Maternal and child nutrition

Multivariate small area modelling of undernutrition prevalence among under-five children in Bangladesh

District-representative data are rarely collected in the surveys for identifying localised disparities in Bangladesh, and so district-level estimates of undernutrition indicators - stunting, wasting and underweight - have remained largely unexplored. This study aims to estimate district-level prevalence of these indicators by employing a multivariate Fay-Herriot (MFH) model which accounts for the underlying correlation among the undernutrition indicators. Direct estimates (DIR) of the target indicators and their variance-covariance matrices calculated from the 2019 Bangladesh Multiple Indicator Cluster Survey microdata have been used as input for developing univariate Fay-Herriot (UFH), bivariate Fay-Herriot (BFH) and MFH models. The comparison of the various model-based estimates and their relative standard errors with the corresponding direct estimates reveals that the MFH estimator provides unbiased estimates with more accuracy than the DIR, UFH and BFH estimators. The MFH model-based district level estimates of stunting, wasting and underweight range between 16 and 43%, 15 and 36%, and 6 and 13% respectively. District level bivariate maps of undernutrition indicators show that districts in north-eastern and south-eastern parts are highly exposed to either form of undernutrition, than the districts in south-western and central parts of the country. In terms of the number of undernourished children, millions of children affected by either form of undernutrition are living in densely populated districts like the capital district Dhaka, though undernutrition indicators (as a proportion) are comparatively lower. These findings can be used to target districts with a concurrence of multiple forms of undernutrition, and in the design of urgent intervention programs to reduce the inequality in child undernutrition at the localised district level.

Response to Malnutrition Treatment in Low Weight-for-Age Children: Secondary Analyses of Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial

Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5–12.5 cm) and a severely low WAZ (<−3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<−3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < −3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < −3.0.

Concurrent wasting and stunting among under-five children in Niakhar, Senegal

The study describes the patterns of concurrent wasting and stunting (WaSt) among children age 6-59 months living in the 1980s in Niakhar, a rural area of Senegal under demographic surveillance. Wasting and stunting were defined by z scores lower than -2 in weight for height and height for age. Both conditions were found to be highly prevalent, wasting more so before age 30 months, stunting more so after age 30 months. As a result, concurrent WaSt peaked around age 18 months and its prevalence (6.2%) was primarily the product of the two conditions, with an interaction term of 1.57 (p < 10^-6 ). The interaction was due to the correlation between both conditions (more stunting if wasted, more wasting if stunted). Before age 30 months, boys were more likely to be concurrently wasted and stunted than girls (RR = 1.61), but the sex difference disappeared after 30 months of age. The excess susceptibility of younger boys could not be explained by muscle mass or fat mass measured by arm or muscle circumference, triceps, or subscapular skinfold. Concurrent WaSt was a strong risk factor for child mortality, and its effect was the product of the independent effect of each component, with no significant interaction.

Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries

BACKGROUND

Wasting and stunting are common. They are implicated in the deaths of almost two million children each year and account for over 12% of disability-adjusted life years lost in young children. Wasting and stunting tend to be addressed as separate issues despite evidence of common causality and the fact that children may suffer simultaneously from both conditions (WaSt). Questions remain regarding the risks associated with WaSt, which children are most affected, and how best to reach them.

METHODS

A database of cross-sectional survey datasets containing data for almost 1.8 million children was compiled. This was analysed to determine the intersection between sets of wasted, stunted, and underweight children; the association between being wasted and being stunted; the severity of wasting and stunting in WaSt children; the prevalence of WaSt by age and sex, and to identify weight-for-age z-score and mid-upper arm circumference thresholds for detecting cases of WaSt. An additional analysis of the WHO Growth Standards sought the maximum possible weight-for-age z-score for WaSt children.

RESULTS

All children who were simultaneously wasted and stunted were also underweight. The maximum possible weight-for-age z-score in these children was below - 2.35. Low WHZ and low HAZ have a joint effect on WAZ which varies with age and sex. WaSt and "multiple anthropometric deficits" (i.e. being simultaneously wasted, stunted, and underweight) are identical conditions. The conditions of being wasted and being stunted are positively associated with each other. WaSt cases have more severe wasting than wasted only cases. WaSt cases have more severe stunting than stunted only cases. WaSt is largely a disease of younger children and of males. Cases of WaSt can be detected with excellent sensitivity and good specificity using weight-for-age.

CONCLUSIONS

The category "multiple anthropometric deficits" can be abandoned in favour of WaSt. Therapeutic feeding programs should cover WaSt cases given the high mortality risk associated with this condition. Work on treatment effectiveness, duration of treatment, and relapse after cure for WaSt cases should be undertaken. Routine reporting of the prevalence of WaSt should be encouraged. Further work on the aetiology, prevention, case-finding, and treatment of WaSt cases as well as the extent to which current interventions are reaching WaSt cases is required.

Public health information in crisis-affected populations: a review of methods and their use for advocacy and action

Valid and timely information about various domains of public health underpins the effectiveness of humanitarian public health interventions in crises. However, obstacles including insecurity, insufficient resources and skills for data collection and analysis, and absence of validated methods combine to hamper the quantity and quality of public health information available to humanitarian responders. This paper, the second in a Series of four papers, reviews available methods to collect public health data pertaining to different domains of health and health services in crisis settings, including population size and composition, exposure to armed attacks, sexual and gender-based violence, food security and feeding practices, nutritional status, physical and mental health outcomes, public health service availability, coverage and effectiveness, and mortality. The paper also quantifies the availability of a minimal essential set of information in large armed conflict and natural disaster crises since 2010: we show that information was available and timely only in a small minority of cases. On the basis of this observation, we propose an agenda for methodological research and steps required to improve on the current use of available methods. This proposition includes setting up a dedicated interagency service for public health information and epidemiology in crises.

Improving estimates of the burden of severe acute malnutrition and predictions of caseload for programs treating severe acute malnutrition: experiences from Nigeria

Background

The burden of severe acute malnutrition (SAM) is estimated using unadjusted prevalence estimates. SAM is an acute condition and many children with SAM will either recover or die within a few weeks. Estimating SAM burden using unadjusted prevalence estimates results in significant underestimation. This has a negative impact on allocation of resources for the prevention and treatment of SAM. A simple method for adjusting prevalence estimates intended to improve the accuracy of burden estimates and caseload predictions has been proposed. This method employs an incidence correction factor. Application of this method using the globally recommended incidence correction factor has led to programs underestimating burden and caseload in some settings.

Methods

A method for estimating a locally appropriate incidence correction factor from prevalence, population size, program caseload, and program coverage was developed and tested using data from the Nigerian national SAM treatment program.

Results

Applying the developed method resulted in errors in caseload prediction of about 10%. This is a considerable improvement upon the current method, which resulted in a 79.5% underestimate. Methods for improving the precision of estimates are proposed.

Conclusions

It is possible to considerably improve predictions of caseload by applying a simple model to data that are readily available to program managers. This implies that more accurate estimates of burden may also be made using the same methods and data.

Rainfall shocks are not necessarily a sensitive early indicator of changes in wasting prevalence

Evidence on the impact of weather shocks on child nutrition focuses on linear growth retardation (stunting) and thus, associates the effect of a short-term measure (weather events) on a cumulative measure (attained height). Relatively little is known on how weather shocks predict increases in wasting in a population. This study explores whether deviation in rainfall in Ethiopia, a drought prone country, is a sensitive indicator of future increases in wasting. Around 12% of children 0–23 months were wasted, but we found no consistent association between the rainfall shock variables and child weight-for-height Z-scores. The results indicate that monitoring rainfall does not provide a practical early warning to use for scaling up financing and management of preventative measures without additional information to increase precision.

Omitting edema measurement: how much acute malnutrition are we missing?

BACKGROUND

Acute malnutrition is a major public health issue in low-income countries. It includes both wasting and edematous malnutrition, but the terms wasting and acute malnutrition are often used interchangeably. Little is known about the burden of edematous malnutrition, and few large-scale surveys measure it.

OBJECTIVE

Most acute malnutrition might be captured by the measurement of wasting alone, but this is unknown. This article aims to fill this gap.

DESIGN

This article presents a secondary data analysis of 852 nutrition cross-sectional survey data sets of children aged 6-59 mo. The data sets assembled included surveys from East, West, South, and Central Africa; the Caribbean; and Asia. The overlap between edematous malnutrition and wasting was assessed, and the impact of including/excluding edema on acute malnutrition prevalence estimates was evaluated.

RESULTS

The prevalence of edematous malnutrition varied from 0% to 32.9%, and children were more likely to have bilateral edema in Central and South Africa (OR: 4; 95% CI: 2.8, 5.6). A large proportion of children with edematous malnutrition were not wasted [62% and 66% based on midupper arm circumference (MUAC) and weight-for-height (WFH), respectively], and most were not severely wasted (83% and 86% based on MUAC and WFH, respectively). When wasting and global acute malnutrition prevalence estimates as well as severe wasting and severe acute malnutrition prevalence estimates overall were compared, the differences between estimates were small (median of 0.0% and mean of 0.3% based on WFH and MUAC for global estimates and slightly higher median of 0.1% and mean of 0.4% based on MUAC and WFH, respectively, for the severe forms), but the picture was different at the regional level.

CONCLUSIONS

The terms acute malnutrition and wasting should not be used interchangeably. The omission of the measurement of edema can have important repercussions, especially at the nutrition program level.

Management of severe acute malnutrition in low-income and middle-income countries

Kwashiorkor and marasmus, collectively termed severe acute malnutrition (SAM), account for at least 10% of all deaths among children under 5 years of age worldwide, virtually all of them in low-income and middle-income countries. A number of risk factors, including seasonal food insecurity, environmental enteropathy, poor complementary feeding practices, and chronic and acute infections, contribute to the development of SAM. Careful anthropometry is key to making an accurate diagnosis of SAM and can be performed by village health workers or even laypeople in rural areas. The majority of children can be treated at home with ready-to-use therapeutic food under the community-based management of acute malnutrition model with recovery rates of approximately 90% under optimal conditions. A small percentage of children, often those with HIV, tuberculosis or other comorbidities, will still require inpatient therapy using fortified milk-based foods.