Effectiveness of a nonweight-based daily dosage of ready-to-use therapeutic food in children suffering from uncomplicated severe acute malnutrition: A nonrandomized, noninferiority analysis of programme data in Afghanistan

Severe acute malnutrition (SAM) remains a major global public health problem. SAM cases are treated using ready-to-use therapeutic food (RUTF) at a dosage of ∼200 kcal/kg/day per the standard treatment protocol (STD). Emerging evidence on simplifications to the standard protocol, which among other adaptations, includes reducing the daily RUTF dosage, indicates that it is effective and safe for treating children with SAM. In response to a foreseen stock shortage of RUTF, the government of Afghanistan endorsed the temporary use of a modified treatment protocol in which the daily RUTF dosage was prescribed at 1000 kcal/day (irrespective of body weight) until the child achieved moderate acute malnutrition status (weight-for-height z-score ≥ -3 or mid-upper arm circumference [MUAC] ≥ 115 mm), at which point 500 kcal/day was prescribed until cured (modified treatment protocol [MTP]). In this paper, we report the results of this nonweight-based daily RUTF dosage experience. Data of 2042 children with SAM, treated using either the STD protocol (n = 269) or the MTP protocol (n = 1773) from August 2019 to March 2021 in five provinces, were analyzed. The per-protocol analyses confirmed noninferiority of MTP protocol when compared to STD protocol for recovery rate [93.3% vs. 90.2%; ∆ (95% confidence interval, CI) = 3.1 (-0.9; 7.2) %] and length-of-stay [82.6 vs. 75.6 days; ∆ (95% CI) = 6.9 (3.3; 10.5) days], considering the margin of noninferiority of -10% and +14 days, respectively. Weight gain velocity was smaller in the MTP protocol group than in the STD protocol group [3.7 (1.7) vs. 5.2 (2.9) g/kg/day; ∆ (95% CI) = -1.5 (-1.8, -1.2); p < 0.001]. The STD group had a significantly higher mean than the MTP group for absolute MUAC gain [∆ (95% CI) = 1.7 (1.0; 2.3) mm; p < 0.001] and the MUAC velocity [∆ (95% CI) = 0.29 (0.20; 0.37) mm/week; p < 0.001]. Our results confirm the noninferiority of a nonweight-based daily dosage and support the endorsement of this modification as an alternative to the standard protocol in resource-constrained contexts.

Influence of engaging female caregivers in households with adolescent girls on adopting equitable family eating practices: a quasi-experimental study

Background

In patriarchal societies, female caregivers decide on food allocation within a family based on prevailing gender and age norms, which may lead to inequality that does not favor young adolescent girls. This study evaluated the effect of a community-based social norm intervention involving female caregivers in West Hararghe, Ethiopia. The intervention was engaging female caregivers along with other adult influential community members to deliberate and act on food allocation social norms in a process referred to as Social Analysis and Action (SAA).

Method

We used data from a large quasi-experimental study to compare family eating practices between those who participated in the Social Analyses and Action intervention and those who did not. The respondents were female caregivers in households with young adolescent girls (ages 13 and 14 years). The study's outcome was the practice of family eating together from the same dish. The difference in difference (DID) analysis with the mixed effect logistic regression model was used to examine the effect of the intervention.

Result

The results showed improved family eating practices in both groups, but the improvement was greater in the intervention group. The DID analysis showed an 11.99 percentage points greater improvement in the intervention arm than in the control arm. The mixed-effect regression produced an adjusted odds ratio of 2.08 (95% CI [1.06-4.09]) after controlling selected covariates, p-value 0.033.

Conclusions

The involvement of influential adult community members significantly improves the family practice of eating together in households where adolescent girls are present in our study. The intervention has great potential to minimize household food allocation inequalities and thus improve the nutritional status of young adolescents. Further studies are necessary to evaluate the effectiveness of the intervention in different social norm contexts to formulate policy and guidelines for scale-up.

Effect of integrated nutrition-sensitive and nutrition-specific intervention package on maternal malnutrition among pregnant women in Rwanda

Maternal undernutrition remains a major public health concern in Rwanda despite significant gains and progress. An integration of nutrition‐specific and nutrition‐sensitive interventions was implemented in five districts of Rwanda to improve maternal and child nutrition. The package included nutrition education and counselling, promotion of agricultural productivity, promotion of financial literacy/economic resilience and provision of Water, Hygiene and Sanitation services. However, there is limited evidence about the effect of such interventions in reducing maternal undernutrition. A postintervention quasi‐experimental study was conducted among pregnant women to determine the effect of the integrated intervention on their nutritional status. It was carried out in two intervention districts, namely Kicukiro and Kayonza, and two control districts, namely Gasabo and Gisagara between November 2020 and June 2021. Five hundred and fifty‐two women were recruited for the intervention arm, while 545 were recruited for the control arm. Maternal undernutrition was defined as either having low mid‐upper arm circumference (<23 cm) during delivery or low body mass index (<18.5 kg/m²) in the first trimester or both. A multivariable logistic regression model was used to assess the effect of the integrated interventions. The prevalence of maternal undernutrition was significantly lower in the intervention group compared with the control group (4.7% vs. 18.2%; p < 0.001). After controlling the potential confounders, the risk of maternal undernutrition was 77.0% lower in the intervention group than in the control group [adjusted odds ratio= 0.23; 95% confidence interval = 0.15–0.36; p < 0.001]. Further studies are therefore recommended to establish causation and inform the potential scale‐up of these interventions nationally in Rwanda.

Empirical evidence on the effect of integrated nutrition‐specific and nutrition‐sensitive interventions on maternal undernutrition is limited as existing studies are mainly directed at the effectiveness of nutritional interventions on improving child nutritional status.

The results indicated that the integrated nutrition‐specific and nutrition‐sensitive intervention package was significantly associated with low maternal undernutrition.

This study adds more evidence to the 2008, 2013 and 2021 Lancet Series regarding the proposed effectiveness of integrated nutrition‐sensitive and nutrition‐specific interventions.

Further research should focus on follow‐up randomized controlled trials and the cost‐effectiveness of these integrated nutrition‐specific and nutrition‐sensitive interventions.

Nutrition Interventions for Children with Cerebral Palsy in Low- and Middle-Income Countries: A Scoping Review

Background: Malnutrition is substantially higher among children with cerebral palsy (CP) in low- and middle-income countries (LMICs) when compared with the general population. Access to appropriate interventions is crucial for better management of malnutrition and nutritional outcomes of those children. We aimed to review the existing evidence on nutrition interventions for children with CP in LMICs. Methods: Online databases, i.e., PubMed and Scopus, and Google Scholar were searched up to 10 January 2022, to identify peer-reviewed publications/evidence on LMIC focused nutritional management guidelines/interventions. Following title screening and abstract review, full articles that met the inclusion/exclusion criteria were retained for data charting. Information about the study characteristics, nutrition interventions, and their effectiveness were extracted. Descriptive data were reported. Results: Eight articles published between 2008 and 2019 were included with data from a total of n = 252 children with CP (age range: 1 y 0 m–18 y 7 m, 42% female). Five studies followed experimental design; n = 6 were conducted in hospital/clinic/center-based settings. Four studies focused on parental/caregiver training; n = 2 studies had surgical interventions (i.e., gastrostomy) and n = 1 provided neurodevelopmental therapy feeding intervention. Dietary modification as an intervention (or component) was reported in n = 5 studies and had better effect on the nutritional outcomes of children with CP compared to interventions focused on feeding skills or other behavioral modifications. Surgical interventions improved nutritional outcomes in both studies; however, none documented any adverse consequences of the surgical interventions. Conclusion: There is a substantial knowledge gap on nutrition interventions for children with CP in LMICs. This hinders the development of best practice guidelines for the nutritional management of children with CP in those settings. Findings suggest interventions directly related to growth/feeding of children had a better outcome than behavioral interventions. This should be considered in planning of nutrition-focused intervention or comprehensive services for children with CP in LMICs.

Stories of Change in Nutrition in Ghana: a focus on stunting and anemia among children under-five years (2009 – 2018)

The current study aimed to understand why child stunting and anemia (CS&A) rates declined in Ghana between 2009 and 2018, and which priority policies and programs will further improve nutrition outcomes. Trends and potential drivers of stunting (height-for-age z-score < -2.0 SD) and anemia (hemoglobin < 11.0 g/dL), and decomposition analysis of DHS data (2003 to 2014) were conducted. The quantitative evidence was triangulated with Net-Map analysis of nutrition stakeholder relationships and influence, desk review of policies and programs 2009–2019, and in-depth interviews with 25 stakeholders who provided additional insights to explain CS&A trends. Declines in stunting (29.6%) and anemia (14.1%) in children were observed at the national level, but with important subgroup variations. Decomposition analyses identified changes in the household, maternal, and child characteristics (including wealth, use of antenatal services, maternal education, and immunization) as correlates of anemia reduction. Stunting reduction was linked with changes in bed-net utilization, household wealth, and pregnancy care service utilization. Additionally, multiple policies and programs initiated/implemented across multiple sectors were considered potentially relevant to CS&A reduction over time, including those focused on infant and young child feeding, water and sanitation, social protection, and health care access. Initiation/strengthening of these interventions was stimulated by awareness creation and subsequently increased prioritization of stunting. However, program delivery was limited by deficits in government funding, perceived low priority of child anemia, low implementation capacity and coverage, and weak coherence across sectors. Reduced CS&A resulted from improved access to services implemented across multiple sectors, albeit limited by implementation scale and capacity. Further reduction in CS&A requires enhanced multi-sectorally coordinated actions and capacity.

The Potential Contribution of the Health System to Reducing Stunting in SUN Countries

BACKGROUND

The global nutrition community has called for a multisectoral approach to improve nutritional outcomes. While most essential nutrition interventions are delivered through the health system, nutrition-sensitive interventions from other sectors are critical.

OBJECTIVE

We modeled the potential impact that Scaling Up Nutrition (SUN) interventions delivered by the health system would have on reaching World Health Assembly (WHA) stunting targets. We also included results for targets 2, 3, and 5.

METHODS

Using all available countries enrolled in the SUN movement, we identified nutrition interventions that are delivered by the health system available in the Lives Saved Tool. We then scaled these interventions linearly from 2012 up to nearly universal coverage (90%) in 2025 and estimated the potential impact that this increase would have with regard to the WHA targets.

RESULTS

Our results show that only 16 countries out of 56 would reach the 40% reduction in the number of stunted children by 2025, with a combined total reduction of 32% across all countries. Similarly, only 2 countries would achieve the 50% reduction in anemia for women of reproductive age, 41 countries would reach at least 50% exclusive breastfeeding in children under 6 months of age, and 0 countries would reach the 30% reduction in low birth weight.

CONCLUSIONS

While the health system has an important role to play in the delivery of health interventions, focusing investments and efforts on the health system alone will not allow countries to reach the WHA targets by 2025. Concerted efforts across multiple sectors are necessary.

Assessment of an Educational Intervention to Improve Healthy Life Habits in Children Living in Vulnerable Socioeconomic Conditions

Nutritional condition impacts academic performance and cognitive development. In Peru, the prevalence of chronic undernutrition in children is 6.9%, increasing the risk of mortality and morbidity. This study aimed to develop an educational intervention to achieve an improvement in the healthy habits of children in a primary education school in Lima who live in vulnerable socioeconomic conditions. We conducted a prospective quasi-experimental pre-test and post-test study of an educational intervention. The information was collected through the adaptation of the WHO questionnaire “Global School-based Student Health Survey” (GSHS), with anthropometric variables, socioeconomic level, hygiene and eating habits. One hundred eight students from 5 to 13 years old from Arenitas del Mar School in Lima (Peru) participated. The educational intervention improved eating habits. Fruit and vegetable consumption 3 or more times/day (50.9%) increased after the educational intervention (49% vs. 62.9%,) p < 0.0001. There was an improvement in hygiene habits, such as the frequency of handwashing with soap (32.4% vs. 63.9%) and the frequency of weekly bathing 4–6 times/week (25% vs. 47.5%) p < 0.0001. The educational intervention promoted better healthy living behaviors, eating habits and hygiene. This kind of initiative is a crucial tool to establish healthy living habits.

A Review of Selected Studies on the Factors Associated with the Nutrition Status of Children Under the Age of Five Years in South Africa

Malnutrition is a considerable contributor to child mortality and morbidity. Child malnutrition further affects the country's economic development. Child malnutrition in South Africa is persistent, continuing to be an alarming burden. The nutritional status of kids under the age of five years is a critical indicator of the country's economic condition and health status. An understanding of the influencers of the nutritional status of children can act as a catalyst in combatting all forms of malnutrition. The purpose of this paper was to review selected studies concerning the factors that affect the nutritional status of children in South Africa. Studies were selected from electronic databases, which were PubMed, Google Scholar, Science Direct, Sabinet African Journals, and the University of Zululand library catalog. The keywords that were used to search studies and articles from the selected database were: risk factors, child nutritional status, children under the age of five years, South Africa, malnutrition, underweight, stunted, wasting, and over-nutrition. Studies and surveys published from 2010-2019 that reported on the factors influencing the nutritional status of children under the age of five years were included in this review. Twenty-seven articles met the inclusion criteria of the study. The 27 articles were made up of 21 cross-sectional articles and six longitudinal articles. The finding from this review highlights that there is a lack of studies conducted in urban areas. The results show that the nutritional status of children is affected by several factors. These include household food insecurity, low household income, illiterate caregivers, unemployment, inadequate dietary intake, low birth weight, consumption of monotonous diets, poor caregiver's nutritional knowledge, poor access to water and sanitation, poor weaning practices, age of the caregiver, and demographic characteristics of a child (age and gender). It is critical to have an understanding of the factors that affect the nutritional status of children. Such knowledge can significantly contribute to formulating policies that can enhance nutrition security and the country's economy. Moreover, insights into strategic interventions to eradicate all forms of malnutrition can be made.