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Walsh K, Delamare de la Villenaise de Chenevarin G, McGurk J, Maitland K, Frost G. Development of a legume-enriched feed for treatment of severe acute malnutrition. Wellcome Open Res 2023; 6:206. [PMID: 36866283 PMCID: PMC9971697 DOI: 10.12688/wellcomeopenres.16771.2] [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] [Accepted: 12/19/2022] [Indexed: 01/28/2023] Open
Abstract
Background: Outcomes in children hospitalised with severe acute malnutrition (SAM) remain poor. The current milk-based formulations focus on restoring weight-gain but fail to address modification of the integrity of the gut barrier and may exacerbate malabsorption owing to functional lactase, maltase and sucrase deficiency. We hypothesise that nutritional feeds should be designed to promote bacterial diversity and restore gastrointestinal (GI) barrier function. Methods: Our major objective was to develop a lactose-free, fermentable carbohydrate-containing alternative to traditional F75 and F100 formulae for the inpatient treatment of SAM. New target nutritional characteristics were developed and relevant food and infant food specific legislation were reviewed. Suitable certified suppliers of ingredients were identified. Processing and manufacture steps were evaluated and optimised for safety (nutritional, chemical and microbiological), and efficacy at meeting target characteristics (lactose-free, containing resistant starch 0.4-0.5% final product weight). Results: A final validated production process was developed and implemented to produce a novel food product for the inpatient treatment of SAM in children in Africa designed to reduce risk of osmotic diarrhoea and support symbiotic gut microbial populations. The final product matched the macronutrient profile of double-concentrated F100, adhered to all relevant legislation regulating infant foods, was lactose free, and contained 0.6% resistant starch. Chickpeas were selected as the source of resistant starch, since they are widely grown and eaten throughout Africa. Micronutrient content could not be matched in this ready-to-use product, so this was replaced at the point of feeding, as was fluid lost through concentration. Conclusions: The processes and product described illustrate the development steps for a novel nutritional product. The new feed product was ready for evaluation for safety and efficacy in a phase II clinical trial in Ugandan children admitted to hospital with SAM (Modifying Intestinal MicroBiome with Legume-Based feed 2: MIMBLE feed 2 (ISRCTN10309022)).
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Affiliation(s)
- Kevin Walsh
- Section for Nutrition Research, Department of Medicine,, Imperial College London,, London, W12 ONN, UK
| | | | - Joe McGurk
- Production and Processing Research Department, Campden BRI Group, Chipping Campden, GL55 6LD, UK
| | - Kathryn Maitland
- Department of Infectious Disease and Institute of Global Health and Innovation, Division of Medicine, Imperial College London, London, W2 1PG, UK
- Clinical, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya, PO Box 230, Kenya
| | - Gary Frost
- Section for Nutrition Research, Department of Medicine,, Imperial College London,, London, W12 ONN, UK
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Renzaho AMN, Dachi G, Ategbo E, Chitekwe S, Doh D. Pathways and approaches for scaling-up of community-based management of acute malnutrition programs through the lens of complex adaptive systems in South Sudan. Arch Public Health 2022; 80:203. [PMID: 36064608 PMCID: PMC9442594 DOI: 10.1186/s13690-022-00934-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Funds for community-based management of acute malnutrition (CMAM) programs are short-term in nature. CMAM programs are implemented in countries with weak policies and health systems and are primarily funded by donors. Beyond operational expansion, their institutionalisation and alignment with governments’ priorities are poorly documented. The study aimed to identify pathway opportunities and approaches for horizontal and vertical scaling up of CMAM programs in South Sudan. Methods The study was conducted in South Sudan between August and September 2021 using an online qualitative survey with 31 respondents from policy and implementing organisations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework guided the study’s design. It was self-administered through the Qualtrics platform. We used Qualitative Content Analysis supported by the Nvivo coding process. A deductive a priori template of codes approach was complemented by a data-driven inductive approach to develop the second level of interpretive understanding. Results Findings from the study demonstrate that the emphasis of CMAM programs was horizontal scaling up, characterised by geographic distribution and coverage as well as operational expansion. Main challenges have included unsustainable funding models, the inadequacy of existing infrastructure, high operational costs, cultural beliefs, and access-related barriers. Factor impacting access to CMAM programs have been geographical terrains, safety, and security concerns. Vertical scaling up, which emphasises institutional and ownership strengthening through a sound policy, regulatory, and fiscal environment, received relatively little attention. Nutrition supplies are not part of the government’s essential drug list and there is limited or no budgetary allocation for nutrition programs by the government in national budgets and fiscal strategies. Factors constraining vertical scalability have included weak government systems and capacity, a lack of advocacy and lobbying opportunities, and an apparent lack of exits strategies. Conclusion Addressing the scalability problems of CMAM programs in South Sudan demands a delicate balancing act that prioritises both horizontal and vertical scalability. Government and political leadership that harness multidisciplinary and multi-sectoral coordination are required. There is a need to increase policy commitment to malnutrition and associated budgetary allocation, emphasise local resource mobilisation, and ensure financial sustainability of integrating CMAM programs into the existing health and welfare system. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-022-00934-y.
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Renzaho AMN, Dachi G, Tesfaselassie K, Abebe KT, Kassim I, Alam Q, Shaban NS, Shiweredo T, Vinathan H, Jaiswal C, Abraham HM, Miluwa KA, Mahumud RA, Ategbo E, Ndiaye B, Ayoya MA. Assessing the Impact of Integrated Community-Based Management of Severe Wasting Programs in Conflict-Stricken South Sudan: A Multi-Dimensional Approach to Scalability of Nutrition Emergency Response Programs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179113. [PMID: 34501705 PMCID: PMC8431605 DOI: 10.3390/ijerph18179113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/16/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022]
Abstract
Community-based management of severe wasting (CMSW) programs have solely focused on exit outcome indicators, often omitting data on nutrition emergency preparedness and scalability. This study aimed to document good practices and generate evidence on the effectiveness and scalability of CMSW programs to guide future nutrition interventions in South Sudan. A total of 69 CMSW program implementation documents and policies were authenticated and retained for analysis, complemented with the analyses of aggregated secondary data obtained over five (2016-2020 for CMSW program performance) to six (wasting prevention) years (2014-2019). Findings suggest a strong and harmonised coordination of CMSW program implementation, facilitated timely and with quality care through an integrated and harmonised multi-agency and multidisciplinary approach. There were challenges to the institutionalisation and ownership of CMSW programs: a weak health system, fragile health budget that relied on external assistance, and limited opportunities for competency-based learning and knowledge transfer. Between 2014 and 2019, the prevalence of wasting fluctuated according to the agricultural cycle and remained above the emergency threshold of 15% during the July to August lean season. However, during the same period, under-five and crude mortality rates (10,000/day) declined respectively from 1.17 (95% confidence interval (CI): 0.91, 1.43) and 1.00 (95% CI: 0.75, 1.25) to 0.57 (95% CI: 0.38, 0.76) and 0.55 (95% CI: 0.39, 0.70). Both indicators remained below the emergency thresholds, hence suggesting that the emergency response was under control. Over a five-year period (2016-2020), a total of 1,105,546 children (52% girls, 48% boys) were admitted to CMSW programs. The five-year pooled performance indicators (mean [standard deviations]) was 86.4 (18.9%) for recovery, 2.1 (7.8%) for deaths, 5.2 (10.3%) for defaulting, 1.7 (5.7%) for non-recovery, 4.6 (13.5%) for medical transfers, 2.2 (4.7%) for relapse, 3.3 (15.0) g/kg/day for weight gain velocity, and 6.7 (3.7) weeks for the length of stay in the program. In conclusion, all key performance indicators, except the weight gain velocity, met or exceeded the Humanitarian Charter and Minimum Standards in Humanitarian Response. Our findings demonstrate the possibility of implementing robust and resilient CMSAM programs in protracted conflict environments, informed by global guidelines and protocols. They also depict challenges to institutionalisation and ownership.
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Affiliation(s)
- Andre M. N. Renzaho
- Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, NSW 2560, Australia
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC 3004, Australia
- Correspondence: ; Tel.: +612-4620-3506
| | - Gilbert Dachi
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Kibrom Tesfaselassie
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Kiross Tefera Abebe
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Ismail Kassim
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Qutab Alam
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Nawal Sadick Shaban
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Tesfatsion Shiweredo
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Hari Vinathan
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Chandrakala Jaiswal
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Hellen Martin Abraham
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | | | - Rashidul Alam Mahumud
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia;
| | - Eric Ategbo
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Biram Ndiaye
- UNICEF Somalia, RA International Compound, Aden Adde International Airport Area, Mogadishu, Somalia; (B.N.); (M.A.A.)
| | - Mohamed Ag Ayoya
- UNICEF Somalia, RA International Compound, Aden Adde International Airport Area, Mogadishu, Somalia; (B.N.); (M.A.A.)
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Walsh K, Delamare de la Villenaise de Chenevarin G, McGurk J, Maitland K, Frost G. Development of a legume-enriched feed for treatment of severe acute malnutrition. Wellcome Open Res 2021; 6:206. [PMID: 36866283 PMCID: PMC9971697 DOI: 10.12688/wellcomeopenres.16771.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Outcomes in children hospitalised with severe acute malnutrition (SAM) remain poor. The current milk-based formulations focus on restoring weight-gain but fail to address modification of the integrity of the gut barrier and may exacerbate malabsorption owing to functional lactase, maltase and sucrase deficiency. We hypothesise that nutritional feeds should be designed to promote bacterial diversity and restore gastrointestinal (GI) barrier function. Methods: Our major objective was to develop a lactose-free, fermentable carbohydrate-containing alternative to traditional F75 and F100 formulae for the inpatient treatment of SAM. New target nutritional characteristics were developed and relevant food and infant food specific legislation were reviewed. Suitable certified suppliers of ingredients were identified. Processing and manufacture steps were evaluated and optimised for safety (nutritional, chemical and microbiological), and efficacy at meeting target characteristics (lactose-free, containing resistant starch 0.4-0.5% final product weight). Results: A final validated production process was developed and implemented to produce a novel food product for the inpatient treatment of SAM in children in Africa designed to reduce risk of osmotic diarrhoea and support symbiotic gut microbial populations. The final product matched the macronutrient profile of double-concentrated F100, adhered to all relevant legislation regulating infant foods, was lactose free, and contained 0.6% resistant starch. Chickpeas were selected as the source of resistant starch, since they are widely grown and eaten throughout Africa. Micronutrient content could not be matched in this ready-to-use product, so this was replaced at the point of feeding, as was fluid lost through concentration. Conclusions: The processes and product described illustrate the development steps for a novel nutritional product. The new feed product was ready for evaluation for safety and efficacy in a phase II clinical trial in Ugandan children admitted to hospital with SAM (Modifying Intestinal MicroBiome with Legume-Based feed 2: MIMBLE feed 2 (ISRCTN10309022)).
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Affiliation(s)
- Kevin Walsh
- Section for Nutrition Research, Department of Medicine,, Imperial College London,, London, W12 ONN, UK
| | | | - Joe McGurk
- Production and Processing Research Department, Campden BRI Group, Chipping Campden, GL55 6LD, UK
| | - Kathryn Maitland
- Department of Infectious Disease and Institute of Global Health and Innovation, Division of Medicine, Imperial College London, London, W2 1PG, UK
- Clinical, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya, PO Box 230, Kenya
| | - Gary Frost
- Section for Nutrition Research, Department of Medicine,, Imperial College London,, London, W12 ONN, UK
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Imam A, Hassan-Hanga F, Sallahdeen A, Farouk ZL. A cross-sectional study of prevalence and risk factors for stunting among under-fives attending acute malnutrition treatment programmes in north-western Nigeria: Should these programmes be adapted to also manage stunting? Int Health 2021; 13:262-271. [PMID: 32780808 PMCID: PMC8079315 DOI: 10.1093/inthealth/ihaa043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/15/2020] [Accepted: 07/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background Stunting and severe wasting can co-occur in under-fives, predisposing them to increased risks for morbidity and mortality. The Community Management of Acute Malnutrition (CMAM) programme, which provides outpatient malnutrition care for severely wasted children, has been successful at managing severe wasting, but there are limited data on stunting among entrants into these programmes. Methods We performed secondary analysis of data collected from attendees of two CMAM centres in north-western Nigeria. Using WHO reference standards, we determined the prevalence of concurrent stunting (height/length-for-age <-2 SD) among severely wasted children (weight-for-height z-scores <-3 SD). We identified individual and household-level risk factors for concurrent stunting using multivariable logistic regression analysis. Results Our cohort comprised 472 severely wasted children and the majority (82.8%) were stunted. Age groups of 12–23 mo (adjusted OR [AOR]=2.38, 95% CI 1.26 to 4.48) and 24–35 mo (AOR=7.81, 95% CI 1.99 to 30.67), male gender (AOR=2.51, 95% CI 1.43 to 4.39) and attending the rural malnutrition clinic (AOR=3.08, 95% CI 1.64 to 5.79) were associated with a significantly increased probability of stunting. Conclusions Stunting prevalence is high among severely wasted children attending CMAM programmes in north-western Nigeria. Policymakers need to adapt these treatment programmes to also cater for stunting, taking into account practical programmatic realities such as available expertise and scarce resource allocation.
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Affiliation(s)
- Abdulazeez Imam
- Department of Vaccines and Immunity, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Atlantic Boulevard, P.O. Box 452, Fajara, Gambia
| | - Fatimah Hassan-Hanga
- Department of Paediatrics, Bayero University Kano, Department of Paediatrics, Aminu Kano Teaching Hospital, P.M.B 3452, Kano, Nigeria
| | - Azeezat Sallahdeen
- Department of Vaccines and Immunity, Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, Atlantic Boulevard, P.O. Box 452, Fajara, Gambia
| | - Zubaida L Farouk
- Department of Paediatrics, Bayero University Kano, Department of Paediatrics, Aminu Kano Teaching Hospital, P.M.B 3452, Kano, Nigeria
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Bitew ZW, Alemu A, Worku T. Treatment outcomes of severe acute malnutrition and predictors of recovery in under-five children treated within outpatient therapeutic programs in Ethiopia: a systematic review and meta-analysis. BMC Pediatr 2020; 20:335. [PMID: 32631260 PMCID: PMC7339430 DOI: 10.1186/s12887-020-02188-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/02/2020] [Indexed: 12/03/2022] Open
Abstract
Background Severe acute malnutrition affects around 17 million under-five children in the world, of which the highest burden is accounted by Sub-Saharan Africa where Ethiopia is found. Though there are few individual, inconsistent and inconclusive studies, there is no nationally representative study on treatment outcomes of SAM in outpatient therapeutic feeding programs of Ethiopia. This study aimed at estimating the pooled treatment outcomes and predictors of recovery rate among under- five children with SAM in Ethiopia. Methods Electronic databases (PubMed, Medline (EBSCOhost), EMBASE (Elsevier), CINAHL (EBSCOhost), web of science, Scopus, Science Direct and Food Science and Technology Abstracts (FSTA)), and grey literature sources (Google scholar, Mednar, World Cat and google) were used to retrieve articles. The random effect model was used to estimate the pooled treatment outcomes. Hazard ratios were used to determine the predictors of recovery rate. Cochran’s Q, I2, and univariate Meta regression were done for heterogeneity. Begg’s & Egger’s tests were used for publication bias. Results Nineteen articles with a total number of 23,395 under-five children with SAM were used for this meta-analysis. The pooled recovery, death, defaulter and non-recovery rates were 70% (95% CI: 64, 76), 2% (95% CI: 1, 2), 10% (95%CI: 7, 12), 15% (95% CI: 10, 20), respectively. Diarrhea (HR = 0.8, 95% CI: 0.75, 0.94), no edema (HR = 0.41, 95% CI: 0.33, 0.50) and amoxicillin (HR = 1.81, 95% CI: 1.18, 2.44) were independent predictors of recovery rate of children with SAM in Ethiopia. Publication year was found to be the potential source of heterogeneity between included studies. Conclusion The treatment outcomes of children with SAM from outpatient therapeutic feeding programs of Ethiopia are lower than the sphere guidelines, WHO and national recommendations. Diarrhea and no edema antagonized the recovery rate of children, while amoxicillin enhanced the recovery rate of children from SAM. Community health workers need to be trained. Especial attention should be given while treating children with diarrhea and severe wasting. Community mobilization is also recommended to improve community awareness about the therapeutic foods.
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Tewabe T, Belachew A. Determinants of Nutritional Status in School-Aged Children in Mecha, Northwest Ethiopia. CURRENT THERAPEUTIC RESEARCH 2020; 93:100598. [PMID: 32939225 PMCID: PMC7476852 DOI: 10.1016/j.curtheres.2020.100598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 07/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Globally, about 50 million children younger than age 5 years experience wasting; of these 16 million (2.4%) are severely wasted. In Ethiopia, about 9% of the children are severely underweight, 10% are wasted, and 3% are severely wasted. OBJECTIVE The purpose of this study was to determine the risk factors that could lead to underweight, stunting, and wasting among school-aged children in Mecha, northwest Ethiopia, along with their magnitude. METHODS A community-based cross-sectional study was conducted in Mecha, northwest Ethiopia from April 1, 2018, to June 15, 2018. The study enrolled 422 school-aged children. A pretested interviewer-administered structured questionnaire was used to collect the data. Binary logistic regression analysis was used for data analysis. RESULTS The prevalence of underweight, wasting, and stunting were 5.8%, 10.8%, and 11.6%, respectively. Access to school-based feeding was significantly associated with a lower level of underweight (adjusted odds ratio [AOR] = 0.137; 95% CI, 0.020-0.921), and claimed decreased frequency of feeding during illness was associated with a higher level of wasting (AOR = 3.307; 95% CI, 1.025-10.670). Furthermore, younger age of the child (AOR = 16.721; 95% CI, 3.314-84.357), mother's age between 18 and 45 years (AOR = 3.474; 95% CI, 1.145-10.544), and increased frequency of feeding (AOR = 0.270; 95% CI, 0.098-0.749) were all associated with a lower level of stunting. CONCLUSIONS In this study, the lack of access to school-based feeding was associated with higher level of underweight, and claimed decreased frequency of feeding during illness was associated with wasting. In addition, older age of the child, increase in mother's age, and decreased frequency of feeding were associated with higher levels of stunting. The associations suggest that increased access to both school-based feeding and frequency of feeding might improve the nutritional status of school-aged Ethiopian children. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX) © 2020 Elsevier HS Journals, Inc.
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Affiliation(s)
- Tilahun Tewabe
- Global Health Department, Australian national University, Canberra, Australian Capital Territory, Australia
- Pediatric and child health, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Amare Belachew
- Pediatric and child health, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
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Dalglish SL, Seni Badou M, Sirat A, Abdullahi O, Adalbert MFE, Biotteau M, Goldsmith A, Kozuki N. Combined protocol for severe and moderate acute malnutrition in emergencies: Stakeholders perspectives in four countries. MATERNAL AND CHILD NUTRITION 2019; 16:e12920. [PMID: 31773867 PMCID: PMC7083443 DOI: 10.1111/mcn.12920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/07/2019] [Accepted: 11/11/2019] [Indexed: 12/29/2022]
Abstract
Each year, acute malnutrition affects an estimated 52 million children under 5 years of age. Current global treatment protocols divide treatment of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) despite malnutrition being a spectrum disease. A proposed Combined Protocol provides for (a) treatment of MAM and SAM at the same location; (b) diagnosis using middle‐upper‐arm circumference (MUAC) and oedema only; (c) treatment using a single product, ready‐to‐use‐therapeutic food (RUTF), and (d) a simplified dosage schedule for RUTF. This study examines stakeholders' knowledge of and opinions on the Combined Protocol in Niger, Nigeria, Somalia, and South Sudan. Data collection included a document review followed by in‐depth interviews with 50 respondents from government, implementing partners, and multilateral agencies, plus 11 global and regional stakeholders. Data were analysed iteratively using thematic content analysis. We find that acute malnutrition protocols in these countries have not been substantially modified to include components of the Combined Protocol, although aspects were accepted for use in emergencies. Respondents generally agreed that MAM and SAM treatment should be provided in the same location, however they said MUAC and oedema‐only diagnosis, although more field‐ready than other diagnostic measures, did not necessarily catch all malnourished children and may not be appropriate for “tall and slim” morphologies. Similarly, using only RUTF presented inherent logistical advantages, but respondents worried about pipeline issues. Respondents did not express strong opinions about simplified dosage schedules. Stakeholders interviewed indicated more evidence is needed on the operational implications and effectiveness of the Combined Protocol in different contexts.
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Affiliation(s)
- Sarah L Dalglish
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Amin Sirat
- Nutrition Department, International Rescue Committee, Maiduguri, Nigeria
| | - Omar Abdullahi
- Nutrition Department, International Rescue Committee, Mogadishu, Somalia
| | | | - Marie Biotteau
- Nutrition Department, International Rescue Committee, Bamako, Mali
| | - Amelia Goldsmith
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Naoko Kozuki
- Nutrition Department, International Rescue Committee, Washington, DC, USA
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Hossain MI, Huq S, Islam MM, Ahmed T. Acceptability and efficacy of ready-to-use therapeutic food using soy protein isolate in under-5 children suffering from severe acute malnutrition in Bangladesh: a double-blind randomized non-inferiority trial. Eur J Nutr 2019; 59:1149-1161. [PMID: 31037340 DOI: 10.1007/s00394-019-01975-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 04/18/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Globally, around 20 million children suffer from severe acute malnutrition (SAM). Identifying a more economical treatment for those affected has the potential to make treatment more available and improve prognosis for recovery and future health. DESIGN/METHODS The double-blind randomized study compared taste acceptability (measured by the eagerness to eat) and efficacy of soy-based RUTF (S-RUTF) with milk-based RUTF (M-RUTF) in 6- to 59-month-old children suffering from SAM (WHZ < -3) at icddr,b, in Bangladesh. These SAM children were enrolled in the study after completion of their stabilization phase of treatment. Tolerance of test-RUTF was also tested during the efficacy trial. RESULTS The cross-over taste acceptability study, conducted in 36 children, revealed similar results between products and an absence of side effects. The efficacy trial enrolled 260 children (130, each group) with similar baseline characteristics, including mean ± SD age 15.0 ± 8.0 months, WHZ - 3.41 ± 0.40 and mid-upper arm circumference (MUAC) 11.1 ± 0.7 cm. The features at the end of study by RUTF group were (in S-RUTF vs. M-RUTF, respectively): total days from enrollment: 44 ± 34 versus 39 ± 30; weight gain (kg): 0.698 ± 0.438 versus 0.741 ± 0.381 and rate of weight gain (g/kg/d): 3.9 ± 3.2 versus 5.2 ± 4.6; MUAC gain (cm): 0.9 ± 0.7 versus 0.9 ± 0.6; and improvement of WHZ: 1.12 ± 0.82 versus 1.22 ± 0.68 (all data were man ± SD and none were significantly different between the groups). At enrollment and the end of intervention, the body composition [total body water (TBW): 70.3 ± 3.2 vs. 69.9 ± 3.5%, and fat: 11.0 ± 4.0 vs.11.5 ± 4.3% at baseline; and TBW: 65.5 ± 4.1 vs. 65.9 ± 4.6%; and fat: 16.8 ± 5.2 vs. 16.2 ± 5.8% in S-RUTF and M-RUTF group, respectively] was found similar. Moreover, the increment of total TBW, FM, and FFM was also observed similar between the groups. CONCLUSIONS This is the first randomized trial comparing S-RUTF using soy protein isolate with milk-based RUTF including comparison of body composition. S-RUTF was found equally acceptable as of milk-based RUTF without any adverse event. Children receiving S-RUTF showed similar pattern of changes in anthropometric indices, and body composition as of milk-based RUTF. Greater number of SAM children can be managed in the community with comparatively low-cost soy-based RUTF. TRIAL REGISTRATION NCT01634009.
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Affiliation(s)
- Md Iqbal Hossain
- Child Malnutrition Unit, Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, 1212, Bangladesh. .,James P Grant School of Public Health, Brac University, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Sayeeda Huq
- Child Malnutrition Unit, Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, 1212, Bangladesh
| | - M Munirul Islam
- Child Malnutrition Unit, Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, 1212, Bangladesh
| | - Tahmeed Ahmed
- Child Malnutrition Unit, Nutrition and Clinical Services Division, icddr,b, Mohakhali, Dhaka, 1212, Bangladesh.,James P Grant School of Public Health, Brac University, Mohakhali, Dhaka, 1212, Bangladesh
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Munirul Islam M, Arafat Y, Connell N, Mothabbir G, McGrath M, Berkley JA, Ahmed T, Kerac M. Severe malnutrition in infants aged <6 months-Outcomes and risk factors in Bangladesh: A prospective cohort study. MATERNAL & CHILD NUTRITION 2019; 15:e12642. [PMID: 29971955 PMCID: PMC6586027 DOI: 10.1111/mcn.12642] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/29/2018] [Accepted: 06/06/2018] [Indexed: 11/28/2022]
Abstract
Severe acute malnutrition (SAM) affects ~4 million infants under 6 months (u6m) worldwide, but evidence underpinning their care is "very low" quality. To inform future research and policy, the objectives of our study were to identify risk factors for infant u6m SAM and describe the clinical and anthropometric outcomes of treatment with current management strategies. We conducted a prospective cohort study in infants u6m in Barisal district, Bangladesh. One group of 77 infants had SAM (weight-for-length Z-score [WLZ] <-3 and/or bipedal oedema); 77 others were "non-SAM" (WLZ ≥-2 to <+2, no oedema, mid-upper-arm circumference ≥125 mm). All were enrolled at 4-8 weeks of age and followed up at 6 months. Maternal education and satisfaction with breastfeeding were among factors associated with SAM. Duration of exclusive breastfeeding was shorter at enrolment (3·9 ± 2.1 vs. 5.7 ± 2.2 weeks, P < 0.0001) and at age 6 months (13.2 ± 8.9 vs. 17.4 ± 7.9 weeks; P = 0.003) among SAM infants. Despite referral, only 13 (17%) reported for inpatient care, and at 6 months, 18 (23%) infants with SAM still had SAM, and 3 (3.9%) died. In the non-SAM group, one child developed SAM, and none died. We conclude that current treatment strategies have limited practical effectiveness: poor uptake of inpatient referral being the main reason. World Health Organization recommendations and other intervention strategies of outpatient-focused care for malnourished but clinically stable infants u6m need to be tested. Breastfeeding support is likely central to future treatment strategies but may be insufficient alone. Better case definitions of nutritionally at-risk infants are also needed.
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Affiliation(s)
- M. Munirul Islam
- Nutrition and Clinical Services DivisionInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b)DhakaBangladesh
| | - Yasir Arafat
- Department of Health and NutritionSave the Children BangladeshDhakaBangladesh
| | - Nichola Connell
- Department of Global HealthSave the Children USAWashingtonDistrict of ColumbiaUSA
| | - Golam Mothabbir
- Department of Health and NutritionSave the Children BangladeshDhakaBangladesh
| | | | - James A. Berkley
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya
- The Childhood Acute Illness & Nutrition Network (CHAIN)NairobiKenya
| | - Tahmeed Ahmed
- Nutrition and Clinical Services DivisionInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b)DhakaBangladesh
| | - Marko Kerac
- Department for Population Health & MARCH CentreLondon School of Hygiene & Tropical MedicineLondonUK
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11
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Ireen S, Raihan MJ, Choudhury N, Islam MM, Hossain MI, Islam Z, Rahman SMM, Ahmed T. Challenges and opportunities of integration of community based Management of Acute Malnutrition into the government health system in Bangladesh: a qualitative study. BMC Health Serv Res 2018; 18:256. [PMID: 29631574 PMCID: PMC5892001 DOI: 10.1186/s12913-018-3087-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/29/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) in children is the most serious form of malnutrition and is associated with very high rates of morbidity and mortality. For sustainable SAM management, United Nations recommends integration of community based management of acute malnutrition (CMAM) into the health system. The objective of the study was to assess the preparedness of the health system to implement CMAM in Bangladesh. METHODS The assessment was undertaken during January to May 2014 by conducting document review, key informant interviews, and direct observation. A total of 38 key informant interviews were conducted among government policy makers and program managers (n = 4), nutrition experts (n = 2), health and nutrition implementing partners (n = 2), development partner (n = 1), government health system staff (n = 5), government front line field workers (n = 22), and community members (n = 2). The assessment was based on: workforce, service delivery, financing, governance, information system, medical supplies, and the broad socio-political context. RESULTS The government of Bangladesh has developed inpatient and outpatient guidelines for the management of SAM. There are cadres of community health workers of government and non-government actors who can be adequately trained to conduct CMAM. Inpatient management of SAM is available in 288 facilities across the country. However, only 2.7% doctors and 3.3% auxiliary staff are trained on facility based management of SAM. In functional facilities, uninterrupted supply of medicines and therapeutic diet are not available. There is resistance and disagreement among nutrition stakeholders regarding import or local production of ready-to-use therapeutic food (RUTF). Nutrition coordination is fragile and there is no functional supra-ministerial coordination platform for multi-sectoral and multi-stakeholder nutrition. CONCLUSION There is an enabling environment for CMAM intervention in Bangladesh although health system strengthening is needed considering the barriers that have been identified. Training of facility based health staff, government community workers, and ensuring uninterrupted supply of medicines and logistics to the functional facilities should be the immediate priorities. Availability of ready-to-use therapeutic food (RUTF) is a critical component of CMAM and government should promote in-country production of RUTF for effective integration of CMAM into the health system in Bangladesh.
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Affiliation(s)
- Santhia Ireen
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammad Jyoti Raihan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Nuzhat Choudhury
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - M. Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ziaul Islam
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - S. M. Mustafizur Rahman
- Institute of Public Health Nutrition and National Nutrition Services, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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12
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Chitekwe S, Biadgilign S, Tolla A, Myatt M. Mid-upper-arm circumference based case-detection, admission, and discharging of under five children in a large-scale community-based management of acute malnutrition program in Nigeria. ACTA ACUST UNITED AC 2018; 76:19. [PMID: 29657713 PMCID: PMC5890342 DOI: 10.1186/s13690-018-0266-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 02/20/2018] [Indexed: 11/10/2022]
Abstract
Background Severe acute malnutrition (SAM) threatens the lives of millions of children worldwide particularly in low and middle-income countries (LMICs). Community-based management of acute malnutrition (CMAM) is an approach to treating large numbers of cases of severe acute malnutrition (SAM) in a community setting. There is a debate about the use of mid-upper arm circumference (MUAC) for admitting and discharging SAM children. This article describes the experience of using MUAC for screening, case-finding, referral, admission, and discharge in a large-scale CMAM program delivered through existing primary health care facilities in Nigeria. Methods Over one hundred thousand (n = 102,245) individual CMAM beneficiary records were collected from two of the eleven states (i.e. Katsina and Jigawa) that provide CMAM programming in Nigeria. The data were double entered and checked using EpiData version 3.2 and analyzed using the R language for data-analysis graphics. Results The median MUAC at admission was 109 mm. Among admissions, 37.4% (38,275) had a comorbidity recorded at admission and 7.4% (7537) were recorded as having developed comorbidity during the treatment. Analysis in the better performing state program in the most recent year for which data were available found that 87.1% (n = 13,273) of admitted cases recovered and were discharged as cured, 9.2% (n = 1396) defaulted and were lost to follow-up, 2.9% (n = 443) were discharged as non-recovered, 0.7% (n = 104) were transferred to inpatient services, and 0.2% (n = 27) were known (died, to be dead or to have passed) during the treatment episode. The program met SPHERE minimum standards for treatment outcomes for therapeutic feeding programs. Factors associated with negative outcomes (default, non-recovery, transfer, and death) were distance between home and the treatment center; lower MUAC, diarrhea and cough at admission; or developing diarrhea, vomiting, fever, or cough during the treatment episode. Conclusions This study confirms that MUAC can be used for both admitting and discharging criteria in CMAM programs with MUAC < 115 mm for admission and MUAC > = 115 mm or at discharge (a higher discharge threshold could be used). Long distances between home and treatment centers, lower MUAC at admission, or having diarrhea, vomiting, fever, or cough during the treatment episode were factors associated with negative outcome. Providing CMAM services closer to the community, using mobile and / or satellite clinics, counseling of mothers by health workers to encourage early treatment seeking behavior, and screening of patients at each patient visit for early detection and treatment of comorbidities are recommended.
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Affiliation(s)
- Stanley Chitekwe
- United Nations Children's Fund (UNICEF), Nigeria country office, UN House, Plot 617/618 Central Area District Diplomatic Zone, Garki, Abuja, P M B 2851 Nigeria
| | - Sibhatu Biadgilign
- United Nations Children's Fund (UNICEF), Nigeria country office, UN House, Plot 617/618 Central Area District Diplomatic Zone, Garki, Abuja, P M B 2851 Nigeria
| | - Assaye Tolla
- United Nations Children's Fund (UNICEF), Nigeria country office, UN House, Plot 617/618 Central Area District Diplomatic Zone, Garki, Abuja, P M B 2851 Nigeria
| | - Mark Myatt
- Consultant Epidemiologist, Brixton Health, Llawryglyn, Wales UK
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13
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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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14
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Tadesse E, Worku A, Berhane Y, Ekström EC. An integrated community-based outpatient therapeutic feeding programme for severe acute malnutrition in rural Southern Ethiopia: Recovery, fatality, and nutritional status after discharge. MATERNAL AND CHILD NUTRITION 2017; 14:e12519. [PMID: 29024381 PMCID: PMC5900575 DOI: 10.1111/mcn.12519] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/07/2017] [Accepted: 08/30/2017] [Indexed: 11/28/2022]
Abstract
A scaled up and integrated outpatient therapeutic feeding programme (OTP) brings the treatment of severely malnourished children closer to the community. This study assessed recovery from severe acute malnutrition (SAM), fatality, and acute malnutrition up to 14 weeks after admission to a programme integrated in the primary health care system. In this cohort study, 1,048 children admitted to 94 OTPs in Southern Ethiopia were followed for 14 weeks. Independent anthropometric measurements and information on treatment outcome were collected at four home visits. Only 32.7% (248/759) of children with SAM on admission fulfilled the programme recovery criteria at the time of discharge (i.e., gained 15% in weight, or oedema, if present at admission, was resolved at discharge). Of all children admitted to the programme for whom nutritional assessment was done 14 weeks later, 34.6% (321/928) were severely malnourished, and 37.5% (348/928) were moderately malnourished; thus, 72.1% were acutely malnourished. Of the children, 27/982 (2.7%) had died by 14 weeks, of whom all but one had SAM on admission. Children with severe oedema on admission had the highest fatality rate (12.0%, 9/75). The median length of admission to the programme was 6.6 weeks (interquartile range: 5.3, 8.4 weeks). Despite children participating for the recommended duration of the programme, many children with SAM were discharged still acutely malnourished and without reaching programme criteria for recovery. For better outcome of OTP, constraints in service provision by the health system as well as challenges of service utilization by the beneficiaries should be identified and addressed.
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Affiliation(s)
- Elazar Tadesse
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Addis Continental Institute of Public Health, Addis Ababa, Ethiopia.,Kotebe Metropolitan University, Addis Ababa, Ethiopia
| | - Amare Worku
- Department of 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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Akparibo R, Harris J, Blank L, Campbell MJ, Holdsworth M. Severe acute malnutrition in children aged under 5 years can be successfully managed in a non-emergency routine community healthcare setting in Ghana. MATERNAL AND CHILD NUTRITION 2017; 13. [PMID: 28185414 DOI: 10.1111/mcn.12417] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 11/15/2016] [Accepted: 11/15/2016] [Indexed: 11/28/2022]
Abstract
This study investigated the performance of community-based management of severe acute malnutrition (CMAM) within routine healthcare services in Ghana. This was a retrospective cohort study of n = 488 children (6-59 months) who had received CMAM. Data for recovery, default, and mortality rates were obtained from enrolment cards in 56 outpatient centres in Upper East region, Ghana. Satisfactory rates of recovery of 71.8% were reported. Children who were enrolled with higher mid-upper arm circumference (MUAC) ≥11.5 cm had seven times greater chance of recovery compared with children who were enrolled with lower MUAC <11.5 cm, OR = 7.35, 95% CI [2.56, 21.15], p < .001. Children who were diagnosed without malaria at baseline were 30 times, OR = 30.39, 95% CI [10.02, 92.13], p < .001, more likely to recover compared with those with malaria (p < .001). The average weight gain was 4.7 g-1 ·kg-1 ·day-1 , which was influenced by MUAC status at baseline, β = .78, 95% CI [0.46, 1.00], p < .001, presence of malaria, β = -1.25, 95% CI [-1.58, 0.92], p < .001, and length of stay, β = 0.13, 95% CI [0.08, 0.18], p < .001. The default rate (28.5%) was higher than international standards recommendations by Sphere. Mortality rate (1.6%) was lower than international standards. Our findings suggest that community-based management of SAM can achieve similar success when delivered in routine non-emergency settings. However, this success can be diluted by a high default rate, and the factors contributing to this need to be explored to improve programme effectiveness within communities.
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Affiliation(s)
- Robert Akparibo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janet Harris
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Lindsay Blank
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike J Campbell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michelle Holdsworth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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16
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Myatt M, Khara T, Collins S. A Review of Methods to Detect Cases of Severely Malnourished Children in the Community for Their Admission into Community-Based Therapeutic Care Programs. Food Nutr Bull 2016; 27:S7-23. [PMID: 17076211 DOI: 10.1177/15648265060273s302] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The complexity and cost of measuring weight-for-height make it unsuitable for use by community-based volunteers. This has led community therapeutic care programs to adopt a two-stage screening and admission procedure in which mid-upper-arm circumference (MUAC) is used for referral and weight-for-height is used for admission. Such a procedure results in many individuals being referred for care on the basis of MUAC but subsequently being refused treatment because they do not meet the weight-for-height admission criterion. This “problem of rejected referrals” has proved to be a major barrier to program uptake. Objective To systematically review methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Methods Clinical and anthropometric methods for case detection of severely malnourished children in the community were reviewed with regard to their ability to reflect both mortality risk and nutritional status. Results MUAC, with the addition of the presence of bipedal edema, was found to be the indicator best suited to screening and case detection of malnutrition in the community. The case definition “MUAC < 110 mm OR the presence of bipedal edema,” with MUAC measured by a color-banded strap, is suitable for screening and case detection of malnutrition in the community for children aged between 6 and 59 months. Monitoring and discharge criteria were also reviewed. Conclusions There is no compelling evidence to support a move away from using weight in combination with clinical criteria for monitoring and discharge.
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Affiliation(s)
- Mark Myatt
- Institute of Ophthalmology, 11-43 Bath St., London EC1V 9EL, UK.
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17
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Manary MJ. Local Production and Provision of Ready-To-Use Therapeutic Food (Rutf) Spread for the Treatment of Severe Childhood Malnutrition. Food Nutr Bull 2016; 27:S83-9. [PMID: 17076214 DOI: 10.1177/15648265060273s305] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Ready-to-use therapeutic food (RUTF) spread has been shown to be very effective in the rehabilitation of severely malnourished children and facilitates home-based therapy of these children. Objective To describe how RUTF spread can be manufactured on a variety of production scales. Principles of production RUTF spread is an edible lipid-based paste that is energy dense, resists bacterial contamination, and requires no cooking. The primary production principles include grinding all ingredients to a particle size < 200 microns, producing the food without the introduction of water, and embedding the protein and carbohydrate components of the food into the lipid matrix. The most widely used RUTF spread is a mixture of milk powder, sugar, vegetable oil, peanut butter, vitamins, and minerals. Scale of production RUTF spread can be produced in quantities sufficient to treat several hundred children using a planetary mixer in a clinic. Production of larger quantities of RUTF spread can be achieved in partnership with local food companies. Production sufficient to meet the needs of several thousand children can be achieved with a dedicated production facility using technology appropriate for use in the developing world. Care must be taken to avoid aflatoxin contamination, and quality control testing of the product is essential. Conclusions RUTF spread can be safely and easily produced in small or large quantities in most settings worldwide. The local availability of the necessary ingredients limits its use in some settings, and further investigation of alternative ingredients is needed to overcome this limitation.
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Affiliation(s)
- Mark J Manary
- Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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18
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Shafiq Y, Saleem A, Lassi ZS, Zaidi AKM. Community-based versus health facility-based management of acute malnutrition for reducing the prevalence of severe acute malnutrition in children 6 to 59 months of age in low- and middle-income countries. Hippokratia 2016. [DOI: 10.1002/14651858.cd010547.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Yasir Shafiq
- Aga Khan University Hospital; Department of Paediatrics and Child Health; Stadium Road PO Box 3500 Karachi Sindh Pakistan 74800
| | - Ali Saleem
- Aga Khan University Hospital; Division of Women and Child Health; Stadium Road PO Box 3500 Karachi Sindh Pakistan 74800
| | - Zohra S Lassi
- The University of Adelaide; The Robinson Research Institute; Adelaide South Australia Australia 5005
| | - Anita KM Zaidi
- Aga Khan University Hospital; Division of Women and Child Health; Stadium Road PO Box 3500 Karachi Sindh Pakistan 74800
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19
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Di Gioia G, Creta A, Fittipaldi M, Giorgino R, Quintarelli F, Satriano U, Cruciani A, Antinolfi V, Di Berardino S, Costanzo D, Bettini R, Mangiameli G, Caricato M, Mottini G. Effects of Malnutrition on Left Ventricular Mass in a North-Malagasy Children Population. PLoS One 2016; 11:e0154523. [PMID: 27140179 PMCID: PMC4854428 DOI: 10.1371/journal.pone.0154523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/14/2016] [Indexed: 01/20/2023] Open
Abstract
Background Malnutrition among children population of less developed countries is a major health problem. Inadequate food intake and infectious diseases are combined to increase further the prevalence. Malnourishment brings to muscle cells loss with development of cardiac complications, like arrhythmias, cardiomyopathy and sudden death. In developed countries, malnutrition has generally a different etiology, like chronic diseases. The aim of our study was to investigate the correlation between malnutrition and left ventricular mass in an African children population. Methods 313 children were studied, in the region of Antsiranana, Madagascar, with age ranging from 4 to 16 years old (mean 7,8 ± 3 years). A clinical and echocardiographic evaluation was performed with annotation of anthropometric and left ventricle parameters. Malnutrition was defined as a body mass index (BMI) value age- and sex-specific of 16, 17 and 18,5 at the age of 18, or under the 15th percentile. Left ventricle mass was indexed by height2.7 (LVMI). Results We identified a very high prevalence of children malnutrition: 124 children, according to BMI values, and 100 children under the 15th percentile. LVMI values have shown to be increased in proportion to BMI percentiles ranging from 29,8 ± 10,8 g/m2.7 in the malnutrition group to 45 ± 15,1 g/m2.7 in >95th percentile group. LVMI values in children < 15th BMI percentile were significantly lower compared to normal nutritional status (29,8 ± 10,8 g/m2,7 vs. 32,9 ± 12,1 g/m2,7, p = 0.02). Also with BMI values evaluation, malnourished children showed statistically lower values of LVMI (29,3 ± 10,1 g/m2,7 vs. 33,6 ± 12,5 g/m2,7, p = 0.001). Conclusion In African children population, the malnourishment status is correlated with cardiac muscle mass decrease, which appears to be reduced in proportion to the decrease in body size.
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Affiliation(s)
- Giuseppe Di Gioia
- Department of Medicine and Surgery, Cardiology Unit, Università Campus Bio-Medico di Roma, Rome, Italy
- * E-mail:
| | - Antonio Creta
- Department of Medicine and Surgery, Cardiology Unit, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Mario Fittipaldi
- Paediatric Cardiothoracic Surgery, Starship Greenlane Paediatric and Congenital Heart Service, Auckland, New Zealand
| | - Riccardo Giorgino
- Department of Medicine and Surgery, Cardiology Unit, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Fabio Quintarelli
- Department of Medicine and Surgery, Pediatrics Service, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Umberto Satriano
- Department of Medicine and Surgery, Cardiology Unit, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Alessandro Cruciani
- Department of Medicine and Surgery, Cardiology Unit, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Vincenzo Antinolfi
- Department of Heart and Great Vessels “Attilio Reale”, Sapienza University, Rome, Italy
| | - Stefano Di Berardino
- Department of Medicine and Surgery, Unit of Geriatric Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Davide Costanzo
- Department of Medicine and Surgery, Cardiology Unit, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Giuseppe Mangiameli
- Department of Medicine and Surgery, Unit of Geriatric Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Marco Caricato
- Department of Medicine and Surgery, Unit of Geriatric Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Giovanni Mottini
- Department of Medicine and Surgery, Institute of Philosophy of Scientific and Technological Practice (FAST), Università Campus Bio-Medico di Roma, Rome, Italy
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Ashaba S, Rukundo GZ, Beinempaka F, Ntaro M, LeBlanc JC. Maternal depression and malnutrition in children in southwest Uganda: a case control study. BMC Public Health 2015; 15:1303. [PMID: 26712120 PMCID: PMC4693407 DOI: 10.1186/s12889-015-2644-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 12/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malnutrition remains one of the most significant child health problems in developing countries with an estimated 53% of child deaths per year attributed to being underweight. The 2011 Uganda Demographic and Health Survey (UDHS) showed that 38 % of the children were stunted and 16% were underweight. While dietary and environmental factors are known major contributors to children's nutritional status, maternal depression may also contribute since it disrupts the mothers' ability to cope with demands of childcare. This study aimed to determine the association between maternal depression and malnutrition in children aged one to 5 years in southwest Uganda. METHODS The study was undertaken between October and December 2014 on children aged one to 5 admitted to the Mbarara regional referral hospital. Cases were malnourished children and controls were children with other chronic conditions but normal nutritional status admitted to the same hospital. Children's ages were recorded, weight and height taken and converted into height for age, weight for height and weight for age and malnutrition was determined based on WHO child growth standards. Mothers of both groups of children were assessed for depression using the depression module of the Mini International Neuropsychiatric Interview (MINI). Participants provided informed consent prior to enrollment. The study was approved by Mbarara University of Science and Technology Research Ethics Committee and funded by MicroResearch. RESULTS All 166 mothers who were approached agreed to participate in the study. The prevalence of depression among mothers of malnourished children (86 cases) was 42% compared to 12% among mothers of controls (86 controls). The mean age was 25 years (SD 4.43, range 18-40 years). The majority (75%) were married and most were peasant farmers (62%). Maternal depression was significantly associated with malnutrition in children with a crude odds ratio of 2.23 (1.08-1.89) and an adjusted odds ratio of 2.4 (1.11-5.18). CONCLUSION Maternal depression impacts negatively on child nutrition and development as shown by a higher prevalence of depression among mothers of malnourished children compared to the control group. Routine screening and treatment for depression should be included in all maternal and child health clinics.
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Affiliation(s)
- Scholastic Ashaba
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Godfrey Zari Rukundo
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Florence Beinempaka
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Moses Ntaro
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - John C LeBlanc
- Department of Paediatrics, Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, Canada.
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Clavier-Rogez S, Rogez JB, Labrin L, Branger B, Dabadie A. [Effectiveness of a nutritional program based upon a ready-to-use therapeutic food in Chad]. Arch Pediatr 2015; 22:1247-55. [PMID: 26527501 DOI: 10.1016/j.arcped.2015.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/11/2015] [Accepted: 09/15/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In the health district of Goundi in Chad, 6.7% of children were affected by acute malnutrition in 2011. The purpose of this study was to evaluate the efficacy of a locally made ready-to-use therapeutic food (RUTF). METHODS One hundred sixty-eight children were suffering from severe acute malnutrition (weight-for-height status less than -3 SD or mid-upper arm circumference less than 115mm). The RUTF was made in a specific laboratory. The product consisted of 49% carbohydrates, 33% lipids, 16% proteins, and 1.5% vitamins. Children received daily one packet of RUTF containing 500kcal as outpatient care. RESULTS At inclusion, the average age was 17.4±8.7 months, and the weight-for-height status -3.8±0.9 SD. At the end of the program, we noted recovery in 58.3% of the children, 2.4% unsuccessful treatment, 21.4% lost to follow-up, and 17.9% deaths (60% of which occurred during the first 2 weeks). At the end of the program, the weight-for-height status had increased by 2.1 SD. At recovery, children treated for tuberculosis had a higher weight-for-height status (-1.2±1.5 SD) than the children who were not infected by tuberculosis (-2±1.9 SD) (P<0.005). CONCLUSION Nutritional treatment using RUTF was effective. To improve treatment, early case detection should be improved, as should management of associated infectious diseases.
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Affiliation(s)
- S Clavier-Rogez
- 883, rue de Verdun, 45160 Saint-Hilaire-Saint-Mesmin, France
| | - J-B Rogez
- 883, rue de Verdun, 45160 Saint-Hilaire-Saint-Mesmin, France
| | - L Labrin
- Hôpital de Goundi, BP 84, Sarh, Tchad
| | - B Branger
- Réseau sécurité naissance, 2, rue de la Loire, 44200 Nantes, France
| | - A Dabadie
- Pôle de pédiatrie, hôpital Sud, CHU de Rennes, 16, boulevard de Bulgarie, BP 90347, 35203 Rennes cedex, France.
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Karakochuk CD, van den Briel T, Stephens D, Zlotkin S. Food Sharing Practices in Households Receiving Supplemental Foods for the Treatment of Moderate Acute Malnutrition in Ethiopian Children. JOURNAL OF HUNGER & ENVIRONMENTAL NUTRITION 2015. [DOI: 10.1080/19320248.2014.962772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mogendi JB, De Steur H, Gellynck X, Saeed HA, Makokha A. Efficacy of mid-upper arm circumference in identification, follow-up and discharge of malnourished children during nutrition rehabilitation. Nutr Res Pract 2015; 9:268-77. [PMID: 26060539 PMCID: PMC4460059 DOI: 10.4162/nrp.2015.9.3.268] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 09/12/2014] [Accepted: 09/16/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND/OBJECTIVES Although it is crucial to identify those children likely to be treated in an appropriate nutrition rehabilitation programme and discharge them at the appropriate time, there is no golden standard for such identification. The current study examined the appropriateness of using Mid-Upper Arm Circumference for the identification, follow-up and discharge of malnourished children. We also assessed its discrepancy with the Weight-for-Height based diagnosis, the rate of recovery, and the discharge criteria of the children during nutrition rehabilitation. SUBJECTS/METHODS The study present findings from 156 children (aged 6-59 months) attending a supplementary feeding programme at Makadara and Jericho Health Centres, Eastern District of Nairobi, Kenya. Records of age, weight, height and mid-upper arm circumference were selected at three stages of nutrition rehabilitation: admission, follow-up and discharge. The values obtained were then used to calculate z-scores as defined by WHO Anthro while estimating different diagnostic indices. RESULTS Mid-upper arm circumference single cut-off (< 12.5 cm) was found to exhibit high values of sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio at both admission and discharge. Besides, children recorded higher rate of recovery at 86 days, an average increment of 0.98 cm at the rate of 0.14mm/day, and a weight gain of 13.49gm/day, albeit higher in female than their male counterparts. Nevertheless, children admitted on basis of low MUAC had a significantly higher MUAC gain than WH at 0.19mm/day and 0.13mm/day respectively. CONCLUSIONS Mid-upper arm circumference can be an appropriate tool for identifying malnourished children for admission to nutrition rehabilitation programs. Our results confirm the appropriateness of this tool for monitoring recovery trends and discharging the children thereafter. In principle the tool has potential to minimize nutrition rehabilitation costs, particularly in community therapeutic centres in developing countries.
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Affiliation(s)
- Joseph Birundu Mogendi
- Faculty of Bioscience Engineering, Ghent University, Coupure Links 653, B-9000 Ghent, Belgium. ; Department of Nutrition and Dietetics, School of Health Sciences, Mount Kenya University 342-01000, Thika, Kenya
| | - Hans De Steur
- Faculty of Bioscience Engineering, Ghent University, Coupure Links 653, B-9000 Ghent, Belgium
| | - Xavier Gellynck
- Faculty of Bioscience Engineering, Ghent University, Coupure Links 653, B-9000 Ghent, Belgium
| | - Hibbah Araba Saeed
- School of Health and Related Research, University of Sheffield, (ScHARR); Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | - Anselimo Makokha
- Department of Food Science, Technology and Nutrition, Faculty of Agriculture, Jomo Kenyatta University of Agriculture and Technology, 62000-00200, Nairobi, Kenya
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Anorexia nervosa, seasonality, and polyunsaturated fatty acids. Med Hypotheses 2015; 85:380-2. [PMID: 25981875 DOI: 10.1016/j.mehy.2015.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 04/27/2015] [Accepted: 05/06/2015] [Indexed: 11/24/2022]
Abstract
Anorexia nervosa is a serious neurobehavioral disorder marked by semistarvation, extreme fear of weight gain, frequently hyperactivity, and low body temperature. The etiology remains unknown. We present a speculation that a primary causative factor is that polyunsaturated fatty acids are skewed to prevent oxidative damage in phospholipid membranes. This causes a change in the trade off of oxidation protection vs homeoviscous adaptation to lower temperatures, which sets off a metabolic cascade that leads to the rogue state of anorexia nervosa.
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Abstract
Severe acute malnutrition is a devastating condition afflicting under-5 children in many developing countries, but concentrated in sub-Saharan Africa. This paper examines the development of home-based lipid-nutrient therapeutic foods for the treatment of acute malnutrition in sub-Saharan Africa and the adoption of these therapies as a standard of care for non-complicated cases of acute malnutrition. Several of the early key clinical and operational effectiveness trials are discussed as well as the adoption of home-based treatment as a standard operating procedure in regions where malnutrition is present.
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Manyike PC, Chinawa JM, Ubesie A, Obu HA, Odetunde OI, Chinawa AT. Prevalence of malnutrition among pre-school children in South-east Nigeria. Ital J Pediatr 2014; 40:75. [PMID: 25209154 PMCID: PMC4422405 DOI: 10.1186/s13052-014-0075-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 08/04/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Malnutrition can be defined as a state of nutrition where the weight for age, height for age and weight for height indices are below -2 Z-score of the NCHS reference. It has posed a great economic burden to the developing world. OBJECTIVES The objective of this study is to assess the prevalence of malnutrition among pre-school children in Abakiliki in Ebonyi state of Nigeria. METHODS This is a cross-sectional studies that assess the prevalence of malnutrition and associated factors among children aged 1-5 years attending nursery and primary schools. Nutritional assessment was done using anthropometry and clinical examination. RESULTS A total of 616 children aged one to 5 years were enrolled into this study. Three hundred and sixty-seven (59.6%) were males while 249 (40.4%) were females. Sixty of the 616 children (9.7%) had acute malnutrition based on WHZ-score. Moderate acute malnutrition (MAM) was present in 33 children (5.3%) while 27 (4.4%) had severe acute malnutrition. CONCLUSIONS The prevalence of global and severe acute malnutrition using z-score is 9.7% and 4.4% respectively while that of stunting is 9.9% with a male preponderance.
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Affiliation(s)
- Pius C Manyike
- Federal Teaching Hospital Abakiliki, Abakiliki, Nigeria.
| | - Josephat M Chinawa
- Department of pediatrics, University of Nigeria/University of Nigeria Teaching Hospital (UNTH), Ituku- Ozalla, Enugu State, Nigeria.
| | - Agozie Ubesie
- Department of pediatrics, University of Nigeria/University of Nigeria Teaching Hospital (UNTH), Ituku- Ozalla, Enugu State, Nigeria.
| | - Herbert A Obu
- Department of pediatrics, University of Nigeria/University of Nigeria Teaching Hospital (UNTH), Ituku- Ozalla, Enugu State, Nigeria.
| | - Odutola I Odetunde
- Department of pediatrics, University of Nigeria/University of Nigeria Teaching Hospital (UNTH), Ituku- Ozalla, Enugu State, Nigeria.
| | - Awoere T Chinawa
- Department of Community Medicine, University of Nigeria/University of Nigeria Teaching Hospital (UNTH), Ituku- Ozalla, Enugu State, Nigeria.
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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: 125] [Impact Index Per Article: 12.5] [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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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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Cercamondi CI, Egli IM, Mitchikpe E, Tossou F, Hessou J, Zeder C, Hounhouigan JD, Hurrell RF. Iron bioavailability from a lipid-based complementary food fortificant mixed with millet porridge can be optimized by adding phytase and ascorbic acid but not by using a mixture of ferrous sulfate and sodium iron EDTA. J Nutr 2013; 143:1233-9. [PMID: 23761652 DOI: 10.3945/jn.113.175075] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Home fortification with lipid-based nutrient supplements (LNSs) is a promising approach to improve bioavailable iron and energy intake of young children in developing countries. To optimize iron bioavailability from an LNS named complementary food fortificant (CFF), 3 stable isotope studies were conducted in 52 young Beninese children. Test meals consisted of millet porridge mixed with CFF and ascorbic acid (AA). Study 1 compared iron absorption from FeSO4-fortifed meals with meals fortified with a mixture of FeSO4 and NaFeEDTA. Study 2 compared iron absorption from FeSO4-fortifed meals without or with extra AA. Study 3 compared iron absorption from FeSO4-fortified meals with meals containing phytase added prior to consumption, once without or once with extra AA. Iron absorption was measured as erythrocyte incorporation of stable isotopes. In study 1, iron absorption from FeSO4 (8.4%) was higher than that from the mixture of NaFeEDTA and FeSO4 (5.9%; P < 0.05). In study 2, the extra AA increased absorption (11.6%) compared with the standard AA concentration (7.3%; P < 0.001). In study 3, absorption from meals containing phytase without or with extra AA (15.8 and 19.9%, respectively) increased compared with meals without phytase (8.0%; P < 0.001). The addition of extra AA to meals containing phytase increased absorption compared with the test meals containing phytase without extra AA (P < 0.05). These findings suggest that phytase and AA, and especially a combination of the two, but not a mixture of FeSO4 and NaFeEDTA would be useful strategies to increase iron bioavailability from a CFF mixed with cereal porridge.
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Affiliation(s)
- Colin I Cercamondi
- Laboratory of Human Nutrition, Institute of Food, Nutrition and Health, ETH Zurich, Zurich, Switzerland.
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Dijkzeul D, Hilhorst D, Walker P. Introduction: evidence-based action in humanitarian crises. DISASTERS 2013; 37 Suppl 1:S1-S19. [PMID: 23905762 DOI: 10.1111/disa.12009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This introductory paper sets the stage for this special issue of Disasters on evidence-based action in humanitarian crises. It reviews definition(s) of evidence and it examines the different disciplinary and methodological approaches to collecting and analysing evidence. In humanitarian action, the need for evidence-based approaches sometimes is viewed in tension with a principled approach, often unnecessarily. Choosing appropriate research methods depends on the objectives of the researcher, in particular whether the research focuses on the intervention and/or the context and the length and complexity of the causal chains involved. The paper concludes by defining some trends in evidence-based approaches in crises: the move away from inputs and outputs of humanitarian action towards outcomes and impacts; the shift towards a higher degree of partnerships in research, and the participation of users and target groups; and the acceptance of a broad array of approaches to establish evidence.
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Affiliation(s)
- Dennis Dijkzeul
- Ruhr University Bochum, Universitätsstraße 150, Bochum, Germany.
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Jayatissa R, Bekele A, Kethiswaran A, de Silva AH. Community-Based Management of Severe and Moderate Acute Malnutrition during Emergencies in Sri Lanka: Challenges of Implementation. Food Nutr Bull 2012; 33:251-60. [DOI: 10.1177/156482651203300405] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background With the documentation of high rates of acute malnutrition in children under 5 years of age, the Ministry of Health of Sri Lanka established a Nutrition Rehabilitation Program in Jaffna District of the Northern Province. Objective To assess the impact of community-based management of acute malnutrition among children under 5 years of age and its operational challenges. Methods The Nutrition Rehabilitation Program was introduced and implemented in phases covering the entire district and was integrated into the routine healthcare system from the beginning. Children were categorized into severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) groups according to World Health Organization weight-for-height growth standards. Children with SAM were given ready-to-use-therapeutic food (RUTF), and children with MAM were given 100 g (450 kcal) of high-energy biscuits (HEBs) provided by UNICEF. All children received daily supplementary food consisting of locally produced Thriposha or 50 g of corn—soya blend provided by the World Food Programme that provides approximately 200 kcal in addition to the general food ration. The children were followed up according to the guidelines stipulated in the Nutrition Rehabilitation Program manual. Results An endline representative survey conducted 2 years after implementation of the Nutrition Rehabilitation Program revealed that the prevalence of global acute malnutrition (GAM) among children under five dropped from 18% to 9.6%, a reduction of 47%, while the prevalence of SAM dropped from 3.5% to 0.7%, a reduction of 80%. However, the prevalence of anemia remained at 34%, which is higher than the national prevalence of 25%, in spite of supplementation with 200% of the Recommended Nutrient Intake of iron and vitamin A. Conclusions Proper targeting of feeding programs with good coverage can reduce the rates of acute malnutrition in emergencies. It is important also to consider the control of anemia in emergencies.
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Karakochuk C, van den Briel T, Stephens D, Zlotkin S. Treatment of moderate acute malnutrition with ready-to-use supplementary food results in higher overall recovery rates compared with a corn-soya blend in children in southern Ethiopia: an operations research trial. Am J Clin Nutr 2012; 96:911-6. [PMID: 22952175 DOI: 10.3945/ajcn.111.029744] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Moderate and severe acute malnutrition affects 13% of children <5 y of age worldwide. Severe acute malnutrition affects fewer children but is associated with higher rates of mortality and morbidity. Supplementary feeding programs aim to treat moderate acute malnutrition and prevent the deterioration to severe acute malnutrition. OBJECTIVE The aim was to compare recovery rates of children with moderate acute malnutrition in supplementary feeding programs by using the newly recommended ration of ready-to-use supplementary food (RUSF) and the more conventional ration of corn-soya blend (CSB) in Ethiopia. DESIGN A total of 1125 children aged 6-60 mo with moderate acute malnutrition received 16 wk of CSB or RUSF. Children were randomly assigned to receive one or the other food. The daily rations were purposely based on the conventional treatment rations distributed at the time of the study in Ethiopia: 300 g CSB and 32 g vegetable oil in the control group (1413 kcal) and 92 g RUSF in the intervention group (500 kcal). The higher ration size of CSB was provided because of expected food sharing. RESULTS The HR for children in the CSB group was 0.85 (95% CI: 0.73, 0.99), which indicated that they had 15% lower recovery (P = 0.039). Recovery rates of children at the end of the 16-wk treatment period trended higher in the RUSF group (73%) than in the CSB group (67%) (P = 0.056). CONCLUSION In comparison with CSB, the treatment of moderate acute malnutrition with RUSF resulted in higher recovery rates in children, despite the large ration size and higher energy content of the conventional CSB ration.
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Affiliation(s)
- Crystal Karakochuk
- Department of Nutritional Sciences and the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Sunguya BF, Poudel KC, Mlunde LB, Otsuka K, Yasuoka J, Urassa DP, Mkopi NP, Jimba M. Ready to Use Therapeutic Foods (RUTF) improves undernutrition among ART-treated, HIV-positive children in Dar es Salaam, Tanzania. Nutr J 2012; 11:60. [PMID: 22931107 PMCID: PMC3478224 DOI: 10.1186/1475-2891-11-60] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 08/24/2012] [Indexed: 11/10/2022] Open
Abstract
Background HIV/AIDS is associated with an increased burden of undernutrition among children even under antiretroviral therapy (ART). To treat undernutrition, WHO endorsed the use of Ready to Use Therapeutic Foods (RUTF) that can reduce case fatality and undernutrition among ART-naïve HIV-positive children. However, its effects are not studied among ART-treated, HIV-positive children. Therefore, we examined the association between RUTF use with underweight, wasting, and stunting statuses among ART-treated HIV-positive children in Dar es Salaam, Tanzania. Methods This cross-sectional study was conducted from September-October 2010. The target population was 219 ART-treated, HIV-positive children and the same number of their caregivers. We used questionnaires to measure socio-economic factors, food security, RUTF-use, and ART-duration. Our outcome variables were underweight, wasting, and stunting statuses. Results Of 219 ART-treated, HIV-positive children, 140 (63.9%) had received RUTF intervention prior to the interview. The percentages of underweight and wasting among non-RUTF-receivers were 12.4% and 16.5%; whereas those of RUTF-receivers were 3.0% (P = 0.006) and 2.8% (P = 0.001), respectively. RUTF-receivers were less likely to have underweight (Adjusted Odd Ratio (AOR) =0.19, CI: 0.04, 0.78), and wasting (AOR = 0.24, CI: 0.07, 0.81), compared to non RUTF-receivers. Among RUTF receivers, children treated for at least four months (n = 84) were less likely to have underweight (P = 0.049), wasting (P = 0.049) and stunting (P < 0.001). Conclusions Among HIV-positive children under ART, the provision of RUTF for at least four months was associated with low proportions of undernutrition status. RUTF has a potential to improve undernutrition among HIV-positive children under ART in the clinical settings in Dar es Salaam, Tanzania.
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Affiliation(s)
- Bruno F Sunguya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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Tekeste A, Wondafrash M, Azene G, Deribe K. Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2012; 10:4. [PMID: 22429892 PMCID: PMC3323427 DOI: 10.1186/1478-7547-10-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 03/19/2012] [Indexed: 11/11/2022] Open
Abstract
Background This study estimated the cost effectiveness of community-based therapeutic care (CTC) for children with severe acute malnutrition (SAM) in Sidama Zone, Ethiopia compared to facility based therapeutic feeding center (TFC). Methods A cost effectiveness analysis comparing costs and outcomes of two treatment programmes was conducted. The societal perspective, which considers costs to all sectors of the society, was employed. Outcomes and health service costs of CTC and TFC were obtained from Save the Children USA (SC/USA) CTC and TFC programme, government health services and UNICEF(in kind supplies) cost estimates of unit costs. Parental costs were estimated through interviewing 306 caretakers. Cost categories were compared and a single cost effectiveness ratio of costs to treat a child with SAM in each program (regardless of outcome) was computed and compared. Results A total of 328 patient cards/records of children treated in the programs were reviewed; out of which 306 (157 CTC and 149 TFC) were traced back to their households to interview their caretakers. The cure rate in TFC was 95.36% compared to 94.30% in CTC. The death rate in TFC was 0% and in CTC 1.2%. The mean cost per child treated was $284.56 in TFC and $134.88 in CTC. The institutional cost per child treated was $262.62 in TFC and $128.58 in CTC. Out of these institutional costs in TFC 46.6% was personnel cost. In contrast, majority (43.2%) of the institutional costs in CTC went to ready to use therapeutic food (RUTF). The opportunity cost per caretaker in the TFC was $21.01 whereas it was $5.87 in CTC. The result of this study shows that community based CTC was two times more cost effective than TFC. Conclusion CTC was found to be relatively more cost effective than TFC in this setting. This indicates that CTC is a viable approach on just economic grounds in addition to other benefits such improved access, sustainability and appropriateness documented elsewhere. If costs of RUTF can be reduced such as through local production the CTC costs per child can be further reduced as RUTF constitutes the highest cost in these study settings.
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Affiliation(s)
- Asayehegn Tekeste
- Jimma University Faculty of Public Health, P,O,Box 2082 code 1250 Addis Ababa, Ethiopia.
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Bergeron G, Castleman T. Program responses to acute and chronic malnutrition: divergences and convergences. Adv Nutr 2012; 3:242-9. [PMID: 22516735 PMCID: PMC3648728 DOI: 10.3945/an.111.001263] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Program approaches for addressing acute malnutrition and those for addressing chronic malnutrition have grown in different directions. Their specialization has led to productive advances in the efficacy of specific interventions but has also created divergences in implementation. Greater convergence and integration between the 2 sets of approaches would help programs respond to the diversity of conditions faced in the field and enable a more comprehensive continuum of care from prevention to treatment. After reviewing the causes of the differences in approach, this paper examines programmatic and scientific challenges to greater convergence and suggests steps to promote effective integration of acute and chronic malnutrition services. Steps include strengthening community linkages between program platforms, assessing the degree and type of integration needed in various situations, identifying cost efficiencies, and developing joint tools where possible.
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Affiliation(s)
- Gilles Bergeron
- Food and Nutrition Technical Assistance Project, FHI Development 360, LLC, Washington, DC, USA.
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Wilford R, Golden K, Walker DG. Cost-effectiveness of community-based management of acute malnutrition in Malawi. Health Policy Plan 2011; 27:127-37. [PMID: 21378101 DOI: 10.1093/heapol/czr017] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This study assessed the cost-effectiveness of community-based management of acute malnutrition (CMAM) to prevent deaths due to severe acute malnutrition among children under-five. The analysis used a decision tree model to compare the costs and effects of two options to treat severe acute malnutrition: existing health services with CMAM vs existing health services without CMAM. The model used outcome and cost data from a CMAM programme in Dowa district, Malawi and a set of key assumptions regarding treatment-seeking behaviour and mortality outcomes. Under our 'base case' scenario, we found that CMAM cost US$42 per disability-adjusted life year (DALY) averted (2007 US$) and US$493 per DALY averted under an assumed 'worst case' scenario for each variable. The results suggest that CMAM was highly cost-effective in the 'base case' as defined by the World Health Organization, as the cost per DALY falls well below Malawi's 2007 gross national income (GNI) per capita of US$250, and is within the range of DALYs reported for other child health interventions. Under a hypothetical 'worst case' for all variables, the model indicates CMAM is still cost-effective. The results indicate the decision to scale-up CMAM within essential health services in Dowa was a cost-effective one and that scaling up CMAM in similar contexts is also likely to be cost-effective. However, several contextual and programmatic factors should be considered when generalizing to diverse contexts.
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Affiliation(s)
- Robyn Wilford
- Concern Worldwide, 52-55 Camden Street Lower, Dublin, Ireland
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Thakwalakwa C, Ashorn P, Phuka J, Cheung YB, Briend A, Puumalainen T, Maleta K. A lipid-based nutrient supplement but not corn-soy blend modestly increases weight gain among 6- to 18-month-old moderately underweight children in rural Malawi. J Nutr 2010; 140:2008-13. [PMID: 20861218 DOI: 10.3945/jn.110.122499] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Although widely used, there is little information concerning the efficacy of corn-soy blend (CSB) supplementation in the treatment of moderate underweight in African children. Lipid-based nutrient supplements (LNS), which have proven to be beneficial treatment for severely wasted children, could offer benefits to less severely affected individuals. We conducted a clinical randomized trial to determine whether LNS or CSB supplementation improves weight gain of moderately underweight children. A total of 182 underweight [weight-for-age Z-score (WAZ) < -2] 6- to 15-mo-old children were randomized to receive for 12 wk a ration of 43 g/d LNS or 71 g/d CSB, providing 1189 and 921 kJ, respectively, or no supplementation (control). The primary outcome was weight change; secondary outcomes included changes in anthropometric indices, hemoglobin levels, and morbidity. The body weight increases (mean ± SD) did not differ and were 620 ± 470, 510 ± 350, and 470 ± 350 g in the LNS, CSB, and control groups, respectively (P = 0.11). Compared with controls, infants and children in the LNS group gained more weight [mean (95% CI) = 150 g (0-300 g); P = 0.05] and had a greater increase in WAZ [0.33 (-0.02-0.65); P = 0.04]. Weight and WAZ changes did not differ between the control and CSB groups. In exploratory stratified analysis, the weight increase was higher in the LNS group compared with the control group among those with lower initial WAZ [250 g (60-430 g; P = 0.01]. Supplementation with LNS but not CSB modestly increases weight gain among moderately underweight children and the effect appears most pronounced among those with a lower initial WAZ.
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Affiliation(s)
- Chrissie Thakwalakwa
- Department of International Health, University of Tampere Medical School, Tampere 33014, Finland.
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Guerrero S, Myatt M, Collins S. Determinants of coverage in community-based therapeutic care programmes: towards a joint quantitative and qualitative analysis. DISASTERS 2010; 34:571-585. [PMID: 20002705 DOI: 10.1111/j.1467-7717.2009.01144.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
One of the most important elements behind the success of Community-based Therapeutic Care (CTC) programmes for the treatment of severe acute malnutrition has been their ability to achieve high levels of coverage. In CTC, coverage is measured using the Centric System Area Sampling (CSAS) method, which provides accurate and reliable estimates of programme coverage as well as information on the primary reasons for non-attendance. Another important feature of CTC programmes is their use of socio-cultural assessments to determine potential barriers to access and to develop context-specific responses. By analysing data on non-attendance provided by CSAS surveys, in conjunction with data from socio-cultural assessments, it is possible to identify common factors responsible for failures in programme coverage. This paper focuses on an analysis of data from 12 CTC programmes across five African countries. It pinpoints three common factors (distance to sites, community awareness of the programme, and the way in which rejections are handled at the sites) that, together, account for approximately 75 per cent of non-attendance.
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Abstract
Famines have long been characterised by rapidly shifting dynamics: sudden price spirals, sharp increases in mortality, the media frenzy that often accompanies such spikes, the swift scaling up of aid flows, and a subsequent decline in interest. In arguing that these aspects of famine have been largely ignored in recent years due to attention to the famine process', this paper attempts to make these dynamics more explicit by applying systems thinking. It uses standard archetypes of systems thinking to explain six situations--watch, price spiral, aid magnet, media frenzy, overshoot, and peaks--that are present in many famine contexts. It illustrates their application with examples from crises in Ethiopia, Malawi, Niger, and Sudan. The paper contends that the systems approach offers a tool for analysing the larger patterns in famines and for pinpointing the most appropriate responses to them, based on an awareness of the dynamics of the crises.
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Affiliation(s)
- Paul Howe
- United Nations World Food Programme, Uganda Country Office, Kampala, Uganda.
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Ford N, Mills EJ, Zachariah R, Upshur R. Ethics of conducting research in conflict settings. Confl Health 2009; 3:7. [PMID: 19591691 PMCID: PMC2717053 DOI: 10.1186/1752-1505-3-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 07/10/2009] [Indexed: 11/10/2022] Open
Abstract
Humanitarian agencies are increasingly engaged in research in conflict and post-conflict settings. This is justified by the need to improve the quality of assistance provided in these settings and to collect evidence of the highest standard to inform advocacy and policy change. The instability of conflict-affected areas, and the heightened vulnerability of populations caught in conflict, calls for careful consideration of the research methods employed, the levels of evidence sought, and ethical requirements. Special attention needs to be placed on the feasibility and necessity of doing research in conflict-settings, and the harm-benefit ratio for potential research participants.
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Affiliation(s)
- Nathan Ford
- Médecins Sans Frontières, Johannesburg, South Africa
- Simon Fraser University, Vancouver, Canada
| | - Edward J Mills
- British Columbia Centre for Excellence in HIV/AIDS, University of British Columbia, Canada
| | | | - Ross Upshur
- Joint Centre for Bioethics, University of Toronto, Canada
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Skordis-Worrall J, Kerac M. Localized or centralized control of food production for treating severe acute malnutrition: echoes of a past child survival revolution? MATERNAL & CHILD NUTRITION 2009; 5:195-8. [PMID: 19531046 PMCID: PMC6860533 DOI: 10.1111/j.1740-8709.2009.00196.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Phuka J, Thakwalakwa C, Maleta K, Cheung YB, Briend A, Manary M, Ashorn P. Supplementary feeding with fortified spread among moderately underweight 6-18-month-old rural Malawian children. MATERNAL AND CHILD NUTRITION 2009; 5:159-70. [PMID: 19292750 DOI: 10.1111/j.1740-8709.2008.00162.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We aimed to analyse growth and recovery from undernutrition among moderately underweight ambulatory children receiving micronutrient-fortified maize-soy flour (Likuni Phala, LP) or ready-to-use fortified spread (FS) supplementary diet. One hundred and seventy-six 6-18-month-old individuals were randomized to receive 500 g LP or 350 g FS weekly for 12 weeks. Baseline and end of intervention measurements were used to calculate anthropometric gains and recovery from underweight, wasting and stunting. Mean weight-for-age increased by 0.22 (95% CI 0.07-0.37) and 0.28 (0.18-0.40) Z-score units in the LP and FS groups respectively. Comparable increase for mean weight-for-length was 0.39 (0.20-0.57) and 0.52 (0.38-0.65) Z-score units. Recovery from underweight and wasting was 20% and 93% in LP group and 16% and 75% in FS group. Few individuals recovered from stunting and mean length-for-age was not markedly changed. There were no statistically significant differences between the outcomes in the two intervention groups. In a poor food-security setting, underweight infants and children receiving supplementary feeding for 12 weeks with ready-to-use FS or maize-soy flour porridge show similar recovery from moderate wasting and underweight. Neither intervention, if limited to a 12-week duration, appears to have significant impact on the process of linear growth or stunting.
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Affiliation(s)
- John Phuka
- College of Medicine, University of Malawi, P/Bag 360 Blantyre, Malawi.
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Phuka JC, Maleta K, Thakwalakwa C, Cheung YB, Briend A, Manary MJ, Ashorn P. Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr 2009; 89:382-90. [PMID: 19056572 DOI: 10.3945/ajcn.2008.26483] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Therapeutic feeding with micronutrient-fortified lipid-based nutrient supplements (LNSs) has proven useful in the rehabilitation of severely malnourished children. We recently reported that complementary feeding of 6-18-mo-old infants with an LNS known as FS50 was associated with improved linear growth and a reduction in the incidence of severe stunting during the supplementation period. OBJECTIVE Our objective was to assess whether a reduction in stunting seen with 12-mo LNS supplementation was sustained over a subsequent 2-y nonintervention period. DESIGN One hundred eighty-two 6-mo-old healthy rural Malawian infants were randomly assigned to receive daily supplementation for 12 mo with 71 g of maize-soy flour [likuni phala (LP); control group, 282 kcal] or either 50 g of FS50 (264 kcal; main intervention group), or 25 g of FS25 (130 kcal). Main outcome measures were incidence of severe stunting and mean z score changes in weight-for-age, length-for-age, and weight-for-length during a 36-mo follow-up period. RESULTS The cumulative 36-mo incidence of severe stunting was 19.6% in LP, 3.6% in FS50, and 10.3% in FS25 groups (P = 0.03). Mean weight-for-age changes were -1.09, -0.76, and -1.22 (P = 0.04); mean length-for-age changes were -0.47, -0.37, and -0.71 (P = 0.10); and mean weight-for-length changes were -1.52, -1.18, and -1.48 (P = 0.27). All differences were more marked among individuals with baseline length-for-age below the median. Differences in length developed during the intervention at age 10-18 mo, whereas weight differences continued to increase after the intervention. CONCLUSIONS Twelve-month-long complementary feeding with 50 g/d FS50 is likely to have a positive and sustained impact on the incidence of severe stunting in rural Malawi. Half-dose intervention may not have the same effect. This trial was registered at (clinicaltrials.gov) as NCT00131209.
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Affiliation(s)
- John C Phuka
- College of Medicine, University of Malawi, Blantyre, Malawi.
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Phuka JC, Maleta K, Thakwalakwa C, Cheung YB, Briend A, Manary MJ, Ashorn P. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-month-old rural Malawians. ACTA ACUST UNITED AC 2008; 162:619-26. [PMID: 18606932 DOI: 10.1001/archpedi.162.7.619] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To compare growth and incidence of malnutrition in infants receiving long-term dietary supplementation with ready-to-use fortified spread (FS) or micronutrient-fortified maize-soy flour (likuni phala [LP]). DESIGN Randomized, controlled, single-blind trial. SETTING Rural Malawi. PARTICIPANTS A total of 182 six-month-old infants. INTERVENTION Participants were randomized to receive 1 year of daily supplementation with 71 g of LP (282 kcal), 50 g of FS (FS50) (256 kcal), or 25 g of FS (FS25) (130 [corrected] kcal). OUTCOME MEASURES Weight and length gains and the incidences of severe stunting, underweight, and wasting. RESULTS Mean weight and length gains in the LP, FS50, and FS25 groups were 2.37, 2.47, and 2.37 kg (P = .66) and 12.7, 13.5, and 13.2 cm (P = .23), respectively. In the same groups, the cumulative 12-month incidence of severe stunting was 13.3%, 0.0%, and 3.5% (P = .01), of severe underweight was 15.0%, 22.5%, and 16.9% (P = .71), and of severe wasting was 1.8%, 1.9%, and 1.8% (P > .99). Compared with LP-supplemented infants, those given FS50 gained a mean of 100 g more weight and 0.8 cm more length. There was a significant interaction between baseline length and intervention (P = .04); in children with below-median length at enrollment, those given FS50 gained a mean of 1.9 cm more than individuals receiving LP. CONCLUSION One-year-long complementary feeding with FS does not have a significantly larger effect than LP on mean weight gain in all infants, but it is likely to boost linear growth in the most disadvantaged individuals and, hence, decrease the incidence of severe stunting.
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Affiliation(s)
- John C Phuka
- College of Medicine, University of Malawi, PO Box 431, Mangochi, Malawi.
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Dubray C, Ibrahim SA, Abdelmutalib M, Guerin PJ, Dantoine F, Belanger F, Legros D, Pinoges L, Brown V. Treatment of severe malnutrition with 2-day intramuscular ceftriaxone vs 5-day amoxicillin. ACTA ACUST UNITED AC 2008; 28:13-22. [PMID: 18318945 DOI: 10.1179/146532808x270635] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Systemic antibiotics are routinely prescribed for severe acute malnutrition (SAM). However, there is no consensus regarding the most suitable regimen. In a therapeutic feeding centre in Khartoum, Sudan, a randomised, unblinded, superiority-controlled trial was conducted, comparing once daily intramuscular injection with ceftriaxone for 2 days with oral amoxicillin twice daily for 5 days in children aged 6-59 months with SAM. METHODS Commencing with the first measured weight gain (WG) following admission, the risk difference and 95% confidence interval (95% CI) for children with a WG > or = 10 g/kg/day were calculated over a 14-day period. The recovery rate and case fatality ratio (CFR) between the two groups were also calculated. RESULTS In an intention-to-treat analysis of 458 children, 53.5% (123/230) in the amoxicillin group and 55.7% (127/228, difference 2.2%, 95% CI -6.9-11.3) in the ceftriaxone group had a WG > or = 10 g/kg/day during a 14-day period. Recovery rate was 70% (161/230) in the amoxicillin group and 74.6% (170/228) in the ceftriaxone group (p=0.27). CFR was 3.9% (9/230) and 3.1% (7/228), respectively (p=0.67). Most deaths occurred within the 1st 2 weeks of admission. CONCLUSION In the absence of severe complications, either ceftriaxone or amoxicillin is appropriate for malnourished children. However, in ambulatory programmes, especially where there are large numbers of admissions, ceftriaxone should facilitate the work of medical personnel.
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The humanitarian emergency in Burundi: evaluation of the operational strategy for management of nutritional crisis. Public Health Nutr 2008; 11:699-705. [DOI: 10.1017/s1368980007001413] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveTo evaluate the impact and appropriateness of programmes for the management and treatment of severe malnutrition in emergency situations.DesignA central unified database was set up with all data and statistics provided by nutritional centres (NC) active in Burundi.SettingThe paper describes the case of Burundi as an example of the response of the humanitarian community to nutritional crisis.SubjectsSince 1999, more than one million (1 054 210) severely malnourished patients were treated in NC established in Burundi.ResultsPeaks of beneficiaries were registered in 2000 and 2001; the admission rate started to decrease in 2002. In 2004, twenty therapeutic feeding centres (TFC) and 224 supplementary feeding centres (SFC) were active for the treatment of 127 420 beneficiaries. Nutritional programmes were present in every province with a coverage rate of 55 %. The most convincing impact of the nutritional programme in Burundi was the reduction of mortality rate in children under 5 years of age; an impact on the prevalence of acute malnutrition could not be demonstrated. Children under 5 years old accounted for 62 % of beneficiaries in TFC and 76 % in SFC. TFC performance indicators fulfilled the minimum standards in disaster response; the performance of SFC was not so optimal with a low recovery rate (69 % v. >80 %) and a high non-respondent rate (16 % v. <5 %). With the combination of coverage and cure rate, the programme met 44 % of the assessed needs in 2004.ConclusionsIn Burundi the stabilisation of security conditions permitted a combination of humanitarian responses ranging from emergency activities to strengthening of community-based initiatives that could correct the coverage and impact limitations.
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Abstract
Vincent Brown and colleagues review Epicentre's 20 years of experience conducting research during complex humanitarian emergencies.
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Savadogo L, Zoetaba I, Donnen P, Hennart P, Sondo BK, Dramaix M. [Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso]. Rev Epidemiol Sante Publique 2007; 55:265-74. [PMID: 17590552 DOI: 10.1016/j.respe.2007.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 03/20/2007] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach. METHODS Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used. RESULTS From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD. CONCLUSION The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.
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Affiliation(s)
- L Savadogo
- Département de biostatistique, école de santé publique, CP 598, université libre de Bruxelles, Bruxelles, Belgium.
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Sadler K, Myatt M, Feleke T, Collins S. A comparison of the programme coverage of two therapeutic feeding interventions implemented in neighbouring districts of Malawi. Public Health Nutr 2007; 10:907-13. [PMID: 17466097 DOI: 10.1017/s1368980007711035] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectiveTo compare therapeutic feeding programme coverage for severely malnourished children achieved by a community-based therapeutic care (CTC) programme and a therapeutic feeding centre (TFC) programme operating in neighbouring districts in Malawi.DesignTwo surveys were implemented simultaneously one in each of the two programme areas. Each survey used a stratified design with strata defined using the centric systematic area sample method. Thirty 100 km2 quadrats were sampled. The community or communities located closest to the centre of each quadrat were sampled using a case-finding approach. Cases were defined as children aged under 5 years with ≤ 70% of the weight-for-height median or bilateral pitting oedema. Receipt of treatment was ascertained by the child's presence in a therapeutic feeding programme or by documentary evidence. Coverage in each quadrat was estimated in two ways, a period estimate that provides an estimation of coverage for the recent period preceding the survey and a point estimate that provides an estimation of coverage at the exact point in time of the survey.ResultsOverall the period coverage was 24.55% (95% confidence interval (CI) = 17.8–31.4%) in the TFC programme and 73.64% (95% CI = 66.0–81.3%) in the CTC programme. The point coverage was 20.04% (95% CI = 13.8–26.3%) in the TFC programme and 59.95% (95% CI = 51.4–68.5%) in the CTC programme.ConclusionsIn this context, CTC gave substantially higher programme coverage than a TFC programme. Given effective treatment, this enabled higher impact of CTC on severe malnutrition in this population.
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Affiliation(s)
- Kate Sadler
- Centre for International Child Health, Institute of Child Health, London, WC1N 1EH, UK.
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Galpin L, Thakwalakwa C, Phuka J, Ashorn P, Maleta K, Wong WW, Manary MJ. Breast milk intake is not reduced more by the introduction of energy dense complementary food than by typical infant porridge. J Nutr 2007; 137:1828-33. [PMID: 17585038 DOI: 10.1093/jn/137.7.1828] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The effect of different energy densities of complementary foods on breast milk consumption is not well understood. In this study, we tested the hypothesis that provision of fortified spread (FS), a micronutrient fortified, energy-dense (22 kJ/g), ready-to-use food, to Malawian infants would not decrease their breast milk intake more than a traditional corn + soy blended flour (CSB). Forty-four healthy 6-mo-old infant and mother pairs were enrolled in a prospective, parallel group, investigator-blinded, randomized controlled complementary feeding trial. Infants were randomized to receive 25 g/d of FS, 50 g/d of FS, or 72 g/d of CSB. The primary outcome was the difference in breast milk intake after 1 mo of complementary feeding as measured by the dose-to-mother deuterium oxide dilution technique. Outcomes were compared using repeated measures ANOVA. A total of 41 mother-infant pairs completed the study. At enrollment, 88% of the infants had received corn porridge. At baseline, the infants consumed 129 +/- 18 g.kg body wt(-1) x d(-1) (mean +/- SD) of breast milk. After 1 mo of complementary feeding with 25 g/d FS, 50 g/d FS, or 72 g/d CSB, their breast milk consumption was 115 +/- 18 g.kg body wt(-1) x d(-1), a significant reduction; however, the effects of the complementary foods did not differ from one another (F-value model = 4.33, P = 0.0008 for effect of time and P = 0.69 for effect of type of food). The results suggest that complementary feeding of Malawian infants with FS has the same effect on their breast milk intake as complementary feeding with traditional CSB porridge.
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Affiliation(s)
- Lauren Galpin
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
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