 38840802 PMCID: PMC11150620 DOI: 10.3389/fped.2024.1337370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/03/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Wasting occurs when the body's nutritional needs are unmet due to insufficient intake or illness. It represents a significant global challenge, with approximately 45 million infants and children under 5 years of age suffering from wasting in 2022. Methods A cluster-randomized, controlled, non-inferiority trial was conducted in three regions of Ethiopia. A non-inferiority margin of 15%, along with a recovery rate of 90% and a minimum acceptable recovery rate of 75%, were considered alongside an intra-cluster correlation coefficient of 0.05 and an anticipated loss to follow-up of 10% in determining the total sample size of 1,052 children. Children with severe acute malnutrition (SAM) in the simplified group received two sachets of ready-to-use therapeutic food (RUTF) daily, while the standard group received RUTF based on their body weight. For moderate acute malnutrition (MAM) cases, the simplified group received one sachet of RUTF, whereas the standard group received one sachet of ready-to-use supplementary food daily. A non-parametric Kaplan-Meir curve was utilized to compare the survival time to recovery. Results A total of 1,032 data points were gathered. For SAM cases, the average length of stay was 8.86 (±3.91) weeks for the simplified protocol and 8.26 (±4.18) weeks for the standard protocol (P = 0.13). For MAM cases, the average length of stay was 8.18 (±2.96) weeks for the simplified approach and 8.32 (±3.55) weeks for the standard protocol (P = 0.61). There was no significant difference (P = 0.502) observed between the simplified protocol [8 weeks, interquartile range (IQR): 7.06-8.94] and the standard protocol [9 weeks (IQR: 8.17-9.83)] among children with SAM on the median time to cure. There was no significant difference (P = 0.502) in the time to cure between the simplified approach [8 weeks (IQR: 7.53-8.47)] and the standard protocol [8 weeks (IQR: 7.66-8.34)] among children with MAM. The survival curves displayed similarity, with the log-rank test not showing significance (P > 0.5), indicating the non-inferiority of the simplified approach for cure time. Conclusion The findings showed that the simplified and standard protocols demonstrated no significant differences in terms of the average duration of stay and time required for recovery. Clinical Trial Registration https://pactr.samrc.ac.za/, Identifier (PACTR202202496481398).
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Affiliation(s)
- Yetayesh Maru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Dessalegn Tamiru
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
- Nutrition and Food Systems Division, Research Center for Inclusive Development in Africa (RIDA), Addis Ababa, Ethiopia
| | | | - Yehenew G. Kifle
- Department of Mathematics and Statistics, University of Maryland Baltimore County, Baltimore, MD, United States
| | - Arnaud Lailou
- Nutrition Section, UNICEF West and Central Africa Regional Office, Dakar, Senegal
| | - Tefera Belachew
- Nurition and Dietetics Department, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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Vresk L, Flanagan M, Daniel AI, Potani I, Bourdon C, Spiegel-Feld C, Thind MK, Farooqui A, Ling C, Miraglia E, Hu G, Wen B, Zlotkin S, James P, McGrath M, Bandsma RHJ. Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations. Nutr Rev 2024:nuad165. [PMID: 38350491 DOI: 10.1093/nutrit/nuad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).
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Affiliation(s)
- Laura Vresk
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mary Flanagan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allison I Daniel
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isabel Potani
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Celine Bourdon
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carolyn Spiegel-Feld
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mehakpreet K Thind
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amber Farooqui
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Catriona Ling
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emiliano Miraglia
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Guanlan Hu
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bijun Wen
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stanley Zlotkin
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Philip James
- Emergency Nutrition Network, Oxford, United Kingdom
| | | | - Robert H J Bandsma
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Akinmoladun OF, Bamidele OP, Jideani VA, Nesamvuni CN. Severe Acute Malnutrition: The Potential of Non-Peanut, Non-Milk Ready-to-Use Therapeutic Foods. Curr Nutr Rep 2023; 12:603-616. [PMID: 37897619 PMCID: PMC10766793 DOI: 10.1007/s13668-023-00505-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW This review provides information on the prospect and effectiveness of ready-to-use therapeutic foods (RUTFs) produced locally without the addition of milk and peanut. RECENT FINDINGS The foods used in fighting malnutrition in the past decades contributed little to the success of the alleviation program due to their non-effectiveness. Hence, RUTFs are introduced to fight malnutrition. The peanut allergies, the high cost of milk, and the high production cost of peanut RUTF have made its distribution, treatment spread, and accessibility very slow, especially in areas where it is highly needed. There is a need, therefore, for a low-cost RUTF that is acceptable and effective in treating severe acute malnutrition among under-5 children. This review shows both the success and failure of reported studies on the use of non-peanut and non-milk RUTF, including their cost of production as compared to the standard milk and peanut-based RUTF. It was hypothesised that replacing the milk ingredient component with legumes like soybeans can reduce the cost of production of RUTFs while also delivering an effective product in managing and treating severe acute malnutrition (SAM). Consumers generally accept them better because of their familiarity with the raw materials.
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Affiliation(s)
- Oluwaseun F Akinmoladun
- Department of Nutrition, Faculty of Health Sciences, University of Venda, Private Bag X5050, Thohoyandou, 0950, South Africa.
- Department of Nutrition and Dietetics, College of Agriculture, Food Science and Technology, Wesley University, PMB 507 Ondo, Ondo State, Nigeria.
- Department of Health Science, University of the People, Pasadena, CA 91101, USA.
| | - Oluwaseun P Bamidele
- Department of Food Science and Technology, University of Venda, Private Bag X5050, Thohoyandou, 09590, South Africa
| | - Victoria A Jideani
- Department of Food Technology, Cape Peninsula University of Technology, P.O. Box 652, Cape Town, 8000, South Africa
| | - Cebisa N Nesamvuni
- Department of Nutrition, Faculty of Health Sciences, University of Venda, Private Bag X5050, Thohoyandou, 0950, South Africa
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Gizaw G, Bahwere P, Argaw A, Wells JCK, Friis H, Olsen MF, Abdissa A, Wibaek R, Abera M, Sadler K, Boyd E, Collins S, Girma T. Growth and Body Composition 5 y After Treatment for Severe Acute Malnutrition: A 5-y Prospective Matched Cohort Study in Ethiopian Children. Am J Clin Nutr 2023; 118:1029-1041. [PMID: 37923494 DOI: 10.1016/j.ajcnut.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Short-term anthropometric outcomes are well documented for children treated for severe acute malnutrition (SAM). However, anthropometric recovery may not indicate restoration of healthy body composition. OBJECTIVES This study aimed to evaluate long-term associations of SAM with growth and body composition of children 5 y after discharge from community-based management of acute malnutrition (CMAM). METHODS We conducted a 5-y prospective cohort study, enrolling children aged 6 to 59 mo discharged from CMAM (post-SAM) (n = 203) and nonmalnourished matched controls (n = 202) from Jimma Zone, Ethiopia in 2013. Anthropometry and body composition (bioelectrical impedance) were assessed. Multiple linear regression models tested differences in height-for-age (HAZ), weight-for-age (WAZ), and body mass index-for-age (BAZ) z-scores; height-adjusted fat-free mass index (FFMI); and FM index (FMI) between groups. RESULTS Post-SAM children had higher stunting prevalence than controls at discharge (82.2% compared with 36.0%; P < 0.001), 1 y (80.2% compared with 53.7%; P < 0.001), and 5 y postdischarge (74.2% compared with 40.8%; P < 0.001). Post-SAM children remained 5 cm shorter throughout follow-up, indicating no HAZ catch-up. No catch-up in WAZ or BAZ was observed. Post-SAM children had lower hip (-2.05 cm; 95% CI: -2.73, -1.36), waist (-0.92 cm; CI: -1.59, -0.23) and mid-upper arm (-0.64 cm; CI: -0.90, -0.42) circumferences and lower-limb length (-1.57 cm; 95% CI: -2.21, -0.94) at 5 y postdischarge. They had larger waist-hip (0.02 cm; 95% CI: 0.008, 0.033) and waist-height (0.013 cm; 95% CI: 0.004, 0.021) ratios, and persistent deficits in FFMI at discharge and 6 mo and 5 y postdischarge (P < 0.001 for all). No difference was detected in head circumference, sitting height, or FMI. CONCLUSIONS Five y after SAM treatment, children maintained deficits in HAZ, WAZ, BAZ, and FFMI, with preservation of FMI, sitting height, and head circumference at the expense of lower-limb length, indicating a "thrifty growth" pattern. Research is urgently needed to identify effective clinical and public health interventions to mitigate these consequences of malnutrition.
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Affiliation(s)
- Getu Gizaw
- Department of Human Nutrition and Dietetics, Jimma University, Jimma, Ethiopia; Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.
| | - Paluku Bahwere
- Valid International, Oxford, United Kingdom; Center for Epidemiology, Biostatistics, and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
| | - Alemayehu Argaw
- Department of Human Nutrition and Dietetics, Jimma University, Jimma, Ethiopia; Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Mette Frahm Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Alemseged Abdissa
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Laboratory Sciences, Jimma University, Jimma, Ethiopia; Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Rasmus Wibaek
- Clinical Epidemiology, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Mubarek Abera
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Psychiatry, Jimma University, Jimma, Ethiopia
| | | | - Erin Boyd
- United States Agency for International Development, Washington DC, USA
| | | | - Tsinuel Girma
- Jimma University Clinical and Nutrition Research Partnership, Jimma University, Jimma, Ethiopia; Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
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Bwakura-Dangarembizi M, Dumbura C, Ngosa D, Majo FD, Piper JD, Sturgeon JP, Nathoo KJ, Amadi B, Norris S, Chasekwa B, Ntozini R, Wells JC, Kelly P, Prendergast AJ. Fat and lean mass predict time to hospital readmission or mortality in children treated for complicated severe acute malnutrition in Zimbabwe and Zambia. Br J Nutr 2023; 130:1024-1033. [PMID: 36573378 PMCID: PMC10442795 DOI: 10.1017/s0007114522004056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
HIV and severe wasting are associated with post-discharge mortality and hospital readmission among children with complicated severe acute malnutrition (SAM); however, the reasons remain unclear. We assessed body composition at hospital discharge, stratified by HIV and oedema status, in a cohort of children with complicated SAM in three hospitals in Zambia and Zimbabwe. We measured skinfold thicknesses and bioelectrical impedance analysis (BIA) to investigate whether fat and lean mass were independent predictors of time to death or readmission. Cox proportional hazards models were used to estimate the association between death/readmission and discharge body composition. Mixed effects models were fitted to compare longitudinal changes in body composition over 1 year. At discharge, 284 and 546 children had complete BIA and skinfold measurements, respectively. Low discharge lean and peripheral fat mass were independently associated with death/hospital readmission. Each unit Z-score increase in impedance index and triceps skinfolds was associated with 48 % (adjusted hazard ratio 0·52, 95 % CI (0·30, 0·90)) and 17 % (adjusted hazard ratio 0·83, 95 % CI (0·71, 0·96)) lower hazard of death/readmission, respectively. HIV-positive v. HIV-negative children had lower gains in sum of skinfolds (mean difference -1·49, 95 % CI (-2·01, -0·97)) and impedance index Z-scores (-0·13, 95 % CI (-0·24, -0·01)) over 52 weeks. Children with non-oedematous v. oedematous SAM had lower mean changes in the sum of skinfolds (-1·47, 95 % CI (-1·97, -0·97)) and impedance index Z-scores (-0·23, 95 % CI (-0·36, -0·09)). Risk stratification to identify children at risk for mortality or readmission, and interventions to increase lean and peripheral fat mass, should be considered in the post-discharge care of these children.
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Affiliation(s)
- Mutsa Bwakura-Dangarembizi
- University of Zimbabwe, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- University of Witwatersrand, Johannesburg, South Africa
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Joe D. Piper
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Jonathan P. Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Kusum J. Nathoo
- University of Zimbabwe, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Shane Norris
- University of Witwatersrand, Johannesburg, South Africa
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jonathan C. Wells
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
- Blizard Institute, Queen Mary University of London, London, UK
| | - Andrew J. Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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9
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Lelijveld N, Cox S, Anujuo K, Amoah AS, Opondo C, Cole TJ, Wells JCK, Thompson D, McKenzie K, Abera M, Berhane M, Kerac M. Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi 'ChroSAM' cohort. Public Health Nutr 2023; 26:1658-1670. [PMID: 36876519 PMCID: PMC10466107 DOI: 10.1017/s1368980023000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 01/05/2023] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE To explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition and describe associations with survival and non-communicable disease (NCD) risk 7 years post-treatment. DESIGN Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score and height-for-age z-score (HAZ). Three categorisation methods included no categorisation, quintiles and latent class analysis (LCA). Associations with mortality risk and seven NCD indicators were analysed. SETTING Secondary data from Blantyre, Malawi between 2006 and 2014. PARTICIPANTS A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score < 70 % median and/or MUAC (mid-upper arm circumference) < 110 mm and/or bilateral oedema) at ages 5-168 months. RESULTS Faster weight gain during treatment (g/d) and after treatment (g/kg/day) was associated with lower risk of death (adjusted OR 0·99, 95 % CI 0·99, 1·00; and adjusted OR 0·91, 95 % CI 0·87, 0·94, respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0·02, 95 % CI 0·00, 0·03) and larger HAZ (6·62, 95 % CI 1·31, 11·9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0·02, 95 % CI 0·01, 0·03), an indicator of later-life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/d during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. CONCLUSIONS A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.
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Affiliation(s)
- Natasha Lelijveld
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Emergency Nutrition Network (ENN), Oxford, UK
- Centre for Maternal, Adolescent & Reproductive Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Sioned Cox
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Kenneth Anujuo
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
| | - Abena S Amoah
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Charles Opondo
- Department of Medical Statistics, Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim J Cole
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jonathan CK Wells
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Debbie Thompson
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | - Kimberley McKenzie
- Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica
| | | | | | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, LondonWC1E 7HT, UK
- Centre for Maternal, Adolescent & Reproductive Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
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10
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Kangas ST, Coulibaly IN, Tausanovitch Z, Ouologuem B, Marron B, Radin E, Ritz C, Dembele S, Ouédraogo CT, Bailey J. Post-Recovery Relapse of Children Treated with a Simplified, Combined Nutrition Treatment Protocol in Mali: A Prospective Cohort Study. Nutrients 2023; 15:nu15112636. [PMID: 37299599 DOI: 10.3390/nu15112636] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
The present study aimed to determine the 6-month incidence of relapse and associated factors among children who recovered from acute malnutrition (AM) following mid-upper arm circumference (MUAC)-based simplified combined treatment using the ComPAS protocol. A prospective cohort of 420 children who had reached a MUAC ≥ 125 mm for two consecutive measures was monitored between December 2020 and October 2021. Children were seen at home fortnightly for 6 months. The overall 6-month cumulative incidence of relapse [95%CI] into MUAC < 125 mm and/or edema was 26.1% [21.7; 30.8] and 1.7% [0.6; 3.6] to MUAC < 115 mm and/or edema. Relapse was similar among children initially admitted to treatment with a MUAC < 115 mm and/or oedema and among those with a MUAC ≥ 115 mm but <125 mm. Relapse was predicted by lower anthropometry both at admission to and discharge from treatment, and a higher number of illness episodes per month of follow-up. Having a vaccination card, using an improved water source, having agriculture as the main source of income, and increases in caregiver workload during follow-up all protected from relapse. Children discharged as recovered from AM remain at risk of relapsing into AM. To achieve reduction in relapse, recovery criteria may need to be revised and post-discharge strategies tested.
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Affiliation(s)
| | | | | | | | | | | | - Christian Ritz
- National Institute of Public Health, Copenhagen, Denmark
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11
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Likoswe BH, Chimera-Khombe B, Patson N, Selemani A, Potani I, Phuka J, Maleta K. A Systematic Review on the Optimal Dose and Duration of Ready-to-Use Therapeutic Food (RUTF) for 6-59-Month-Old Children with Severe Wasting or Oedema. Nutrients 2023; 15:nu15071750. [PMID: 37049590 PMCID: PMC10096907 DOI: 10.3390/nu15071750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
The World Health Organisation (WHO) recommends that severe wasting and/or oedema should be treated with ready-to-use therapeutic food (RUTF) at a dose of 150-220 kcal/kg/day for 6-8 weeks. Emerging evidence suggests that variations of RUTF dosing regimens from the WHO recommendation are not inferior. We aimed to assess the comparative efficacy and effectiveness of different RUTF doses and durations in comparison with the current WHO RUTF dose recommendation for treating severe wasting and/or oedema among 6-59-month-old children. A systematic literature search identified three studies for inclusion, and the outcomes of interest included anthropometric recovery, anthropometric measures and indices, non-response, time to recovery, readmission, sustained recovery, and mortality. The study was registered with PROSPERO, CRD 42021276757. Only three studies were eligible for analysis. There was an overall high risk of bias for two of the studies and some concerns for the third study. Overall, there were no differences between the reduced and standard RUTF dose groups in all outcomes of interest. Despite the finding of no differences between reduced and standard-dose RUTF, the studies are too few to conclusively declare that reduced RUTF dose was more efficacious than standard RUTF.
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Affiliation(s)
- Blessings H Likoswe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Bernadette Chimera-Khombe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Noel Patson
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Apatsa Selemani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Isabel Potani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - John Phuka
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Kenneth Maleta
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
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12
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Lewis JI, Friis H, Mupere E, Wells JC, Grenov B. Calibration of Bioelectrical Impedance Analysis Against Deuterium Dilution for Body Composition Assessment in Stunted Ugandan Children. J Nutr 2023; 153:426-434. [PMID: 36894235 DOI: 10.1016/j.tjnut.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/09/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND BIA represents an important tool in body composition (BC) assessment, especially in low-income settings in which simple and affordable options are preferred. There is a particular need to measure BC in stunted children, in which cases population-specific BIA estimating equations are lacking. OBJECTIVES We calibrated an equation to estimate body composition from BIA using deuterium dilution (2H) as the criterion method in stunted children. METHODS We measured BC with 2H and performed BIA in stunted Ugandan children (n = 50). Multiple linear regression models were constructed to predict 2H-derived FFM from BIA-derived whole-body impedance and other relevant predictors. Model performance was expressed as adjusted R2 and RMSE. Prediction errors were also calculated. RESULTS Participants were aged 16-59 mo, of whom 46% were girls, and their median (IQR) height-for-age z-score (HAZ) was -2.58 (-2.92 to -2.37) according to the WHO growth standards. Impedance index (height2/impedance measured at 50 kHz) alone explained 89.2% variation in FFM and had an RMSE of 583 g (precision error 6.5%). The final model contained age, sex, impedance index, and height-for-age z-score as predictors and explained 94.5% variation in FFM with an RMSE of 402 g (precision error 4.5%). CONCLUSIONS We present a BIA calibration equation for a group of stunted children with a relatively low prediction error. This may help evaluate the efficacy of nutritional supplementation in large-scale trials in the same population. J Nutr 20XX;xxx:xx.
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Affiliation(s)
- Jack I Lewis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Population, Policy, and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.
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13
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Kangas ST, Salpéteur C, Nikièma V, Ritz C, Friis H, Briend A, Kaestel P. Predictors of time to recovery and non-response during outpatient treatment of severe acute malnutrition. PLoS One 2022; 17:e0267538. [PMID: 35639683 PMCID: PMC9154090 DOI: 10.1371/journal.pone.0267538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/27/2022] [Indexed: 11/19/2022] Open
Abstract
Background Every year, over 4 million children are treated for severe acute malnutrition with varying program performance. This study sought to explore the predictors of time to recovery from and non-response to outpatient treatment of SAM. Methods Children with weight-for-height z-score (WHZ) <-3 and/or mid-upper arm circumference (MUAC) <115 mm, without medical complications were enrolled in a trial (called MANGO) from outpatient clinics in Burkina Faso. Treatment included a weekly ration of ready-to-use therapeutic foods. Recovery was declared with WHZ ≥-2 and/or MUAC ≥125 mm, for two weeks without illness. Children not recovered by 16 weeks were considered as non-response to treatment. Predictors studied included admission characteristics, morbidity and compliance during treatment and household characteristics. Cox proportional hazard models were fitted and restricted mean time to recovery calculated. Logistic regression was used to analyse non-response to treatment. Results Fifty-five percent of children recovered and mean time to recovery was eight weeks while 13% ended as non-response to treatment. Independent predictors of longer time to recovery or non-response included low age, being admitted with WHZ <-3, no illness nor anaemia at admission, illness episodes during treatment, skipped or missed visits, low maternal age and not practising open defecation. Eighty-four percent of children had at least one and 59% at least two illness episodes during treatment. This increased treatment duration by 1 to 4 weeks. Thirty-five percent of children missed at least one treatment visit. One missed visit predicted 3 weeks longer and two or more missed visits 5 weeks longer treatment duration. Conclusions Both longer time to recovery and higher non-response to treatment seem most strongly associated with illness episodes and missed visits during treatment. This indicates that prevention of illnesses would be key to shortening the treatment duration and that there is a need to seek ways to facilitate adherence.
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Affiliation(s)
- Suvi T. Kangas
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
- * E-mail:
| | - Cécile Salpéteur
- Expertise and Advocacy Department, Action Against Hunger (ACF), Paris, France
| | - Victor Nikièma
- Nutrition and Health Department, Action Against Hunger (ACF) Mission in Burkina Faso, Paris, France
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Center for Child Health Research, University of Tampere School of Medicine, Tampere University, Tampere, Finland
| | - Pernille Kaestel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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14
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Thurstans S, Sessions N, Dolan C, Sadler K, Cichon B, Isanaka S, Roberfroid D, Stobaugh H, Webb P, Khara T. The relationship between wasting and stunting in young children: A systematic review. MATERNAL & CHILD NUTRITION 2022; 18:e13246. [PMID: 34486229 PMCID: PMC8710094 DOI: 10.1111/mcn.13246] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/26/2021] [Accepted: 06/22/2021] [Indexed: 11/27/2022]
Abstract
In 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low- and middle-income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near-term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid-upper-arm circumference combined with weight-for-age Z score might effectively identify children at most risk of near-term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.
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Affiliation(s)
- Susan Thurstans
- Department of Population HealthLondon School of Hygiene and Tropical MedicineLondonUnited KingdomUK
- Emergency Nutrition NetworkOxfordUK
| | | | | | | | | | - Sheila Isanaka
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Department of ResearchEpicentreParisFrance
| | - Dominique Roberfroid
- Faculty of MedicineUniversity of NamurNamurBelgium
- Department of Food Technology, Safety and HealthGhent UniversityGhentBelgium
| | - Heather Stobaugh
- Action Against Hunger USANew YorkNew YorkUSA
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | - Patrick Webb
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
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15
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Wei Z, Zhou N, Zou L, Shi Z, Dun B, Ren G, Yao Y. Soy Protein Alleviates Malnutrition in Weaning Rats by Regulating Gut Microbiota Composition and Serum Metabolites. Front Nutr 2021; 8:774203. [PMID: 34926551 PMCID: PMC8678609 DOI: 10.3389/fnut.2021.774203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/19/2021] [Indexed: 12/25/2022] Open
Abstract
Dietary intervention with plant protein is one of the main methods that is used to lessen the symptoms of malnutrition. Supplementary soy protein to undernourished weaning rats for 6 weeks significantly increased their body weight gain. After the intervention, the level of total short-chain fatty acids (SCFAs) was restored to 1,512.7 μg/g, while the level was only 637.1 μg/g in the 7% protein group. The amino acids (valine, isoleucine, phenylalanine, and tryptophan) increased in the colon, and vitamin B6 metabolism was significantly influenced in undernourished rats. The tryptophan and glycine-serine-threonine pathways were elevated, leading to an increase in the level of tryptophan and 5-hydroxytryptophan (5-HTP) in the serum. In addition, the relative abundance of Lachnospiraceae_NK4A136_group and Lactobacillus increased, while Enterococcus and Streptococcus decreased compared to undernourished rats. Overall, soy protein improved the growth of rats with malnutrition in early life by regulating gut microbiota and metabolites in the colon and serum.
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Affiliation(s)
- Zuchen Wei
- Institute of Crop Science, Chinese Academy of Agricultural Sciences (CAAS), Beijing, China.,Laboratory for Green Cultivation and Deep Processing of Three Gorges Reservoir Area's Medicinal Herbs, College of Life Science and Engineering, The Chongqing Engineering, Chongqing Three Gorges University, Chongqing, China
| | - Nong Zhou
- Laboratory for Green Cultivation and Deep Processing of Three Gorges Reservoir Area's Medicinal Herbs, College of Life Science and Engineering, The Chongqing Engineering, Chongqing Three Gorges University, Chongqing, China
| | - Liang Zou
- Key Laboratory of Coarse Cereal Processing, Ministry of Agriculture and Rural Affairs, Chengdu University, Chengdu, China
| | - Zhenxing Shi
- Institute of Crop Science, Chinese Academy of Agricultural Sciences (CAAS), Beijing, China
| | - Baoqing Dun
- Institute of Crop Science, Chinese Academy of Agricultural Sciences (CAAS), Beijing, China
| | - Guixing Ren
- Institute of Crop Science, Chinese Academy of Agricultural Sciences (CAAS), Beijing, China
| | - Yang Yao
- Institute of Crop Science, Chinese Academy of Agricultural Sciences (CAAS), Beijing, China
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16
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Nel E, Lombard M. Ready-to-use therapeutic foods for the treatment of malnourished children and infants. Curr Opin Clin Nutr Metab Care 2021; 24:276-280. [PMID: 33741753 DOI: 10.1097/mco.0000000000000747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Ready-to-use therapeutic foods (RUTF) allow effective community-based management of severe acute malnutrition (SAM). Current interest focuses on their optimal composition and use. RECENT FINDINGS Studies of alternative RUTF have yielded differing results. Partial soybean, sorghum flour, and whey protein replacement RUTF were inferior to standard RUTF. In contrast, soy-based RUTF was as effective as milk-based RUTF and an alternative RUTF with added oats lead to superior recovery in comparison to standard RUTF.Reducing the dose of RUTF in the later phases of SAM recovery resulted in small reductions in the growth of uncertain clinical significance.Although iron and vitamin A status improve during treatment with standard RUTF, a significant proportion of children remained deficient. Alternative soya, maize, and sorghum-based formulas with no milk protein may improve recovery of iron status compared to standard RUTF.Finally, in children with SAM, plasma essential fatty acids and conversion to long-chain polyunsaturated fatty acids are reduced. Despite the improvement, these parameters remain lower than in normal children after 3 months. SUMMARY New RUTF formulations may provide a cost-effective alternative to standard RUTF. Future research should focus on addressing micronutrient deficiency, lipid metabolism, and long-term recovery.
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Affiliation(s)
- Etienne Nel
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape
| | - Martani Lombard
- Centre of Excellence for Nutrition (CEN), North-West University, Potchefstroom, South Africa
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17
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N'Diaye DS, Wassonguema B, Nikièma V, Kangas ST, Salpéteur C. Economic evaluation of a reduced dosage of ready-to-use therapeutic foods to treat uncomplicated severe acute malnourished children aged 6-59 months in Burkina Faso. MATERNAL AND CHILD NUTRITION 2021; 17:e13118. [PMID: 33621428 PMCID: PMC8189238 DOI: 10.1111/mcn.13118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/06/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
Ready‐to‐use therapeutic foods (RUTF) used to treat children with severe acute malnutrition (SAM) are costly, and the prescribed dosage has not been optimized. The MANGO trial, implemented by Action Contre la Faim in Burkina Faso, proved the non‐inferiority of a reduced RUTF dosage in community‐based treatment of uncomplicated SAM. We performed a cost‐minimization analysis to assess the economic impact of transitioning from the standard to the reduced RUTF dose. We used a decision‐analytic model to simulate a cohort of 399 children/arm, aged 6–59 months and receiving SAM treatment. We adopted a societal perspective: direct medical costs (drugs, materials and staff time), non‐medical costs (caregiver expenses) and indirect costs (productivity loss) in 2017 international US dollar were included. Data were collected through interviews with 35 caregivers and 20 informants selected through deliberate sampling and the review trial financial documents. The overall treatment cost for 399 children/arm was $36,550 with the standard and $30,411 with the reduced dose, leading to $6,140 (16.8%) in cost savings ($15.43 saved/child treated). The cost/consultation was $11.6 and $9.6 in the standard and reduced arms, respectively, with RUTF accounting for 56.2% and 47.0% of the total. The savings/child treated was $11.4 in a scenario simulating the Burkinabè routine SAM treatment outside clinical trial settings. The reduced RUTF dose tested in the MANGO trial resulted in significant cost savings for SAM treatment. These results are useful for decision makers to estimate potential economic gains from an optimized SAM treatment protocol in Burkina Faso and similar contexts.
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Affiliation(s)
- Dieynaba S N'Diaye
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France
| | - Bibata Wassonguema
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France
| | | | - Suvi T Kangas
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France.,Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Cécile Salpéteur
- Research unit, Expertise & Advocacy Department, Action Contre la Faim, Paris, France
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18
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Bourdon C, Bartels RH, Chimwezi E, Kool J, Chidzalo K, Perot L, Brals D, Bandsma RHJ, Boele van Hensbroek M, Voskuijl WP. The clinical use of longitudinal bio-electrical impedance vector analysis in assessing stabilization of children with severe acute malnutrition. Clin Nutr 2020; 40:2078-2090. [PMID: 33097306 DOI: 10.1016/j.clnu.2020.09.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Severe Acute Malnutrition (SAM) in children is determined using anthropometry. However, bio-electrical impedance (BI) analysis could improve the estimation of altered body composition linked to edema and/or loss of lean body mass in children with SAM. We aimed to assess: 1) the changes in BI parameters during clinical stabilization and 2) whether BI parameters add prognostic value for clinical outcome beyond the use of anthropometry. METHODS This prospective observational study enrolled children, aged 6-60 months, that were admitted at Queen Elizabeth Central Hospital in Blantyre, Malawi, for complicated SAM (i.e., having either severe wasting or edematous SAM with a complicating illness). Height, weight, mid-upper arm circumference (MUAC), and BI were measured on admission and after clinical stabilization. BI measures were derived from height-adjusted indices of resistance (R/H), reactance (Xc/H), and phase angle (PA) and considered to reflect body fluids and soft tissue in BI vector analysis (BIVA). RESULTS We studied 183 children with SAM (55% edematous; age 23.0 ± 12.0 months; 54% male) and 42 community participants (age 20.1 ± 12.3 months; male 62%). Compared to community participants, the BIVA of children with edematous SAM were short with low PA and positioned low on the hydration axis which reflects severe fluid retention. In contrast, children with severe wasting had elongated vectors with a PA that was higher than children with edematous SAM but lower than community participants. Their BIVA position fell within the top right quadrant linked to leanness and dehydration. BIVA from severely wasted and edematous SAM patients differed between groups and from community children both at admission and after stabilization (p < 0.001). Vector position shifted during treatment only in children with edematous SAM (p < 0.001) and showed a upward translation suggestive of fluid loss. While PA was lower in children with SAM, PA did not contribute more than anthropometry alone towards explaining mortality, length of stay, or time-to-discharge or time-to-mortality. The variability and heterogeneity in BI measures was high and their overall added predictive value for prognosis of individual children was low. CONCLUSIONS BIVA did not add prognostic value over using anthropometry alone to predict clinical outcome. Several implementation challenges need to be optimized. Thus, in low-resource settings, the routine use of BI in the management of pediatric malnutrition is questionable without improved implementation.
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Affiliation(s)
- Céline Bourdon
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Rosalie H Bartels
- Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Emmanuel Chimwezi
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jacintha Kool
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Katherine Chidzalo
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lyric Perot
- Woodrow Wilson School of Public and International Affairs, Princeton University, NJ, USA
| | - Daniella Brals
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | - Robert H J Bandsma
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Wieger P Voskuijl
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi; Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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