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Nwachan MB, Ejoh RA, Noumo NT, Njong CE. The effects of nutrition and health education on the nutritional status of internally displaced schoolchildren in Cameroon: a randomised controlled trial. J Nutr Sci 2024; 13:e15. [PMID: 38572369 PMCID: PMC10988160 DOI: 10.1017/jns.2024.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/11/2024] [Accepted: 02/09/2024] [Indexed: 04/05/2024] Open
Abstract
Lack of nutrition knowledge and poor dietary practices have profound adverse implications on nutritional status particularly among displaced children. Evidence of the effectiveness of nutrition education interventions in improving the nutritional status of internally displaced schoolchildren in Cameroon is scarce. The study objective was to assess the effects of nutrition education on the nutritional status of internally displaced schoolchildren in the West and Littoral Regions of Cameroon. A pre-test-post-test randomised experimental study design was used with an experimental and control group of 160 children from ten primary schools and their caregivers. Anthropometric, biochemical, and clinical signs of malnutrition, dietary, and health status of the children were evaluated, and the caregiver's nutrition knowledge was assessed in both groups at baseline and end-line with the aid of standard anthropometric and biochemical equipment and recorded in pretested questionnaires. Nutrition education was carried out only with the caregivers of children in the test group. In the test group, significant beneficial outcomes were noticed only for Bitot's spot (p = 0.047), pallor (0.025), frequency of consumption of fruits (p = 0.002) and vegetables (p = 0.036), caregiver's nutrition knowledge (p = 0.000), all health-seeking practices of the children (p < 0.05) except immunisation (p = 0.957). No significant change was seen in any of the parameters studied among the participants in the control group. Nutrition education alone was not effective in improving the nutritional status of the children and should be implemented together with other food-based nutrition interventions to improve the nutritional status of internally displaced schoolchildren in the West and Littoral Regions of Cameroon.
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Affiliation(s)
- Mirabelle Boh Nwachan
- The University of Bamenda, Department of Nutrition, Food and Bioresource Technology, Bambili, Cameroon
| | - Richard Aba Ejoh
- The University of Bamenda, Department of Nutrition, Food and Bioresource Technology, Bambili, Cameroon
| | - Ngangmou Thierry Noumo
- The University of Bamenda, Department of Nutrition, Food and Bioresource Technology, Bambili, Cameroon
| | - Clementine Endam Njong
- The University of Bamenda, Department of Nutrition, Food and Bioresource Technology, Bambili, Cameroon
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Cichon B, Das JK, Salam RA, Padhani ZA, Stobaugh HC, Mughal M, Pajak P, Rutishauser-Perera A, Bhutta ZA, Black RE. Effectiveness of Dietary Management for Moderate Wasting among Children > 6 Months of Age-A Systematic Review and Meta-Analysis Exploring Different Types, Quantities, and Durations. Nutrients 2023; 15:nu15051076. [PMID: 36904076 PMCID: PMC10005276 DOI: 10.3390/nu15051076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023] Open
Abstract
Currently, no World Health Organization guidelines exist for the management of approximately 31.8 million moderately wasted children globally. The objective of this review was to synthesise evidence on the optimal type, quantity, and duration of dietary treatment for moderate wasting. Ten electronic databases were searched until the 23rd of August 2021. Experimental studies comparing interventions for the dietary management of moderate wasting were included. Meta-analyses were conducted and results were presented as risk ratios or mean differences with 95% confidence intervals. Seventeen studies comparing specially formulated foods were included involving 23,005 participants. Findings suggest little or no difference in recovery between Fortified Blended Foods (FBFs) with improved micronutrient and/or milk content (enhanced FBFs) and lipid-based nutrient supplements (LNS), whereas children treated with non-enhanced FBFs (locally produced FBFs or standard corn-soy blend) may have lower recovery rates than those treated with LNS. There was no difference in recovery when ready-to-use therapeutic and ready-to-use supplementary food were compared. Other outcomes mostly aligned with results for recovery. In conclusion, LNSs improve recovery compared to non-enhanced FBFs, but are comparable to enhanced FBFs. Programmatic choice of supplement should consider factors such as cost, cost-effectiveness, and acceptability. Further research is required to determine optimal dosing and duration of supplementation.
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Affiliation(s)
- Bernardette Cichon
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
- Correspondence:
| | - Jai K. Das
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Rehana A. Salam
- The Daffodil Centre, The University of Sydney, Sydney 2006, Australia
| | - Zahra A. Padhani
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
| | - Heather C. Stobaugh
- Action Against Hunger USA, Technical Services and Innovation Department, Washington, DC 20463, USA
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA
| | - Muzna Mughal
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
| | - Patrizia Pajak
- Action Against Hunger UK, Operations Department, London SE10 0ER, UK
| | | | - Zulfiqar A. Bhutta
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Robert E. Black
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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Eyi SE, Debele GR, Negash E, Bidira K, Tarecha D, Nigussie K, Hajure M, Ahmed MH, Kefeni BT. Severe acute malnutrition’s recovery rate still below the minimum standard: predictors of time to recovery among 6- to 59-month-old children in the healthcare setting of Southwest Ethiopia. JOURNAL OF HEALTH, POPULATION AND NUTRITION 2022; 41:48. [PMID: 36333768 PMCID: PMC9635096 DOI: 10.1186/s41043-022-00331-9] [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: 08/18/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background Despite currently available, scientifically proven treatments and national guideline, the SAM recovery rate is still considerably behind expectations, and it continues to have a devastating impact on under-five children. Identifying predictors of time to recovery might help to reach the minimal criterion established by the WHO and the national Sphere which decreases child mortality. Therefore, the current study assessed time to recovery and its predictors among children aged 6–59 months admitted with SAM in the Healthcare Setting of Southwest Ethiopia, 2021.
Methods An institutional-based multicenter retrospective follow-up study was conducted on 486 children aged 6 to 59 months admitted with SAM cases. Data were entered into Epi-Data version 4.6 and exported to Stata version 14 for further analysis. Cox–Snell residual plot was used to assess the final model’s overall goodness of fit. Finally, a significant predictor of time to recovery was identified using Weibull survival regression model, at 0.05 significance level. Result Overall, 68.72 (95% CI 64.8, 73) of the children recovered and 4.32% died. The overall incidence density was 3.35/100-person day. Independent predictors of time to recovery were, starting complementary feeding at six months (AHR = 1.44; 95%, CI 1.073, 1.935), pneumonia at baseline (AHR = 1.33, 95%, CI 1.049, 1.696), amoxicillin (AHR = 1.31, 95%, CI 1.021, 1.685), and folic acid supplementation (AHR = 1.82, 95% CI 1,237, 2.665). Conclusion The recovery from SAM at study area after a maximum of 60 days of treatment was below the accepted minimum standard. Complementary feeding, pneumonia, treated by amoxicillin, and folic acid supplementation were predictors of time to recovery. Therefore, providing folic acid and amoxicillin for those in need as well as the earliest possible treatment of concomitant conditions like pneumonia is highly recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s41043-022-00331-9.
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Griswold SP, Langlois BK, Shen Y, Cliffer IR, Suri DJ, Walton S, Chui K, Rosenberg IH, Koroma AS, Wegner D, Hassan A, Manary MJ, Vosti SA, Webb P, Rogers BL. Effectiveness and cost-effectiveness of 4 supplementary foods for treating moderate acute malnutrition: results from a cluster-randomized intervention trial in Sierra Leone. Am J Clin Nutr 2021; 114:973-985. [PMID: 34020452 PMCID: PMC8408853 DOI: 10.1093/ajcn/nqab140] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/05/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Moderate acute malnutrition (MAM) affects 33 million children annually. Investments in formulations of corn-soy blended flours and lipid-based nutrient supplements have effectively improved MAM recovery rates. Information costs and cost-effectiveness differences are still needed. OBJECTIVES We assessed recovery and sustained recovery rates of MAM children receiving a supplementary food: ready-to-use supplementary food (RUSF), corn soy whey blend with fortified vegetable oil (CSWB w/oil), or Super Cereal Plus with amylase (SC + A) compared to Corn Soy Blend Plus with fortified vegetable oil (CSB+ w/oil). We also estimated differences in costs and cost effectiveness of each supplement. METHODS In Sierra Leone, we randomly assigned 29 health centers to provide a supplement containing 550 kcal/d for ∼12 wk to 2691 children with MAM aged 6-59 mo. We calculated cost per enrollee, cost per child who recovered, and cost per child who sustained recovery each from 2 perspectives: program perspective and caregiver perspective, combined. RESULTS Of 2653 MAM children (98.6%) with complete data, 1676 children (63%) recovered. There were no significant differences in the odds of recovery compared to CSB+ w/oil [0.83 (95% CI: 0.64-1.08) for CSWB w/oil, 1.01 (95% CI: 0.78-1.3) for SC + A, 1.05 (95% CI: 0.82-1.34) for RUSF]. The odds of sustaining recovery were significantly lower for RUSF (0.7; 95% CI 0.49-0.99) but not CSWB w/oil or SC + A [1.08 (95% CI: 0.73-1.6) and 0.96 (95% CI: 0.67-1.4), respectively] when compared to CSB+ w/oil. Costs per enrollee [US dollars (USD)/child] ranged from $105/child in RUSF to $112/child in SC + A and costs per recovered child (USD/child) ranged from $163/child in RUSF to $179/child in CSWB w/oil, with overlapping uncertainty ranges. Costs were highest per sustained recovery (USD/child), ranging from $214/child with the CSB+ w/oil to $226/child with the SC + A, with overlapping uncertainty ranges. CONCLUSIONS The 4 supplements performed similarly across recovery (but not sustained recovery) and costed measures. Analyses of posttreatment outcomes are necessary to estimate the full cost of MAM treatment. This trial was registered at clinicaltrials.gov as NCT03146897.
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Affiliation(s)
| | - Breanne K Langlois
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ye Shen
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ilana R Cliffer
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Devika J Suri
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Shelley Walton
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ken Chui
- Department of Public Health and Community Medicine, School of Medicine, Tufts University, Boston, MA, USA
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Aminata S Koroma
- Ministry of Health and Sanitation, Directorate of Food and Nutrition, Freetown, Sierra Leone
| | - Donna Wegner
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Amir Hassan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California‐Davis, Davis, CA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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Incidence of relapse following a new approach to simplifying and optimising acute malnutrition treatment in children aged 6-59 months: a prospective cohort in rural Northern Burkina Faso. J Nutr Sci 2021; 10:e27. [PMID: 33996040 PMCID: PMC8080230 DOI: 10.1017/jns.2021.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 01/22/2023] Open
Abstract
The present study aimed to determine the 3-month incidence of relapse and associated factors among children who recovered under the Optimising treatment for acute MAlnutrition (OptiMA) strategy, a MUAC-based protocol. A prospective cohort of children successfully treated for acute malnutrition was monitored between April 2017 and February 2018. Children were seen at home by community health workers (CHWs) every 2 weeks for 3 months. Relapse was defined as a child who had met OptiMA recovery criteria (MUAC ≥ 125 mm for two consecutive weeks) but subsequently had a MUAC < 125 mm at any home visit. Cumulative incidence and incidence rates per 100 child-months were estimated. Multivariable survival analysis was conducted using a shared frailty model with a random effect on health facilities to identify associated factors. Of the 640 children included, the overall 3-month cumulative incidence of relapse was 6⋅8 % (95 % CI 5⋅2, 8⋅8). Globally, the incidence rate of relapse was 2⋅5 (95 % CI 1⋅9, 3⋅3) per 100 child-months and 3⋅7 (95 % CI 1⋅9, 6⋅8) per 100 child-months among children admitted with a MUAC < 115 mm. Most (88⋅6 %) relapses were detected early when MUAC was between 120 and 124 mm. Relapse was positively associated with hospitalisation, with an adjusted hazard ratio (aHR) of 2⋅06 (95 % CI 1⋅01, 4⋅26) for children who had an inpatient stay at any point during treatment compared with children who did not. The incidence of relapse following recovery under OptiMA was relatively low in this context, but the lack of a standard relapse definition does not allow for comparison across settings Closer follow-up with caretakers whose children are admitted with MUAC < 115 mm or required hospitalisation during treatment should be considered in managing groups at high risk of relapse. Training caretakers to screen their children for relapse at home using MUAC could be more effective at detecting early relapse, and less costly, than home visits by CHWs.
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Key Words
- AM, acute malnutrition
- Acute malnutrition
- CHWs, community health workers
- CIs, confidence intervals
- CORTASAM, Council of Research & Technical Advice on Acute Malnutrition
- Children
- HAZ, height-for-age Z-score
- IQR, interquartile range
- Incidence
- MAM, moderate acute malnutrition
- MUAC, mid-upper arm circumference
- MUAC-based and reduced doses protocol
- OptiMA, Optimising treatment for acute MAlnutrition
- RDT, rapid diagnostic tests
- RUTF, ready-to-use therapeutic food
- Relapse
- SAM, severe acute malnutrition
- WHO, World Health Organization
- WHZ, weight-for-height Z-score
- West Africa
- aHR, adjusted hazard ratio
- sd, standard deviation
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6
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Schaefer R, Mayberry A, Briend A, Manary M, Walker P, Stobaugh H, Hanson K, McGrath M, Black R. Relapse and regression to severe wasting in children under 5 years: A theoretical framework. MATERNAL & CHILD NUTRITION 2021; 17:e13107. [PMID: 33145990 PMCID: PMC7988852 DOI: 10.1111/mcn.13107] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/04/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
Systematic reviews have highlighted that repeated severe wasting after receiving treatment is likely to be common, but standardised measurement is needed urgently. The Council of Research & Technical Advice for Acute Malnutrition (CORTASAM) released recommendations on standard measurement of relapse (wasting within 6 months after exiting treatment as per recommended discharge criteria), regression (wasting within 6 months after exiting treatment before reaching recommended discharge criteria) and reoccurrence (wasting after 6 months of exit from treatment as per recommended discharge criteria). We provide a theoretical framework of post-treatment relapse and regression to severe wasting to guide discussions, risk factor analyses, and development and evaluations of interventions. This framework highlights that there are factors that may impact risk of relapse and regression in addition to the impact of contextual factors associated with incidence and reoccurrence of severe wasting more generally. Factors hypothesised to be associated with relapse and regression relate specifically to the nutrition and health status of the child on admission to, during and exit from treatment and treatment interventions, platforms and approaches as well as type of exit from treatment (e.g., before reaching recommended criteria). These factors influence whether children reach full recovery, and poorer nutritional and immunological status at exit from treatment are more proximate determinants of risk of severe wasting after treatment, although post-treatment interventions may modify risks. The evidence base for many of these factors is weak. Our framework can guide research to improve our understanding of risks of relapse and regression and how to prevent them and inform programmes on what data to collect to evaluate relapse. Implementation research is needed to operationalise results in programmes and reduce post-treatment severe wasting at scale.
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Affiliation(s)
| | - Amy Mayberry
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - André Briend
- Center for Child Health ResearchTampere UniversityTampereFinland
- Department of Nutrition, Exercise and SportsUniversity of CopenhagenCopenhagenDenmark
| | - Mark Manary
- Department of PediatricsWashington University in St. LouisSt. LouisMissouriUSA
- School of Public Health and Family Medicine, College of MedicineUniversity of MalawiBlantyreMalawi
| | - Polly Walker
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - Heather Stobaugh
- Action Against Hunger USNew YorkNew YorkUSA
- Friedman School Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | | | | | - Robert Black
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
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7
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Lambebo A, Temiru D, Belachew T. Frequency of relapse for severe acute malnutrition and associated factors among under five children admitted to health facilities in Hadiya Zone, South Ethiopia. PLoS One 2021; 16:e0249232. [PMID: 33765081 PMCID: PMC7993841 DOI: 10.1371/journal.pone.0249232] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Severe acute malnutrition is a common cause of morbidity and mortality among under five children in Ethiopia. A child may experience more than one episode of SAM depending on the improvement of the underlying factors. However, there is no study that determined the frequency of relapse of SAM cases after discharge in Ethiopia. OBJECTIVE To identify the frequency of relapse and associated factors among children discharged after undergoing treatment for SAM in Hadiya Zone, South, Ethiopia. METHODS An institution based retrospective cohort study was done among children admitted to health posts for treatment of SAM from 2014/2015-2019/2020 under-five children's after discharge in health post for severe acute malnutrition in the last five years in Hadiya zone, SNNPR, Ethiopia. Both first admission data and relapse data were abstracted from the records of the SAM children from Aguste 1-30 /2020 Using a data collection format. Data were coded and edited manually, then doubly entered into Epi-Data statistical software version 3.1 and then exported to SPSS for windows version 26. After checking all the assumptions finally Negative binomial regression for poison has been used. All tests were two sided and P values <0.05 were used to declare statistical significance. RESULTS In the last five year there were the proportion of relapsed cases were 9.6%, 95% CI: (7.7%, 11.7%) On multivariable negative binomial regression model, after adjusting for background variables relapse of severe acute undernutrition was significantly associated with having edema during admission with (IRR = 2.21, 95% CI:1.303-3.732), being in the age group of 6-11 months (IRR = 4.74,95% CI:1.79-12.53), discharge MUAC for the first admission (P = 0.001, IRR = 0.37, 95% CI:0.270-0.50) increase the risk of incidence rate ratio(IRR) relapse case of severe acute under nutrition. CONCLUSION Frequency of SAM relapse was positively associated with age, having edema during admission, while it was negatively associated with discharge MUAC. The results imply the need for reviewing the discharge criteria taking into account the recovery of MUAC as a marker for lean tissue accretion, especially in edematous children and those in the younger age.
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Affiliation(s)
- Abera Lambebo
- Department of Public Health, Institute of Medical and Health Science, Collage of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
| | - Deselegn Temiru
- Department of Nutrition and Dietetics, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Tefera Belachew
- Department of Nutrition and Dietetics, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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Das JK, Salam RA, Saeed M, Kazmi FA, Bhutta ZA. Effectiveness of interventions to manage acute malnutrition in children under 5 years of age in low- and middle-income countries: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2020; 16:e1082. [PMID: 37131422 PMCID: PMC8356333 DOI: 10.1002/cl2.1082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Childhood malnutrition is a major public health concern as it is associated with significant short- and long-term morbidity and mortality. Objectives To comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization protocol using facility- and community-based approaches as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use and vitamin A supplementation. Search methods We searched relevant electronic databases till 11 February 2019. No date or language restrictions were applied. Selection criteria We included randomised controlled trials (RCTs) and quasi-experimental studies including controlled before-after (CBA) studies and interrupted time series (ITS) studies. Data collection and analysis Two review authors independently screened studies for relevance, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software and set out the main findings of the review in "Summary of findings" tables. Main results This review summarises findings from a total of 42 studies (48 papers) including 35,017 children. Thirty-three of the included studies were RCTs; six studies were quasi-experimental and three studies were cost studies. Majority of the studies were judged to be at high risk of bias for blinding of the participants, personnel and outcome assessment. Majority of the outcomes were rated as either moderate or low quality. Outcomes were downgraded mainly due to study limitations, high heterogeneity, imprecision and small sample size. Community-based strategies to screen and manage SAM/MAM versus no community-based strategies (two studies): Integrated community-based management probably improves recovery rate by 4% [risk ratio (RR): 1.04; 95% confidence interval (CI): 1.00 to 1.09; one study; 1,957 participants; moderate-quality outcome], and reduces weight gain by 0.8 g·kg-1·day-1 [mean difference (MD): -0.80 g·kg-1·day-1; 95% CI: -0.82 to -0.78; one study; 1,957 participants; moderate-quality outcome] compared with no community-based strategies, while mortality was similar between the two groups (RR: 0.93; 95% CI: 0.60 to 1.45; one study; 1,957 participants; moderate-quality outcome). Facility-based strategies to screen and manage uncomplicated SAM versus other standard of care (four studies): There was no evidence of effect on recovery (RR: 1.00; 95% CI: 0.80, 1.25; one study; 60 participants; very-low-quality evidence) and mortality (RR: 1.21; 95% CI: 0.75 to 1.94; two studies; 473 participants; low-quality outcome). Facility-based management with RUTF versus F100 ("catch-up" formula to rebuild wasted tissues containing 100 kcal and 2.9 g protein per 100 ml) for SAM (three studies): There was no evidence of effect on weight gain (MD: 2 g·kg-1·day-1; 95% CI: -0.23 to 4.23; three studies; 266 participants; very-low-quality outcome) and mortality (RR: 1.20; 95% CI: 0.34 to 4.22; two studies; 168 participants; low-quality outcome). Community-based management of SAM with standard RUTF compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUTF was compared to non-milk/peanut butter-based RUTF (RR: 1.03; 95% CI: 0.99 to 1.08; five studies; 5743 participants; I2 50%; moderate quality outcome), energy-dense, home-prepared food (RR: 1.14; 95% CI 0.95 to 1.36; four studies; 959 participants; I2 75%; low quality outcome), or high oleic RUTF (RR: 1.06; 95% CI: 0.85 to 1.31; one study; 141 participants; moderate quality outcome). Standard RUTF may improve weight gain by 0.5 g·kg-1·day-1 (MD: 0.5 g·kg-1·day-1; 95% CI: 0.02 to 0.99; three studies; 3,069 participants; low-quality outcome) when compared with non-milk/peanut butter-based RUTF and by 5.5 g·kg-1·day-1 when compared with F100 (MD: 5.50 g·kg-1·day-1; 95% CI: 2.92 to 8.08; one study; 70 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUTF was compared with other foods (RR: 0.99; 95% CI: 0.69 to 1.41; nine studies; 7,667 participants; low-quality outcome). RUSF for MAM compared with other foods (14 studies): There was no evidence of effect on recovery rate when standard RUSF was compared with local/home made food (RR: 0.92; 95% CI: 0.64 to 1.33; three studies; 435 participants; low-quality outcome) and whey RUSF (RR: 0.96; 95% CI: 0.92 to 1.00; one study; 2230 participants; high-quality outcome); while standard RUSF may improve recovery by 7% when compared with corn-soy blend (CSB) (RR: 1.07; 95% CI: 1.02 to 1.13; six studies; 5,744 participants; low-quality outcome). There was no evidence of effect on weight gain when standard RUSF was compared with local home made food (MD: -0.75 g·kg-1·day-1; 95% CI: -2.03 to 0.43; one study; 73 participants; low-quality outcome) and whey RUSF (MD: -0.16 g·kg-1·day-1; 95% CI: -0.33 to 0.01; one study; 2,230 participants; high-quality outcome); while standard RUSF may improve weight gain by 0.49 g·kg-1·day-1 when compared with CSB (MD: 0.49 g·kg-1·day-1; 95% CI: 0.10 to 0.87; five studies; 4,354 participants; low-quality outcome). There was no evidence of effect on mortality when standard RUSF was compared with other foods (RR: 0.98; 95% CI: 0.57 to 1.68; eight studies; 8,310 participants; moderate-quality outcome). Prophylactic antibiotic versus no antibiotic (three studies): Prophylactic antibiotic therapy for uncomplicated SAM improves recovery rate by 6% (RR: 1.06; 95% CI: 1.03 to 1.08; two studies; 5,166 participants; high-quality outcome), probably improves weight gain by 0.67 g·kg-1·day-1 (MD: 0.67 g·kg-1·day-1; 95% CI: 0.28, 1.06; two studies; 5,052 participants; moderate-quality outcome) and probably reduces mortality by 26% (RR: 0.74; 95% CI: 0.55, 0.98; three studies; 6944 participants; moderate quality outcome) compared to no antibiotics group. High-dose vitamin A versus low-dose vitamin A (two studies): There was no evidence of effect on weight gain (MD: 0.05 g·kg-1·day-1; 95% CI: -0.08 to 0.18; one study; 207 participants; moderate-quality outcome) and mortality (RR: 7.07; 95% CI: 0.37 to 135.13; one study; 207 participants; moderate-quality outcome). Authors’ conclusions Limited data show some benefit of integrated community-based screening, identification and management of SAM and MAM on improving recovery. Facility-based screening and management of uncomplicated SAM has no benefit on recovery and mortality, while the effect of F100 for SAM is similar to RUTF for weight gain and mortality. Local food and whey RUSF have similar effects as standard RUSF on recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate, weight gain and reduces mortality, while limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.
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Affiliation(s)
- Jai K. Das
- Division of Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Rehana A. Salam
- Division of Women and Child HealthAga Khan University HospitalKarachiPakistan
| | - Marwah Saeed
- Division of Women and Child Health, Aga Khan UniversityKarachiPakistan
| | - Faheem Ali Kazmi
- Division of Women and Child Health, Aga Khan UniversityKarachiPakistan
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick ChildrenTorontoOntarioCanada
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Abitew DB, Yalew AW, Bezabih AM, Bazzano AN. Predictors of relapse of acute malnutrition following exit from community-based management program in Amhara region, Northwest Ethiopia: An unmatched case-control study. PLoS One 2020; 15:e0231524. [PMID: 32320426 PMCID: PMC7176369 DOI: 10.1371/journal.pone.0231524] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 03/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Community-based management of acute malnutrition (CMAM) is an effective program to manage children with acute malnutrition, including both severe and moderate acute malnutrition. However, little is known about continued child nutritional status after discharge from community based management of acute malnutrition programs in Ethiopia. OBJECTIVE The study aimed to identify factors associated with relapse of acute malnutrition among children 6-59 months after been discharged recovered from community based management program in South Gondar Zone, Northwest Ethiopia. METHODS A case-control study was conducted in three districts of South Gondar Zone by tracing children age 6-59 months who were reported as recovered from the community based management program. Sample size calculated for the first objective of assessing prevalence of severe acute malnutrition among children following discharge as recovery using Epi- Info version 7.1.3.3 StatCalc taking 95% CL, 17.8% post discharge relapse (Ashraf H, et al. (2012), 3% margin of error, design effect of 2 and adding 5% non-response rate was the largest sample size and used to this study. Children with Mid Upper Arm Circumference (MUAC) <12.5cm constituted cases and children with > = 12.5cm served as controls. Data were collected from 10 November 2017 to 30 January 2018 using a survey questionnaire and families were asked to bring children to a health facility for anthropometric measurements, following which data were entered and analyzed. Bivariate and multivariable logistic regression models were utilized to measure association between the risk factors and acute malnutrition. RESULTS Overall, 1,273 participants were interviewed. The mean age in months of children was 23.1 (±9.1 SD) for cases and 23.1 (±8.9 SD) for controls. About 40% of the cases and 50% of the controls were female children. The factors associated with acute malnutrition were: male children (AOR = 1.84, 95% CI: 1.42-2.39), living in a food insecure household (AOR = 1.67, 95% CI:1.15-2.44), non-receipt of Vitamin A supplement (AOR = 1.76, 95% CI: 1.28-2.41), prelacteal feeding (AOR = 2.81 (95%CI, 1.57-5.05), distance to water source more than 15 walk (AOR = 1.88, 95% CI:1.32-2.71), less frequent self-reported hand washing (AOR = 1.35, 95% CI:1.05-1.75), mother not having consumed extra food during this pregnancy/lactation (AOR = 1.36, 95% CI: 1.03-1.78), and respondent age above 30 years (AOR = 1.43, 95% CI:1.10-1.87). CONCLUSION The key factors contributing to relapse of acute malnutrition were related to childcare and feeding practices. Social and behavior change communication strategies targeting families at risk of undernutrition, along with improved food security and integrated programming are recommended to prevent relapse of acute malnutrition.
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Affiliation(s)
| | | | | | - Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States of America
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10
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Abitew DB, Worku A, Mulugeta A, Bazzano AN. Rural children remain more at risk of acute malnutrition following exit from community based management of acute malnutrition program in South Gondar Zone, Amhara Region, Ethiopia: a comparative cross-sectional study. PeerJ 2020; 8:e8419. [PMID: 32071802 PMCID: PMC7008819 DOI: 10.7717/peerj.8419] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/17/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Community-based management of acute malnutrition has been reported effective in terms of recovery rate, but recovered children may be at increased risk of developing acute malnutrition after returning to the same household (HH) environment. OBJECTIVE Compare the magnitude and factors associated with acute malnutrition among recovered and never treated children in South Gondar Zone, Amhara Region, Ethiopia. METHOD A comparative cross-sectional study was conducted in three districts of South Gondar Zone by tracing 720 recovered and an equal number of age matched children who were never treated for acute malnutrition. Parents were asked to bring children to health post for survey data collection, anthropometric measurements, and edema assessment. Data were collected using a survey questionnaire, entered in to EpiData and analyzed using SPSS v20. Anthropometric indices were generated according to the WHO's 2006 Child Growth Standards using WHO Anthro software version 3.2.2. Bivariate and multivariable logistic regression was utilized. Values with P < 0.05 were considered statistically significant and Odds Ratio with 95% CI was used to measure strength of association. RESULT A total of 1,440 parents were invited, of which 1,414 participated (98.2% response rate). Mean age in months of children (±SD) was 23.7 (±10.4) for recovered and 23.3 (±10.8) for comparison group. About 49% of recovered and 46% of comparison children were females. A significant difference was observed on magnitude of acute malnutrition between recovered (34.2% (95% CI [30.9-38.0]) and comparison groups (26.7% (95% CI [23.5-30.2]), P = 0.002. Factors associated with acute malnutrition among recovered were district of Ebnat (AOR = 3.7; 95% CI [1.9-7.2]), Tach-Gayint (AOR = 2.4; 95% CI [1.2-4.7]); male child (AOR = 1.4; 95% CI [1.0-2.0]); prelactal feeding (AOR = 2.6; 95% CI [1.3 -5.1]); not feeding colostrum (AOR = 1.5; 95% CI [1.1-2.3]); not consuming additional food during pregnancy/lactation (AOR = 1.6; 95% CI [1.1-2.3]); not given Vitamin A supplement (AOR = 2.1; 95% CI [1.4-3.2]); and safe child feces disposal practice (AOR = 1.7; 95% CI [1.2-2.5]) while district of Tach-Gayint (AOR = 2.5; 95% CI [1.3-4.8]); male child (AOR = 1.5; 95% CI [1.1-2.1]), not feeding colostrum (AOR = 1.7; 95% CI [1.2-2.5]), poor hand washing practice (AOR = 1.6; 95% CI [1.1-2.2]); food insecure HH (AOR = 1.6; 95% CI [1.1-2.4]), birth interval <24 months (AOR = 1.9; 95% CI [1.2-3.2]), and poor access to health facility (AOR = 1.7; 95% CI [1.2-2.4]) were factors associated with acute malnutrition among comparison group. CONCLUSION Recovered children were more at risk of acute malnutrition than the comparison group. Nutrition programs should invest in improving nutrition counseling and education; as well as the hygienic practices to protect children against post-discharge relapse of acute malnutrition.
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Affiliation(s)
- Dereje B. Abitew
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemayehu Worku
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
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11
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Stobaugh HC, Rogers BL, Rosenberg IH, Webb P, Maleta KM, Manary MJ, Trehan I. Children with Poor Linear Growth Are at Risk for Repeated Relapse to Wasting after Recovery from Moderate Acute Malnutrition. J Nutr 2018; 148:974-979. [PMID: 29726948 DOI: 10.1093/jn/nxy033] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/30/2018] [Indexed: 02/06/2023] Open
Abstract
Background Nutrition programs frequently approach wasting and stunting as 2 separate conditions with distinct causes and effects. Although several cross-sectional studies have identified an association between the 2 conditions, longitudinal studies are useful to quantify the risk of acute malnutrition based on the trajectory of linear growth. Objective We analyzed data from a longitudinal study to explore associations between linear growth and relapse to acute malnutrition in high-risk children during the year after recovery from moderate acute malnutrition (MAM). Methods This was a secondary data analysis from a cluster randomized trial involving 1487 Malawian children 6-62 mo old treated for MAM and enrolled upon recovery. Children were followed for 1 y, during which data were collected on anthropometric progress, symptoms of illness, and household food security. Multivariate fixed-effects logistic regression was used to identify associations between linear growth and relapse to acute malnutrition. Results Children who have recovered from MAM proved to be a high-risk population, with nearly half experiencing a decrease in height-for-age z score (HAZ) for 12 mo. Children whose HAZ was declining were more likely to relapse to MAM or SAM than were those whose linear growth rate maintained or increased their HAZ (P < 0.001). Mean changes of +0.15, -0.03, -0.17, and -0.53 in HAZ were observed for those who sustained recovery, relapsed to MAM once, relapsed to MAM multiple times, and developed SAM, respectively. Conclusion Our results add to the body of evidence suggesting that acute wasting is a harbinger of subsequent stunting. Children who experience poor linear growth after MAM are more likely to experience relapse. Given this bidirectional relation between wasting and stunting, supplementary feeding programs should consider both when designing protocols, aiming to optimize linear growth and achieve acute weight gain, as a means of reducing relapse. This trial was registered at clinicaltrials.gov as NCT02351687.
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Affiliation(s)
- Heather C Stobaugh
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA.,RTI International, Research Triangle Park, NC
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, and Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,School of Public Health and Family Medicine, and Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi.,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi.,Lao Friends Hospital for Children, Luang Prabang, Lao PDR
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12
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Household-level factors associated with relapse following discharge from treatment for moderate acute malnutrition. Br J Nutr 2018; 119:1039-1046. [PMID: 29502542 DOI: 10.1017/s0007114518000363] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Factors associated with relapse among children who are discharged after reaching a threshold denoted 'recovered' from moderate acute malnutrition (MAM) are not well understood. The aim of this study was to identify factors associated with sustained recovery, defined as maintaining a mid-upper-arm circumference≥12·5 cm for 1 year after release from treatment. On the basis of an observational study design, we analysed data from an in-depth household (HH) survey on a sub-sample of participants within a larger cluster randomised controlled trial (cRCT) that followed up children for 1 year after recovery from MAM. Out of 1497 children participating in the cRCT, a subset of 315 children participated in this sub-study. Accounting for other factors, HH with fitted lids on water storage containers (P=0·004) was a significant predictor of sustained recovery. In addition, sustained recovery was better among children whose caregivers were observed to have clean hands (P=0·053) and in HH using an improved sanitation facility (P=0·083). By contrast, socio-economic status and infant and young child feeding practices at the time of discharge and HH food security throughout the follow-up period were not significant. Given these results, we hypothesise that improved water, sanitation and hygiene conditions in tandem with management of MAM through supplemental feeding programmes have the possibility to decrease relapse following recovery from MAM. Furthermore, the absence of associations between relapse and nearly all HH-level factors indicates that the causal factors of relapse may be related mostly to the child's individual, underlying health and nutrition status.
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13
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Adamu W, Jara D, Alemayehu M, Burrowes S. Risk factors associated with poor health outcomes for children under the age of 5 with moderate acute malnutrition in rural fagita lekoma district, Awi Zone, Amhara, Ethiopia, 2016. BMC Nutr 2017; 3:88. [PMID: 32153864 PMCID: PMC7050731 DOI: 10.1186/s40795-017-0208-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Left untreated, moderate acute malnutrition (MAM) in children can lead to severe acute malnutrition, stunting, developmental delays, and death. Despite recent progress the prevalence of malnutrition remains high throughout Ethiopia. The ability to make accurate prognoses and develop effective treatment strategies for children with MAM is currently limited and, as result, a significant proportion of children with MAM fail to recover even with treatment. We seek to address this limitation by assessing the risk factors for poor outcomes among children under the age of 5 with MAM in a rural area of Ethiopia's Amhara Region. This region is considered relatively food secure and does not have food supplementation treatment programs. METHODS We conducted a prospective cohort study of 404 randomly sampled children, 0-59 months old stratified by household food security status. We followed the study children for approximately 2 months, assessing their health status; and used bivariate and multivariate Cox-proportional hazard regression models to identify risk factors for poor health outcomes. RESULTS Household food security was significantly associated with low recovery from MAM: 191 (60%) of children in food-insecure and 129 (40%) of children in food-secure households had poor health outcomes. The risk factors found to be significantly associated with poor health outcomes included the duration of exclusive breastfeeding (AHR 1.50, 95%CI: 1.05, 2.15), dietary diversity (AHR 1.74, 95%CI: 1.18, 2.54), and maternal mid-upper arm circumference (AHR=1.36, 95% CI: 1.04, 1.86). Children from pregnancies that were wanted but unplanned had 80% higher incidence of poor health outcomes than others, and children from pregnancies that were both unwanted and unplanned had more than double the incidence of poor health outcomes compared to their counterparts. CONCLUSION We found that without treatment, the majority of children from food insecure households and over a third of children from food secure households did not recover from MAM. Maternal factors particularly the mother's ability to plan her pregnancy were the main determinants of recovery in this study. Together these findings support arguments for targeting of nutrition support programs to vulnerable households regardless of regional food security status, and for closely integrating robust family planning, and antenatal care services with nutrition interventions.
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Affiliation(s)
| | - Dube Jara
- Department of Public Health, College of Medicine and Health Science Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Mulunesh Alemayehu
- Department of Public Health, College of Medicine and Health Science Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Sahai Burrowes
- Public Health Program, College of Education and Health Sciences, Touro University California, 1310 Club Drive, Mare Island Vallejo, CA 94592 USA
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14
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Stobaugh HC, Bollinger LB, Adams SE, Crocker AH, Grise JB, Kennedy JA, Thakwalakwa C, Maleta KM, Dietzen DJ, Manary MJ, Trehan I. Effect of a package of health and nutrition services on sustained recovery in children after moderate acute malnutrition and factors related to sustaining recovery: a cluster-randomized trial. Am J Clin Nutr 2017; 106:657-666. [PMID: 28615258 PMCID: PMC6482975 DOI: 10.3945/ajcn.116.149799] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/15/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Children who recover from moderate acute malnutrition (MAM) have high rates of relapse in the year after nutritional recovery. Interventions to decrease these adverse outcomes are needed to maximize the overall effectiveness of supplemental feeding programs (SFPs).Objective: We evaluated the effectiveness of a package of health and nutrition interventions on improving the proportion of children who sustained recovery for 1 y after MAM treatment. We further explored factors related to sustained recovery.Design: We conducted a cluster-randomized clinical effectiveness trial involving rural Malawian children aged 6-62 mo who were enrolled on discharge from an SFP for MAM. We enrolled 718 children at 10 control sites and 769 children at 11 intervention sites. In addition to routine health and nutrition counseling, the intervention group received a package of health and nutrition interventions that consisted of a lipid nutrient supplement, deworming medication, zinc supplementation, a bed net, and malaria chemoprophylaxis. A survival analysis was used to determine the effectiveness of the intervention as well as to identify factors associated with sustained recovery.Results: Of 1383 children who returned for the full 12-mo follow-up period, 407 children (56%) and 347 children (53%) sustained recovery in the intervention and control groups, respectively. There was no significant difference in relapse-free survival curves between the treatment and control groups (P = 0.380; log-rank test). The risk factors for relapse or death after initial recovery were a smaller midupper arm circumference on SFP admission (P = 0.01) and discharge (P < 0.001), a lower weight-for-height z score on discharge (P < 0.01), and the receipt of ready-to-use supplementary food as opposed to ready-to-use therapeutic food during treatment (P < 0.05).Conclusion: The provision of a package of health and nutrition services in addition to traditional SFP treatment has no significant effect on improving sustained recovery in children after treatment of MAM. This trial was registered at clinicaltrials.gov as NCT02351687.
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Affiliation(s)
- Heather C Stobaugh
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Lucy B Bollinger
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Sara E Adams
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Audrey H Crocker
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Jennifer B Grise
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Julie A Kennedy
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | | | | | - Dennis J Dietzen
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- School of Public Health and Family Medicine and
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX; and
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO;
- Department of Pediatrics and Child Health, University of Malawi, Blantyre, Malawi
- Partners In Health, Harper, Liberia
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15
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Magnin M, Stoll B, Voahangy R, Jeannot E. Most children who took part in a comprehensive malnutrition programme in Madagascar reached and maintained the recovery threshold. Acta Paediatr 2017; 106:960-966. [PMID: 28231385 DOI: 10.1111/apa.13796] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 12/07/2016] [Accepted: 02/20/2017] [Indexed: 11/28/2022]
Abstract
AIM The benefits of including nutritional education in programmes that tackle moderate and severe acute malnutrition remain poorly documented. This study in Madagascar evaluated the nutritional status of children who took part in an innovative programme that included maternal education, on completion and after a year. METHODS Each year, this outpatient programme admits 2400 malnourished children from six months to 59 months in the lower districts of Antananarivo, Madagascar. Children were drawn by lots, and their anthropometric data were measured. A descriptive retrospective longitudinal study was conducted on 573 children who took part between 2010 and 2013. RESULTS The programme lasted an average of 38 days and, on completion, 82.2% had reached the recovery threshold, and 16.2% had moved up to mild malnutrition. This was achieved with food supplements of 720 kcal per day, despite the Malagasy Public Health recommendation of 1000-1500 kcal per day. After one year, 79.1% were still above the recovery threshold, and 15% had mild malnutrition. The recovery rate was higher for children under 24 months of age (odds ratio 2.9, 95% confidence interval 1.93-4.59). CONCLUSION Most children who attended this malnutrition programme with maternal education in Madagascar reached the recovery threshold on completion and had maintained it after one year.
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Affiliation(s)
- Margot Magnin
- Faculty of Medicine; Institute of Global Health; University of Geneva; Geneva Switzerland
| | - Beat Stoll
- Faculty of Medicine; Institute of Global Health; University of Geneva; Geneva Switzerland
| | - Rajaobelina Voahangy
- Medical Dispensary, Maternity Ward and CRENAM (Outpatient Nutritional Recovery and Education Centres Which Deal with Moderate Acute Cases of Malnutrition) of Anosizato and Miray Association; Antananarivo Madagascar
| | - Emilien Jeannot
- Faculty of Medicine; Institute of Global Health; University of Geneva; Geneva Switzerland
- School of Health Sciences; University of Applied Sciences and Arts, Western Switzerland; Geneva Switzerland
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16
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Grellety E, Babakazo P, Bangana A, Mwamba G, Lezama I, Zagre NM, Ategbo EA. Effects of unconditional cash transfers on the outcome of treatment for severe acute malnutrition (SAM): a cluster-randomised trial in the Democratic Republic of the Congo. BMC Med 2017; 15:87. [PMID: 28441944 PMCID: PMC5405483 DOI: 10.1186/s12916-017-0848-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/30/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cash transfer programs (CTPs) aim to strengthen financial security for vulnerable households. This potentially enables improvements in diet, hygiene, health service access and investment in food production or income generation. The effect of CTPs on the outcome of children already severely malnourished is not well delineated. The objective of this study was to test whether CTPs will improve the outcome of children treated for severe acute malnutrition (SAM) in the Democratic Republic of the Congo over 6 months. METHODS We conducted a cluster-randomised controlled trial in children with uncomplicated SAM who received treatment according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. Analyses were by intention to treat. RESULTS The hazard ratio of reaching full recovery from SAM was 35% higher in the intervention group than the control group (adjusted hazard ratio, 1.35, 95% confidence interval (CI) = 1.10 to 1.69, P = 0.007). The adjusted hazard ratios in the intervention group for relapse to moderate acute malnutrition (MAM) and SAM were 0.21 (95% CI = 0.11 to 0.41, P = 0.001) and 0.30 (95% CI = 0.16 to 0.58, P = 0.001) respectively. Non-response and defaulting were lower when the households received cash. All the nutritional outcomes in the intervention group were significantly better than those in the control group. After 6 months, 80% of cash-intervened children had re-gained their mid-upper arm circumference measurements and weight-for-height/length Z-scores and showed evidence of catch-up. Less than 40% of the control group had a fully successful outcome, with many deteriorating after discharge. There was a significant increase in diet diversity and food consumption scores for both groups from baseline; the increase was significantly greater in the intervention group than the control group. CONCLUSIONS CTPs can increase recovery from SAM and decrease default, non-response and relapse rates during and following treatment. Household developmental support is critical in food insecure areas to maximise the efficiency of SAM treatment programs. TRIAL REGISTRATION ClinicalTrials.gov, NCT02460848 . Registered on 27 May 2015.
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Affiliation(s)
| | - Pélagie Babakazo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Amina Bangana
- United Nations International Children Emergency Fund, Kinshasa, Democratic Republic of the Congo
| | - Gustave Mwamba
- Save the Children United Kingdom, Kinshasa, Democratic Republic of the Congo
| | - Ines Lezama
- United Nations International Children Emergency Fund, Kinshasa, Democratic Republic of the Congo
| | - Noël Marie Zagre
- United Nations International Children Emergency Fund West and Central Africa Regional Office, Dakar, Senegal
| | - Eric-Alain Ategbo
- United Nations International Children Emergency Fund, Kinshasa, Democratic Republic of the Congo
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Bhandari N, Mohan SB, Bose A, Iyengar SD, Taneja S, Mazumder S, Pricilla RA, Iyengar K, Sachdev HS, Mohan VR, Suhalka V, Yoshida S, Martines J, Bahl R. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Glob Health 2016; 1:e000144. [PMID: 28588982 PMCID: PMC5321385 DOI: 10.1136/bmjgh-2016-000144] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the efficacy of ready-to-use therapeutic food (RUTF), centrally produced RUTF (RUTF-C) or locally prepared RUTF (RUTF-L) for home-based management of uncomplicated severe acute malnutrition (SAM) compared with micronutrient-enriched (augmented) energy-dense home-prepared foods (A-HPF, the comparison group). METHODS In an individually randomised multicentre trial, we enrolled 906 children aged 6-59 months with uncomplicated SAM. The children enrolled were randomised to receive RUTF-C, RUTF-L or A-HPF. We provided foods, counselling and feeding support until recovery or 16 weeks, whichever was earlier and measured outcomes weekly (treatment phase). We subsequently facilitated access to government nutrition services and measured outcomes once 16 weeks later (sustenance phase). The primary outcome was recovery during treatment phase (weight-for-height ≥-2 SD and absence of oedema of feet). RESULTS Recovery rates with RUTF-L, RUTF-C and A-HPF were 56.9%, 47.5% and 42.8%, respectively. The adjusted OR was 1.71 (95% CI 1.20 to 2.43; p=0.003) for RUTF-L and 1.28 (95% CI 0.90 to 1.82; p=0.164) for RUTF-C compared with A-HPF. Weight gain in the RUTF-L group was higher than in the A-HPF group (adjusted difference 0.90 g/kg/day, 95% CI 0.30 to 1.50; p=0.003). Time to recovery was shorter in both RUTF groups. Morbidity was high and similar across groups. At the end of the study, the proportion of children with weight-for-height Z-score (WHZ) >-2 was similar (adjusted OR 1.12, 95% CI 0.74 to 1.95; p=0.464), higher for moderate malnutrition (WHZ<-2 and ≥-3; adjusted OR 1.46, 95% CI 1.02 to 2.08; p=0.039), and lower for those with SAM (adjusted OR 0.58, 95% CI 0.40 to 0.85; p=0.005) in the RUTF-L when compared with the A-HPF group. CONCLUSIONS This first randomised trial comparing options for home management of uncomplicated SAM confirms that RUTF-L is more efficacious than A-HPF at home. Recovery rates were lower than in African studies, despite longer treatment and greater support for feeding. TRIAL REGISTRATION NUMBER NCT01705769; Pre-results.
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Affiliation(s)
- Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | | | - Anuradha Bose
- Christian Medical College, Vellore, Tamil Nadu, India
| | - Sharad D Iyengar
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Sarmila Mazumder
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | | | - Kirti Iyengar
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | | | | | - Virendra Suhalka
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
| | - Jose Martines
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
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An important chapter in the infection-malnutrition story. LANCET GLOBAL HEALTH 2016; 4:e430-1. [PMID: 27289200 DOI: 10.1016/s2214-109x(16)30110-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 06/05/2016] [Indexed: 11/23/2022]
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Meyer R, Marino L. Identifying acute malnutrition – do we have an answer for policy makers? BMC Nutr 2016. [DOI: 10.1186/s40795-016-0060-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Stobaugh HC, Ryan KN, Kennedy JA, Grise JB, Crocker AH, Thakwalakwa C, Litkowski PE, Maleta KM, Manary MJ, Trehan I. Including whey protein and whey permeate in ready-to-use supplementary food improves recovery rates in children with moderate acute malnutrition: a randomized, double-blind clinical trial. Am J Clin Nutr 2016; 103:926-33. [PMID: 26864368 DOI: 10.3945/ajcn.115.124636] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 12/22/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The utility of dairy ingredients in the supplementary foods used in the treatment of childhood moderate acute malnutrition (MAM) remains unsettled. OBJECTIVE We evaluated the effectiveness of a peanut-based ready-to-use supplementary food (RUSF) with soy protein compared with a novel RUSF containing dairy ingredients in the form of whey permeate and whey protein concentrate in the treatment of children with MAM. DESIGN We conducted a randomized, double-blind clinical effectiveness trial involving rural Malawian and Mozambican children 6-59 mo of age with MAM treated with either soy RUSF or a novel whey RUSF treatment of ~75 kcal · kg(-1) · d(-1) for up to 12 wk. RESULTS The proportion of children that recovered from MAM was significantly higher in the group that received whey RUSF (960 of 1144; 83.9%) than in the group that received soy RUSF (874 of 1086; 80.5%; P < 0.04; risk difference 3.4%, 95% CI: 0.3%, 6.6%). Children who consumed whey RUSF also demonstrated better growth markers, with a higher mean midupper arm circumference (MUAC) at the time of discharge (P < 0.009), greater MUAC gain during the course of treatment (P < 0.003), higher mean weight-for-height z score at discharge (P < 0.008), and greater weight gain (P < 0.05). No significant differences were identified in length gain or time to recovery between the 2 groups. CONCLUSION This study highlights the importance of milk protein in the treatment of MAM, because the use of a novel whey RUSF resulted in higher recovery rates and improved growth than did soy RUSF, although the whey RUSF supplement provided less total protein and energy than the soy RUSF. This study was registered at clinicaltrials.gov as NCT01790048.
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Affiliation(s)
- Heather C Stobaugh
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA; Departments of Pediatrics and
| | | | | | | | | | | | | | | | - Mark J Manary
- Departments of Pediatrics and Departments of Community Health and Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - Indi Trehan
- Departments of Pediatrics and Paediatrics and Child Health, University of Malawi, Blantyre, Malawi; and
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Fabiansen C, Phelan KP, Cichon B, Ritz C, Briend A, Michaelsen KF, Friis H, Shepherd S. Short children with a low midupper arm circumference respond to food supplementation: an observational study from Burkina Faso. Am J Clin Nutr 2016; 103:415-21. [PMID: 26739038 DOI: 10.3945/ajcn.115.124644] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 12/04/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The management of children with moderate acute malnutrition (MAM) is based on food supplementation in outpatient programs. When midupper arm circumference (MUAC) is used as the sole admission criterion, it is common practice to exclude children with lengths <67 cm from treatment. The WHO calls for research to determine the treatment effect among children with MAM included by MUAC and aged ≥6 mo with lengths <67 cm. OBJECTIVE We hypothesized that among children given supplementary feeding based on an MUAC of 115-124 mm as the sole criterion, there would be no difference in growth rate between children <67 cm and those ≥67 cm in length at program admission. DESIGN This was an observational study nested in a randomized trial that investigated the effectiveness of new formulations of corn-soy blend and lipid-based nutrient supplements. Children aged 6-23 mo were included if their MUAC was between 115 and 124 mm but with a weight-for-height z score (WHZ) ≥-2. This cohort was divided into 2 groups by length at admission: <67 cm ("short") and ≥67 cm ("long"). Linear mixed-effects models and regression models were used to compare gains in weight and MUAC while adjusting for intervention, season, sex, age, and site. RESULTS Weight-gain velocity (expressed as g · kg(-1) · d(-1)) and MUAC-gain velocity (expressed as 0.01 mm · cm(-1) · d(-1)) were not different between short and long children. Weight-gain velocity was slightly higher in the shortest quartile of length (P = 0.03), whereas there was no effect modification by stunting across length quartiles (P = 0.32). CONCLUSIONS We found no evidence of a difference in percentage of weight gain or weight-gain velocity during supplementary feeding in short or long children aged 6-23 mo. We recommend a policy change to include children <67 cm in supplementary feeding programs if their MUAC is between 115 and 124 mm and their WHZ is ≥-2. This could benefit millions of children currently excluded from supplementary feeding. This trial was registered at www.controlled-trials.com as ISRCTN42569496.
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Affiliation(s)
- Christian Fabiansen
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark; Médecins Sans Frontières-Denmark, Copenhagen, Denmark
| | - Kevin Pq Phelan
- Alliance for International Medical Action, Dakar, Senegal; and
| | - Bernardette Cichon
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Christian Ritz
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - André Briend
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark; Department for International Health, University of Tampere School of Medicine, Tampere, Finland
| | - Kim F Michaelsen
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal; and
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Extending supplementary nutrition in malnutrition: more is better? J Pediatr Gastroenterol Nutr 2015; 60:424-5. [PMID: 25611035 DOI: 10.1097/mpg.0000000000000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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