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Hartman SJ, Hibberd MC, Mostafa I, Naila NN, Islam MM, Zaman MU, Huq S, Mahfuz M, Islam MT, Mukherji K, Moghaddam VA, Chen RY, Province MA, Webber DM, Henrissat S, Henrissat B, Terrapon N, Rodionov DA, Osterman AL, Barratt MJ, Ahmed T, Gordon JI. A microbiome-directed therapeutic food for children recovering from severe acute malnutrition. Sci Transl Med 2024; 16:eadn2366. [PMID: 39356745 DOI: 10.1126/scitranslmed.adn2366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 07/22/2024] [Indexed: 10/04/2024]
Abstract
Globally, severe acute malnutrition (SAM), defined as a weight-for-length z-score more than three SDs below a reference mean (WLZ < -3), affects 14 million children under 5 years of age. Complete anthropometric recovery after standard, short-term interventions is rare, with children often left with moderate acute malnutrition (MAM; WLZ -2 to -3). We conducted a randomized controlled trial (RCT) involving 12- to 18-month-old Bangladeshi children from urban and rural sites, who, after initial hospital-based treatment for SAM, received a 3-month intervention with a microbiome-directed complementary food (MDCF-2) or a calorically more dense, standard ready-to-use supplementary food (RUSF). The rate of WLZ improvement was significantly greater in MDCF-2-treated children (P = 8.73 × 10-3), similar to our previous RCT of Bangladeshi children with MAM without antecedent SAM (P = 0.032). A correlated meta-analysis of plasma levels of 4520 proteins in both RCTs revealed 215 positively associated with WLZ (largely representing musculoskeletal and central nervous system development) and 44 negatively associated (primarily related to immune activation). Moreover, the positively associated proteins were significantly enriched by MDCF-2 (q = 1.1 × 10-6). Characterizing the abundances of 754 bacterial metagenome-assembled genomes in serially collected fecal samples disclosed the effects of acute rehabilitation for SAM on the microbiome and how, during treatment for MAM, specific strains of Prevotella copri function at the intersection between MDCF-2 glycan metabolism and anthropometric recovery. These results provide a rationale for further testing the generalizability of MDCF efficacy and for identifying biomarkers to define treatment responses.
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Affiliation(s)
- Steven J Hartman
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Newman Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Matthew C Hibberd
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Newman Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ishita Mostafa
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Nurun N Naila
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Md Munirul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Mahabub Uz Zaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Sayeeda Huq
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Mustafa Mahfuz
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Md Tazul Islam
- Terre des Hommes Netherlands - Bangladesh Country Office, Dhaka 1209, Bangladesh
| | - Kallol Mukherji
- Terre des Hommes Netherlands - Bangladesh Country Office, Dhaka 1209, Bangladesh
| | - Vaha Akbary Moghaddam
- Division of Statistical Genomics, Department of Genetics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Robert Y Chen
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Newman Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michael A Province
- Division of Statistical Genomics, Department of Genetics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Daniel M Webber
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Newman Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Suzanne Henrissat
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Newman Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Bernard Henrissat
- Department of Biotechnology and Biomedicine (DTU Bioengineering), Technical University of Denmark, DK-2800 Kgs. Lyngby, Denmark
| | - Nicolas Terrapon
- Architecture et Fonction des Macromolécules Biologiques, CNRS, Aix-Marseille University, F-13288 Marseille, France
| | - Dmitry A Rodionov
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Andrei L Osterman
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Michael J Barratt
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Newman Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Jeffrey I Gordon
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Newman Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Daures M, Hien J, Cazes C, Alitanou R, Saillet L, Séri B, Aly AAM, Maidadji O, Sanoussi A, Mahamadou A, Altmann M, Phelan K, Becquet R, Shepherd S. Factors associated with non-response and nutrional status of non-responders at 6-month post-discharge: a cohort study nested in a MUAC-based nutrition programme for acutely malnourished children in Mirriah, Niger. Front Public Health 2024; 12:1357891. [PMID: 39206006 PMCID: PMC11349736 DOI: 10.3389/fpubh.2024.1357891] [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: 12/18/2023] [Accepted: 07/08/2024] [Indexed: 09/04/2024] Open
Abstract
Background In the treatment of acute malnutrition (AM), non-response is considered a treatment failure for not meeting recovery criteria within a therapeutic window of 12-16 weeks, but this category of children is misunderstood. As current research emphasizes ways to simplify and optimize treatment protocols, non-response emerges as a new issue to enhance program efficiency. Methods A prospective cohort study was conducted from 2019 to 2020 at two health centres in Mirriah, Niger among children aged 6-59 months with uncomplicated AM treated under the Optimising treatment for Acute MAlnutrition (OptiMA) protocol. Children who did not meet recovery criteria by 12 weeks (mid-upper arm circumference (MUAC) ≥125 mm without oedema for two consecutive weeks) were classified as non-responders. Non-responders received a home visit six-months post-discharge. Logistic regression was used to analyze factors associated with non-responders compared with children who recovered. Results Of the 1,112 children enrolled, 909 recovered and 139 were non-responders, of which 127 (80.6%) had significant MUAC gain (mean: +9.6 mm, sd = 5.1) at discharge. Girls (adjusted hazard ratio (aHR) = 2.07, 95% CI 1.33-3.25), children <12 months of age (aHr = 4.23, 95% CI 2.02-9.67), those with a MUAC <115 mm (aHR = 11.1, 95% CI 7.23-17.4) or severe stunting (aHR = 2.5, 1.38-4.83) at admission and a negative or flat MUAC trajectory between admission and week 4 (aHR = 4.66, 95% CI 2.54-9.13) were more likely to be non-responders. The nutritional status of non-responders had generally improved 6 months after discharge, but only 40% had achieved MUAC ≥125 mm. Conclusion Non-responders are not a homogeneous group; while most children ultimately show significant nutritional improvement, rapid hospital referral is crucial for those not gaining MUAC early in treatment. As efforts to expand MUAC-based programming progress, adapting exit criterion and/or providing additional food supplementation with smaller daily ration for children with risk factors discussed here may help improve programme efficiency without adding to the cost of treatment.
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Affiliation(s)
- Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Jérémie Hien
- The Alliance for International Medical Action (ALIMA), Niamey, Niger
| | - Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Niamey, Niger
| | - Laure Saillet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Benjamin Séri
- PRISME-CI ANRS|MIE Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | | | | | - Atté Sanoussi
- Ministry of Health, Nutrition Division, Niamey, Niger
| | - Aboubacar Mahamadou
- High-Commission of the Nigériens Nourrissent les Nigériens (3N) Initiative, Niamey, Niger
| | - Mathias Altmann
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
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Houngbédji M, Jespersen JS, Wilfrid Padonou S, Jespersen L. Cereal-based fermented foods as microbiota-directed products for improved child nutrition and health in sub-Saharan Africa. Crit Rev Food Sci Nutr 2024:1-22. [PMID: 38973125 DOI: 10.1080/10408398.2024.2365342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Several strategies, programs and policies have long been developed and implemented to alleviate child malnutrition in sub-Saharan African countries. However, stunting and wasting still persist at an alarming rate, suggesting that alternative strategies are needed to induce faster progress toward the 2030 SDGs targets of reducing malnutrition. Gut microbiota-directed intervention is now being recognized as an unconventional powerful approach to mitigate malnutrition and improve overall child health. In an African setting, manufactured probiotic and synbiotic foods or supplements may not be successful owing to the non-affordability and high attachment of African populations to their food tradition. This review analyses the potential of indigenous fermented cereal-based products including porridges, doughs, beverages, bread- and yoghurt-like products, to be used as microbiota-directed foods for over 6 months children. The discussion includes relevant strategies to effectively enhance the beneficial effects of these products on gut microbiota composition for improved child health and nutrition in sub-Saharan Africa. Characterization of probiotic features and general safety of food processing in sub-Saharan Africa as well as randomized clinical studies are still lacking to fully ascertain the health effects and suitability of these fermented foods in preventing and treating child malnutrition and diarrhea.
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Affiliation(s)
- Marcel Houngbédji
- Laboratoire de Sciences et Technologies des Aliments, Faculté des Sciences Agronomiques, Université d'Abomey-Calavi, Jéricho, Cotonou, Benin
- Laboratoire de Sciences et Technologie des Aliments, des Bioressources et de Nutrition Humaine, Université Nationale d'Agriculture, Sakété, Bénin
| | | | - Sègla Wilfrid Padonou
- Laboratoire de Sciences et Technologies des Aliments, Faculté des Sciences Agronomiques, Université d'Abomey-Calavi, Jéricho, Cotonou, Benin
- Laboratoire de Sciences et Technologie des Aliments, des Bioressources et de Nutrition Humaine, Université Nationale d'Agriculture, Sakété, Bénin
| | - Lene Jespersen
- Department of Food Science, University of Copenhagen, Copenhagen, Frederiksberg C, Denmark
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MacLeod C, Ngabirano L, N'Diaye DS, Braun L, Cumming O. Household-level water, sanitation and hygiene factors and interventions and the prevention of relapse after severe acute malnutrition recovery: A systematic review. MATERNAL & CHILD NUTRITION 2024; 20:e13634. [PMID: 38372439 PMCID: PMC11168358 DOI: 10.1111/mcn.13634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/20/2024]
Abstract
Severe acute malnutrition (SAM) is the most serious form of acute malnutrition and is associated with high mortality risk among children under 5. While the Community-based Management of Acute Malnutrition (CMAM) approach, recommended for treating cases of uncomplicated SAM, has increased treatment coverage and recovery outcomes, high relapse rates have been reported. Several risk factors for SAM relapse, such as insufficient food intake and high infectious disease burden in the community, have been identified. However, the role of household water, sanitation and hygiene (WASH) conditions remains unclear. This systematic review: (1) assesses the effectiveness of WASH interventions on preventing SAM relapse and (2) identifies WASH-related conditions associated with relapse to SAM among children aged 6-59 months discharged as recovered following SAM CMAM treatment. We performed electronic searches of six databases to identify relevant studies published between 1 January 2000 and 6 November 2023 and assessed their quality. After deduplication, 10,294 documents were screened by title and abstract, with 13 retrieved for full-text screening. We included three studies ranging from low- to medium-quality. One intervention study found that providing a WASH kit during SAM outpatient treatment did not reduce the risk of relapse to SAM. Two observational studies found inconsistent associations between household WASH conditions-unimproved sanitation and unsafe drinking water-and SAM relapse. Despite the paucity of evidence, the hypothesised causal pathways between WASH conditions and the risk of relapse remain plausible. Further evidence is needed to identify interventions for an integrated postdischarge approach to prevent relapse.
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Affiliation(s)
- Clara MacLeod
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | | | | | - Laura Braun
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Oliver Cumming
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUnited Kingdom
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Wells J, Abugo DG, Angong J, Lamwaka NG, Gallandat K, Hassan JL, Deng L, Save D, Braun L, Gose M, Amanya J, Ayoub K, King S, Stobaugh H, Cumming O, D'Mello‐Guyett L. Risk factors for food contamination among children discharged from community management of acute malnutrition programmes in South Sudan: A cross-sectional study and hazard analysis critical control point approach. MATERNAL & CHILD NUTRITION 2024; 20:e13612. [PMID: 38143422 PMCID: PMC10981483 DOI: 10.1111/mcn.13612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/26/2023]
Abstract
Children under-5 years of age are particularly vulnerable to severe acute malnutrition (SAM), and the risk factors associated with relapse to SAM are poorly understood. Possible causes are asymptomatic or symptomatic infection with enteric pathogens, with contaminated food as a critical transmission route. This cross-sectional study comprised a household survey with samples of child food (n = 382) and structured observations of food preparation (n = 197) among children aged 6-59 months that were discharged from treatment in community management of acute malnutrition (CMAM) programmes in South Sudan. We quantified Escherichia coli and total coliforms (TCs), measured in colony forming units per g of food (CFU/g), as indicators of microbial contamination of child food. A modified hazard analysis critical control point (HACCP) approach was utilised to determine critical control points (CCPs) followed by multivariate logistic regression analysis to understand the risk factors associated with contamination. Over 40% (n = 164) of samples were contaminated with E. coli (43% >0 E. coli CFU/g, 95% CI 38%-48%), and 90% (n = 343) had >10 TCs (CFU/g) (>10 TC CFU/g, 95% CI 87%-93%). Risk factors associated (p < 0.05) with child food contamination included if the child fed themselves (9.05 RR, 95% CI [3.18, 31.16]) and exposure to animals (2.63 RR, 95% CI [1.33, 5.34]). This study highlights the risk factors and potential control strategies that can support interventions that reduce food contamination exposure in young children and help further protect those that are highly vulnerable to recurrent exposure to enteric pathogens.
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Affiliation(s)
- Joseph Wells
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUK
| | - David Gama Abugo
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUK
- Action Against Hunger (ACF)JubaSouth Sudan
| | | | | | - Karin Gallandat
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Lino Deng
- Action Against Hunger (ACF)JubaSouth Sudan
| | | | - Laura Braun
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUK
| | - Mesfin Gose
- Action Against Hunger (ACF)New YorkNew YorkUSA
| | | | | | - Sarah King
- Action Against Hunger (ACF)New YorkNew YorkUSA
| | - Heather Stobaugh
- Action Against Hunger (ACF)New YorkNew YorkUSA
- Tufts UniversityMedfordMassachusettsUSA
| | - Oliver Cumming
- Department of Disease ControlLondon School of Hygiene and Tropical MedicineLondonUK
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Yitayew YA, Yalew ZM, Nebiyu S, Jember DA. Acute malnutrition relapse and associated factors among 6-59 months old children treated in the community-based management of acute malnutrition in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia. Front Public Health 2024; 11:1273594. [PMID: 38259754 PMCID: PMC10801196 DOI: 10.3389/fpubh.2023.1273594] [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: 10/03/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction Undernutrition is a major health concern in many developing countries, and is one of the main health problems affecting children in Ethiopia. Although many children experience multiple relapses following the management of severe acute malnutrition, it is scarcely studied in Ethiopia. Methods A community-based cross-sectional study was conducted in Dessie, Kombolcha, and Haik towns among 6-59-month-old children enrolled and discharged from community-based acute malnutrition management (CMAM). The total sample size was 318 children, and data were collected from April 15, 2021, to May 14, 2021. The data were entered into EPI data version 4.4.1 before being exported and analyzed with SPSS version 25 software. A multivariate logistic regression analysis was performed, and a 95% confidence interval and p-value <0.05 were used to identify significantly associated variables. Additionally, the weight-for-height z-score (WHZ) was generated using the WHO Anthro 3.2.2 software. Result The overall acute malnutrition relapse after discharge from CMAM was 35.2% (6.6% relapsed to severe acute malnutrition and 28.6% relapsed to moderate acute malnutrition). The following variables were significantly associated with the relapse of acute malnutrition: child age (AOR: 3.08, 95% CI; 1.76, 5.39), diarrhea after discharge (AOR: 2.93, 95%CI; 1.51, 5.69), have not immunized (AOR: 3.05, 95% CI; 1.14, 8.23), MUAC at discharge (AOR: 3.16, 95% CI; 1.56, 6.40), and poorest and poor wealth index (AOR: 3.65, 95% CI; 1.45, 9.18) and (AOR: 2.73, 95% CI; 1.13, 6.59), respectively. Conclusion Over one-third of children treated with the CMAM program reverted to SAM or MAM. The age of the child, diarrhea after discharge, lack of immunization, MUAC at discharge (<13 cm), and poor and poorest wealth index were significantly associated with acute malnutrition relapse. Therefore, adequate health education and counseling services are essential for mothers to improve child immunization coverage and maintain adequate hygiene to prevent diarrhea. In addition, further experimental research is needed to investigate the effect of MUAC at discharge on the risk of acute malnutrition relapse.
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Affiliation(s)
- Yibeltal Asmamaw Yitayew
- Department of Pediatric and Child Health Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Zemen Mengesha Yalew
- Department of Comprehensive Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Samuel Nebiyu
- Department of Pediatric and Child Health Nursing, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
| | - Desalegn Abebaw Jember
- Department of Pediatric Nursing, St. Paul Millennium Medical College, Addis Ababa, Ethiopia
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Sánchez-Martínez LJ, Charle-Cuéllar P, Gado AA, Dougnon AO, Sanoussi A, Ousmane N, Lazoumar RH, Toure F, Vargas A, Hernández CL, López-Ejeda N. Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger. Front Nutr 2023; 10:1253545. [PMID: 38099186 PMCID: PMC10719846 DOI: 10.3389/fnut.2023.1253545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Of the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers. Methods This study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers. Results The recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff. Conclusion The outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.
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Affiliation(s)
- Luis Javier Sánchez-Martínez
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey, Niger
| | | | | | - Fanta Toure
- Action Against Hunger, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Candela Lucía Hernández
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Noemí López-Ejeda
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
- EPINUT Research Group (Ref. 920325), Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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8
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Schwartz DJ, Langdon A, Sun X, Langendorf C, Berthé F, Grais RF, Trehan I, Isanaka S, Dantas G. Effect of amoxicillin on the gut microbiome of children with severe acute malnutrition in Madarounfa, Niger: a retrospective metagenomic analysis of a placebo-controlled trial. THE LANCET. MICROBE 2023; 4:e931-e942. [PMID: 37866373 PMCID: PMC10620469 DOI: 10.1016/s2666-5247(23)00213-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Children with severe acute malnutrition are treated with antibiotics as outpatients. We aimed to determine the effect of 7 days of amoxicillin on acute and long-term changes to the gut microbiome and antibiotic resistome in children treated for severe acute malnutrition. METHODS We conducted a secondary analysis of a randomised, double-blinded, placebo-controlled trial (NCT01613547) of amoxicillin in children (aged 6-59 months) with severe acute malnutrition treated as outpatients in Madarounfa, Niger. We randomly selected 161 children from the overall cohort (n=2399) for initial 12-week follow-up from Sept 23, 2013 to Feb 3, 2014. We selected a convenience sample of those 161 children, on the basis of anthropometric measures, for follow-up 2 years later (Sept 28 to Oct 27, 2015). Children provided faecal samples at baseline, week 1, week 4, week 8, week 12, and, for those in the 2-year follow-up cohort, week 104. We conducted metagenomic sequencing followed by microbiome and resistome profiling of faecal samples. 38 children without severe acute malnutrition and six children with severe acute malnutrition matching the baseline ages of the original cohort were used as reference controls. FINDINGS In the 12-week follow-up group, amoxicillin led to an immediate decrease in gut microbiome richness from 37·6 species (95% CI 32·6-42·7) and Shannon diversity index (SDI) 2·18 (95% CI 1·97-2·39) at baseline to 27·7 species (95% CI 22·9-32·6) species and SDI 1·55 (95% CI 1·35-1·75) at week 1. Amoxicillin increased gut antibiotic resistance gene abundance to 6044 reads per kilobase million (95% CI 4704-7384) at week 1, up from 4800 (3391-6208) at baseline, which returned to baseline 3 weeks later. 35 children were included in the 2-year follow-up; the amoxicillin-treated children (n=22) had increased number of species in the gut microbiome compared with placebo-treated children (n=13; 60·7 [95% CI 54·7-66·6] vs 36·9 [29·4-44·3]). Amoxicillin-treated children had increased Prevotella spp and decreased Bifidobacterium spp relative to age-matched placebo-treated children, indicating a more mature, adult-like microbiome. INTERPRETATION Amoxicillin treatment led to acute but not sustained increases in antimicrobial resistance genes and improved gut microbiome maturation 2 years after severe acute malnutrition treatment. FUNDING Bill & Melinda Gates Foundation; Médecins sans Frontières Operational Center Paris; National Institute of Allergy and Infectious Diseases; National Institute of General Medical Sciences; Eunice Kennedy Shriver National Institute of Child Health and Human Development; Edward Mallinckrodt Jr Foundation; Doris Duke Foundation.
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Affiliation(s)
- Drew J Schwartz
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Center for Women's Infectious Disease Research, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Molecular Microbiology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Obstetrics & Gynecology, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Amy Langdon
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Clinical Research Training Center, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Xiaoqing Sun
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pathology & Immunology, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | | | | | | | - Indi Trehan
- Departments of Pediatrics, Global Health, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Sheila Isanaka
- Department of Research, Epicentre, Paris, France; Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Molecular Microbiology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Pathology & Immunology, Washington University School of Medicine in St Louis, St Louis, MO, USA; Department of Biomedical Engineering, Washington University School of Medicine in St Louis, St Louis, MO, USA.
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9
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Mertens A, Benjamin-Chung J, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Jilek W, Rosete S, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Malenica I, Hejazi N, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Christian P, Brown KH, Arnold BF. Child wasting and concurrent stunting in low- and middle-income countries. Nature 2023; 621:558-567. [PMID: 37704720 PMCID: PMC10511327 DOI: 10.1038/s41586-023-06480-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, CA, USA.
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10
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Kangas ST, Coulibaly IN, Tausanovitch Z, Ouologuem B, Marron B, Radin E, Ritz C, Dembele S, Ouédraogo CT, Bailey J. Post-Recovery Relapse of Children Treated with a Simplified, Combined Nutrition Treatment Protocol in Mali: A Prospective Cohort Study. Nutrients 2023; 15:nu15112636. [PMID: 37299599 DOI: 10.3390/nu15112636] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
The present study aimed to determine the 6-month incidence of relapse and associated factors among children who recovered from acute malnutrition (AM) following mid-upper arm circumference (MUAC)-based simplified combined treatment using the ComPAS protocol. A prospective cohort of 420 children who had reached a MUAC ≥ 125 mm for two consecutive measures was monitored between December 2020 and October 2021. Children were seen at home fortnightly for 6 months. The overall 6-month cumulative incidence of relapse [95%CI] into MUAC < 125 mm and/or edema was 26.1% [21.7; 30.8] and 1.7% [0.6; 3.6] to MUAC < 115 mm and/or edema. Relapse was similar among children initially admitted to treatment with a MUAC < 115 mm and/or oedema and among those with a MUAC ≥ 115 mm but <125 mm. Relapse was predicted by lower anthropometry both at admission to and discharge from treatment, and a higher number of illness episodes per month of follow-up. Having a vaccination card, using an improved water source, having agriculture as the main source of income, and increases in caregiver workload during follow-up all protected from relapse. Children discharged as recovered from AM remain at risk of relapsing into AM. To achieve reduction in relapse, recovery criteria may need to be revised and post-discharge strategies tested.
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Affiliation(s)
| | | | | | | | | | | | - Christian Ritz
- National Institute of Public Health, Copenhagen, Denmark
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11
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Adema BG, Atnafu NT, Ashagre FM. Perceived quality of care for severe acute malnutrition management among caregivers of under-five children with severe acute malnutrition in Addis Ababa, Ethiopia, 2022: a mixed-method study. Front Public Health 2023; 11:1089323. [PMID: 37181687 PMCID: PMC10169666 DOI: 10.3389/fpubh.2023.1089323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 03/28/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction All the factors at the institutional, provider, and client levels have an impact on the quality of care. In low- and middle-income countries, poor quality of severe acute malnutrition (SAM) management at health institutions is a major contributor to child morbidity and mortality. This study aimed to determine the perceived quality of care for SAM management among caregivers of under-five children. Methods This study was conducted in public health facilities that provide inpatient SAM management in Addis Ababa, Ethiopia. An institution-based convergent mixed-method study design was implemented. Quantitative data were analyzed by using a logistic regression model, while thematic analysis was used to analyze the qualitative data. Results A total of 181 caregivers and 15 healthcare providers were recruited. The overall perceived quality of care for SAM management was 55.80% (CI: 48.5-63.10). Urban residence (AOR = 0.32, 95% CI: 0.16-0.66), college and above level education (AOR = 4.42, 95% CI: 1.41-13.86), working as a government employee (AOR = 2.72, 95% CI: 1.05-7.05), readmitted to the hospital (AOR = 0.47, 95% CI: 0.23-0.94), and length of hospital stays >7 days (AOR = 2.1, 95% CI: 1.01-4.27) were found to be significantly associated factors with perceived low-quality care for SAM management. Additionally, lack of support and attention from higher levels of management, and lack of supplements, separate units, and laboratory facilities were among the factors that impede the provision of quality care. Discussion Perceived quality of SAM management services was low against the national goal of quality improvement to meet the expectations of both internal and external clients. Rural residents, those with more educational qualifications, government employees, newly admitted patients, and patients who stayed longer in hospitals were the most unsatisfied groups. Improving support and logistic supply to health facilities, providing client-centered care, and responding to caregivers' demands may help to improve quality and satisfaction.
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Affiliation(s)
- Bulcha Guye Adema
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Health Sciences, Wolaita Sodo University, Sodo, Ethiopia
| | - Niguse Tadele Atnafu
- Departments of Nursing, School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Feven Mulugeta Ashagre
- Departments of Nursing, School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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12
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Likoswe BH, Chimera-Khombe B, Patson N, Selemani A, Potani I, Phuka J, Maleta K. A Systematic Review on the Optimal Dose and Duration of Ready-to-Use Therapeutic Food (RUTF) for 6-59-Month-Old Children with Severe Wasting or Oedema. Nutrients 2023; 15:nu15071750. [PMID: 37049590 PMCID: PMC10096907 DOI: 10.3390/nu15071750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
The World Health Organisation (WHO) recommends that severe wasting and/or oedema should be treated with ready-to-use therapeutic food (RUTF) at a dose of 150-220 kcal/kg/day for 6-8 weeks. Emerging evidence suggests that variations of RUTF dosing regimens from the WHO recommendation are not inferior. We aimed to assess the comparative efficacy and effectiveness of different RUTF doses and durations in comparison with the current WHO RUTF dose recommendation for treating severe wasting and/or oedema among 6-59-month-old children. A systematic literature search identified three studies for inclusion, and the outcomes of interest included anthropometric recovery, anthropometric measures and indices, non-response, time to recovery, readmission, sustained recovery, and mortality. The study was registered with PROSPERO, CRD 42021276757. Only three studies were eligible for analysis. There was an overall high risk of bias for two of the studies and some concerns for the third study. Overall, there were no differences between the reduced and standard RUTF dose groups in all outcomes of interest. Despite the finding of no differences between reduced and standard-dose RUTF, the studies are too few to conclusively declare that reduced RUTF dose was more efficacious than standard RUTF.
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Affiliation(s)
- Blessings H Likoswe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Bernadette Chimera-Khombe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Noel Patson
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Apatsa Selemani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Isabel Potani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - John Phuka
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Kenneth Maleta
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
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13
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Cazes C, Phelan K, Hubert V, Boubacar H, Bozama LI, Sakubu GT, Senge BB, Baya N, Alitanou R, Kouamé A, Yao C, Gabillard D, Daures M, Augier A, Anglaret X, Kinda M, Shepherd S, Becquet R. Optimising the dosage of ready-to-use therapeutic food in children with uncomplicated severe acute malnutrition in the Democratic Republic of the Congo: a non-inferiority, randomised controlled trial. EClinicalMedicine 2023; 58:101878. [PMID: 36915287 PMCID: PMC10006445 DOI: 10.1016/j.eclinm.2023.101878] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Current standard management of severe acute malnutrition uses ready-to-use therapeutic food (RUTF) at a single weight-based calculation resulting in an increasing amount of RUTF provided to the family as the child's weight increases during recovery. Using RUTF at a gradually reduced dosage as the child recovers could reduce costs while achieving similar growth response. METHODS We conducted an open-label, non-inferiority, randomised controlled trial in the Democratic Republic of the Congo. Children aged 6-59 months with a mid-upper-arm circumference (MUAC) of less than 115 mm or a weight-for-height z-score (WHZ) of less than -3 or bipedal oedema and without medical complication were randomly assigned (1:1 ratio) using a specially developed software and random blocks (size was kept confidential), to either the current standard treatment (increasing the RUTF amount with increasing weight) or the OptiMA strategy (decreasing the RUTF dose with increasing weight and MUAC). The main endpoint was proportion of children who achieved recovery over the 6 months follow up period, as defined as meeting the following criteria for two consecutive weeks after a minimum of 4 weeks' treatment: axillary temperature less than 37.5 °C, no bipedal oedema, and anthropometric improvement (either MUAC 125 mm or greater or WHZ -1.5 or higher). We performed analyses on the intention-to-treat (ITT) (all children) and per-protocol populations (participants who had a minimum prescription of 4 weeks' RUTF, received at least 90% of the total amount of RUTF they were supposed to receive as per the protocol, and had a maximum interval of 6 weeks between any two visits in the 6-month follow-up). The non-inferiority margin was 10%. This trial is registered at ClinicalTrials.gov, and is now closed NCT03751475. FINDINGS Between July 22, 2019, and January 20, 2020, 491 children were randomly assigned, of whom 482 were analysed (240 in the standard group and 242 in the OptiMA group). In the ITT analysis, 234 (98%) children in the standard group and 231 (96%) children in OptiMA recovered (difference 2.0%, 95% CI -2.0% to 6.4%). In the PP analysis, 234 (98%) children in the standard group and 228 (97%) in OptiMA recovered (difference 1.3%, 95% CI -2.3% to 5.1%). Sensitivity analyses applying the same anthropometric recovery criteria to each group also showed non-inferiority of the OptiMA strategy in ITT and PP analysis. INTERPRETATION This non-inferiority trial treating uncomplicated children with MUAC of less than 115 mm or a WHZ of less than -3 or bipedal oedema with decreasing RUTF dose as MUAC and weight increase demonstrated non-inferiority compared to the standard protocol in a highly food-insecure context in the Democratic Republic of the Congo. These findings add evidence on the safety of RUTF dose reduction with significant RUTF cost savings. FUNDING Innocent Foundation and European Civil Protection and Humanitarian Aid Operations. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Cécile Cazes
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Liévin Izie Bozama
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Gilbert Tshibangu Sakubu
- Kamuesha Health Zone in the Kasaï Province, Ministry of Health, Kamuesha, Democratic Republic of the Congo
| | - Bruno Bindamba Senge
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Norbert Baya
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of the Congo
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of the Congo
| | - Antoine Kouamé
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Cyrille Yao
- PACCI ANRS Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Maguy Daures
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Augustin Augier
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Xavier Anglaret
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Research Centre, University of Bordeaux, Bordeaux, France
- Corresponding author. Bordeaux Population Health Centre, Team GHiGS, University of Bordeaux, Bordeaux 33076, France.
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14
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Khara T, Myatt M, Sadler K, Bahwere P, Berkley JA, Black RE, Boyd E, Garenne M, Isanaka S, Lelijveld N, McDonald C, Mertens A, Mwangome M, O’Brien K, Stobaugh H, Taneja S, West KP, Briend A. Anthropometric criteria for best-identifying children at high risk of mortality: a pooled analysis of twelve cohorts. Public Health Nutr 2023; 26:1-17. [PMID: 36734049 PMCID: PMC10131149 DOI: 10.1017/s136898002300023x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 11/18/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme implications. DESIGN A multiple cohort individual data meta-analysis of mortality risk (within 6 months of measurement) by anthropometric case definitions. Sensitivity, specificity, informedness and inclusivity in predicting mortality, face validity and compatibility with current standards and practice were assessed and operational consequences were modelled. SETTING Community-based cohort studies in twelve low-income countries between 1977 and 2013 in settings where treatment of wasting was not widespread. PARTICIPANTS Children aged 6 to 59 months. RESULTS Of the twelve anthropometric case definitions examined, four (weight-for-age Z-score (WAZ) <-2), (mid-upper arm circumference (MUAC) <125 mm), (MUAC < 115 mm or WAZ < -3) and (WAZ < -3) had the highest informedness in predicting mortality. A combined case definition (MUAC < 115 mm or WAZ < -3) was better at predicting deaths associated with weight-for-height Z-score <-3 and concurrent wasting and stunting (WaSt) than the single WAZ < -3 case definition. After the assessment of all criteria, the combined case definition performed best. The simulated workload for programmes admitting based on MUAC < 115 mm or WAZ < -3, when adjusted with a proxy for required intensity and/or duration of treatment, was 1·87 times larger than programmes admitting on MUAC < 115 mm alone. CONCLUSIONS A combined case definition detects nearly all deaths associated with severe anthropometric deficits suggesting that therapeutic feeding programmes may achieve higher impact (prevent mortality and improve coverage) by using it. There remain operational questions to examine further before wide-scale adoption can be recommended.
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Affiliation(s)
- Tanya Khara
- Emergency Nutrition Network, ENN, 2nd Floor, Marlborough House, 69 High St, Kidlington, OX5 2DN, UK
| | - Mark Myatt
- Brixton Health, Llwyngwril, Gwynedd, Wales, UK
| | - Kate Sadler
- Emergency Nutrition Network, ENN, 2nd Floor, Marlborough House, 69 High St, Kidlington, OX5 2DN, UK
| | - Paluku Bahwere
- Epidemiology, Biostatistics and Clinical Research Centre, School of Public Health, Université libre de Bruxelles
| | - James A Berkley
- Centre for Tropical Medicine & Global Health, University of Oxford, UK
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Erin Boyd
- USAID/Bureau of Humanitarian Assistance, USA
| | - Michel Garenne
- IRD, UMI Résiliences, Paris, France
- Institut Pasteur, Epidémiologie des Maladies Emergentes, Paris, France
- FERDI, Université d’Auvergne, Clermont-Ferrand, France
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheila Isanaka
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Epicentre, Paris, France
| | - Natasha Lelijveld
- Emergency Nutrition Network, ENN, 2nd Floor, Marlborough House, 69 High St, Kidlington, OX5 2DN, UK
| | - Christine McDonald
- Departments of Pediatrics, Epidemiology and Biostatistics, University of California, San Francisco, USA
- Department of Nutrition, University of California, Davis, USA
| | - Andrew Mertens
- Division of Epidemiology & Biostatistics, University of California, Berkeley, USA
| | | | - Kieran O’Brien
- The F.I. Proctor Foundation, University of San Francisco, San Francisco, USA
| | - Heather Stobaugh
- Action Against Hunger USA, New York, NY, USA
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Sunita Taneja
- Center for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Keith P West
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - André Briend
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Medical Technology, Tampere University, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Fredericksberg, Denmark
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15
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Rate, risk factors and estimated time to develop attrition after under-five children started moderate acute malnutrition treatment in Gubalafto, North East Ethiopia. J Nutr Sci 2023; 12:e15. [PMID: 36843963 PMCID: PMC9947591 DOI: 10.1017/jns.2023.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 01/03/2023] [Accepted: 01/10/2023] [Indexed: 02/11/2023] Open
Abstract
Lost from follow-up, after starting moderate acute malnutrition (MAM) is an ongoing challenge of public health until the admitted children reached the standard weight of a reference child. Thus, the present study aimed to assess the rate and estimated time to attrition after under-five children started treatment for MAM in the Gubalafto district. A facility-based retrospective cohort study was employed among 487 participant children who had been managed targeted therapeutic feeding from 1 June 2018 to 1 May 2021. The overall mean (±sd) age of the participants' children was 22⋅1 (±12⋅6) months. At the end of the study period, 55 (11⋅46 %) under-five children developed attrition from the treatment after starting ready use of therapeutic feeding. After checking all assumptions, a multivariable Cox regression model was used to claim independent predictors for time to attritions. The median time of attrition after starting treatment of MAM was 13 (IQR ±9) weeks, with the overall incidence of attrition rate reported at 6⋅75 children Per Week (95 % CI 5⋅56, 9⋅6). In the final model of multivariable Cox regression, the hazard of attrition was significantly higher for children from rural residence (AHR 1⋅61; 95 % CI 1⋅18, 2⋅18; P = 0⋅001), and caregivers with their dyads did not get nutritional counselling at baseline (AHR 2⋅78; 95 % CI 1⋅34, 5⋅78; P = 0⋅001). The findings of the present study showed that nearly one in every eleven under-five children was attrition (lost to follow-up) in a median time of 13 (IQR ±9) weeks. We strongly recommended for caregivers provisions of diversification of daily nutrition supplementation of their dyads.
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Key Words
- AHR, adjusted hazard ratio
- Attrition rate
- CHR, crude hazard ratio
- CI, confidence interval
- Ethiopia
- FMOH, Ethiopian Federal Ministry of Health
- MAM, moderate acute malnutrition
- MUAC, mid-upper arm circumference
- Moderate acute malnutrition
- OTP, oral therapeutic programme
- RUTF, ready-to-use therapeutic feeding
- Under-five children
- WFH, weight for height
- sd, standard deviation
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16
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Odei Obeng‐Amoako GA, Stobaugh H, Wrottesley SV, Khara T, Binns P, Trehan I, Black RE, Webb P, Mwangome M, Bailey J, Bahwere P, Dolan C, Boyd E, Briend A, Myatt MA, Lelijveld N. How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies. MATERNAL & CHILD NUTRITION 2023; 19:e13434. [PMID: 36262055 PMCID: PMC9749592 DOI: 10.1111/mcn.13434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/13/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022]
Abstract
Children with weight-for-age z-score (WAZ) <-3 have a high risk of death, yet this indicator is not widely used in nutrition treatment programming. This pooled secondary data analysis of children aged 6-59 months aimed to examine the prevalence, treatment outcomes, and growth trajectories of children with WAZ <-3 versus children with WAZ ≥-3 receiving outpatient treatment for wasting and/or nutritional oedema, to inform future protocols. Binary treatment outcomes between WAZ <-3 and WAZ ≥-3 admissions were compared using logistic regression. Recovery was defined as attaining mid-upper-arm circumference ≥12.5 cm and weight-for-height z-score ≥-2, without oedema, within a period of 17 weeks of admission. Data from 24,829 children from 9 countries drawn from 13 datasets were included. 55% of wasted children had WAZ <-3. Children admitted with WAZ <-3 compared to those with WAZ ≥-3 had lower recovery rates (28.3% vs. 48.7%), higher risk of death (1.8% vs. 0.7%), and higher risk of transfer to inpatient care (6.2% vs. 3.8%). Growth trajectories showed that children with WAZ <-3 had markedly lower anthropometry at the start and end of care, however, their patterns of anthropometric gains were very similar to those with WAZ ≥-3. If moderately wasted children with WAZ <-3 were treated in therapeutic programmes alongside severely wasted children, we estimate caseloads would increase by 32%. Our findings suggest that wasted children with WAZ <-3 are an especially vulnerable group and those with moderate wasting and WAZ <-3 likely require a higher intensity of nutritional support than is currently recommended. Longer or improved treatment may be necessary, and the timeline and definition of recovery likely need review.
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Affiliation(s)
| | - Heather Stobaugh
- Action Against Hunger USANew York CityNew YorkUSA
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA
| | | | - Tanya Khara
- Emergency Nutrition Network (ENN)KidlingtonUK
| | | | - Indi Trehan
- Departments of Paediatrics, Global Health, and EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Robert E. Black
- Institute for International ProgrammesJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA
- Emergency Nutrition Network (ENN)KidlingtonUK
| | - Martha Mwangome
- Kenya Medical Research Institute (KEMRI)Centre for Geographic Medicine Research‐CoastKilifiKenya
| | | | - Paluku Bahwere
- Center for Epidémiology, Biostatistics and Clinical Research (CR2), School of Public HealthUniversité Libre de BruxellesBrusselsBelgium
| | | | - Erin Boyd
- Friedman School of Nutrition Science and Policy at Tufts UniversityBostonMassachusettsUSA
- USAID/BHAWashingtonDistrict of ColumbiaUSA
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of ScienceUniversity of CopenhagenFrederiksbergDenmark
- Center for Child Health Research, Faculty of Medicine and Health TechnologyTampere UniversityTampereFinland
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17
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Kebede F. Time to readmission and associated factors after post treatment discharge of severe acute malnourished under-five children in Pawe General Hospital. JOURNAL OF HEALTH, POPULATION AND NUTRITION 2022; 41:29. [PMID: 35804464 PMCID: PMC9270764 DOI: 10.1186/s41043-022-00308-8] [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: 08/03/2021] [Accepted: 06/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Relapse or repeated episodes is the admission of a child with the diagnosis of severe acute malnutrition (SAM) after being discharged to a status of treated and cured from a stabilizing center. A child may experience more than one episode of SAM depending on the improvement of the underlying comorbidity. Thus, this study aimed to estimate the time to readmission of SAM and associated factors for under-five children in North West Ethiopia.
Methods An institution-based retrospective cohort study was employed in 760 files of under-five children spanning from 2014/15 to 2019/20. The data extraction tool was developed from SAM treatment guidelines and medical history sheets. Epi Data version 3.2 and STATA version 14 were used for data entry and final analysis, respectively. After checking all assumptions, the multivariable Cox Proportional Hazard model was fitted to the isolated independent predictors for time to readmission. A categorical variable with p < 0.05 was considered a risk factor for the relapse of SAM.
Result The mean (± SD) age of participant children was 27.8 (± 16.5) months with mean (± SD) time to relapse of SAM cases were 30.4(± 21.39) weeks posttreatment discharge. The overall incidence density rate of relapse was determined as 10.8% (95% CI 8.3; 12.6). The average time (± SD) for treatment recovery from the first admission of the SAM case was 28.8(± 18.7) days. Time of readmission was significantly associated with living in rural resident (AHR 5⋅3 = 95% CI, 2⋅95, 13⋅87, p = 0.021), having HIV infection (AHR6⋅8 = 95%CI; 4.1–11.9 p = 0.001), and first admission with edema (AHR = 3.5 = 95% CI; 1.92, 6.2, p = 0.018). Conclusion Nearly one in every ten severely acute malnourished under-five children relapsed within a mean time to relapse 30.4(± 21.39) weeks posttreatment discharge. Time to relapse was significantly associated with being a rural resident for children, having edema during the first admission, and being HIV-infected cases. A protocol ought to be drafted for extending Supplementary Nutrition in Acute Malnutrition management program following discharge is highly needed. Supplementary Information The online version contains supplementary material available at 10.1186/s41043-022-00308-8.
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Incidence and predictors of attrition rate after children started inpatient treatments for complicated severe acute malnutrition in North West Ethiopia. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2022; 41:54. [PMID: 36447294 PMCID: PMC9706866 DOI: 10.1186/s41043-022-00332-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Retaining children for inpatient treatment of complicated severe acute malnutrition (SAM) is a growing challenge until achieved the reference weight of a child. In Ethiopia, there is limited information regarding the time to be lost from the stabilizing centers after initiation of treatment. Thus, this study aimed to identify incidence and predictors of attrition for children suffering from SAM after started inpatient treatment in North West Ethiopia. METHODS A retrospective cohort study was conducted among under-five children admitted and started inpatient treatment for complicated SAM from 2015/2016 to 2020/2021. Data were entered using Epi-data version 4.2 and then exported to STATA (SE) version R-14 software for further analysis. The analysis was computed using Cox proportional hazard regression model after checking all proportional hazard assumptions. Covariates having < 0.2 of P values in the bi-variable analysis were candidates transferred to the multivariable Cox proportional hazard regression model. Finally, a statistical significance was declared at a P value of < 0.05. RESULT Overall, 760 files of under-five children were analyzed with a mean (± SD) age of participants 27.8 (± 16.5) months. About 6944 child-days of treatment observation were recorded with the crude incidence of attrition rate of 9.7% (95% CI 7.9-12.6). The overall median time of attrition and half-life time S(t1/2) of survival rates was determined as 14 (IQR = ± 7) days and 91.6% (95% CI 88.2-93.1), respectively. The attrition rate was significantly associated with cases living in rural residents (AHR = 6.03; 95% CI 2.2; 25.2), being re-admitted SAM cases (AHR = 2.99; 95% CI 1.62; 5.5), and caregivers did not have formal education (AHR = :5.6, 95% CI 2.7; 11.7) were all independent predictors for attrition from inpatient treatment. CONCLUSIONS Nearly one in every ten severely acute malnourished under-five children defaulted at the end of treatment observation with a median time of 14 (IQR = ± 7) days. Living in a rural residence, being re-admitted cases, caregivers who did not have a formal education were significantly associated with the attrition rate. Hence, it is crucial to detect and control the identified causes of defaulting from treatment observation promptly. Furthermore, serious counseling during admission and nutritional provision strategies are essential for virtuous treatment outcomes.
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19
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Puett C, King S, Stobaugh H. A multi-country, prospective cohort study to evaluate the economic implications of relapse among children recovered from severe acute malnutrition: a study protocol. BMC Nutr 2022; 8:139. [DOI: 10.1186/s40795-022-00631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/02/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
Background
Community-based management of acute malnutrition (CMAM) is an effective intervention at recovering children from severe acute malnutrition (SAM) and preventing mortality. However, there is growing evidence that for many children recovery is not sustained post-discharge. This study will assess the economic implications of relapse by calculating the average cost of treating a case of SAM that relapses after initial CMAM treatment compared to the cost of a case that remains recovered for 6 months post-discharge.
Methods
This protocol outlines the methods for a cost-efficiency analysis to assess cost per episode of treatment for acute malnutrition for children enrolled in CMAM programs for initial SAM treatment in Mali, Somalia and South Sudan. Cost data will be collected and analyzed on a monthly basis for each CMAM service component (outpatient treatment program for SAM, supplementary feeding program for moderate acute malnutrition, and inpatient stabilization care for SAM with medical complications). Financial data will be extracted from expenditure records from institutional accounting systems where possible. Where these are not present, cost data will be collected via interview and review of financial documents. Staff time allocation interviews will be conducted. This data will be applied to quantify personnel costs, to apportion costs that are shared between programs and to exclude staff time spent on research activities.
Discussion
This study will provide the first estimates to address the limited evidence on the economic implications of SAM relapse in CMAM programs. Data from this economic analysis will help raise awareness and provide actionable data for the global nutrition community to address the financial burden of relapse. Estimating the cost of relapse in three countries representing different geographic and operational contexts will help in generalizing these results.
Trial registration
Registration # IORG0007116, Date of registration: 06/09/2020. This study is not registered as a clinical trial as it is observational research and does not include an intervention. The study has received the required ethical approvals as outlined in the declarations.
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20
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Utilization of mid-upper arm circumference as discharge tool for children in outpatient therapeutic program, Ethiopia. J Nutr Sci 2022; 11:e101. [PMID: 36405092 PMCID: PMC9672833 DOI: 10.1017/jns.2022.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/13/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022] Open
Abstract
Mid-upper arm circumference (MUAC) is simple to use and inexpensive in Ethiopia; both MUAC and target weight are employed, although the time to cure for MUAC is not indicated. The present study is aimed to determine cure time of MUAC for children in outpatient therapeutic program. A prospective cohort study was conducted among 414 severe acute malnourished under-five children admitted to selected health twenty-two posts from 1 February to 30 July 2021, in Oromia, Ethiopia. Data were coded, entered to Ep-data version 4.2 software, and transferred to SPSS for windows version 25 software for analysis. The Multivariate Cox Proportional Hazards model was used to fit independent determinants of time to cure. All tests were two-sided and statistical implications at P-values < 0⋅05. In the present study, the minimum week for a cure was 4 weeks, the maximum was 16 weeks and the overall time to cure severe acute malnutrition as measured by MUAC is judged to be 10 at 95 % CI (9⋅65-10⋅35). Families with six or more members are 2⋅16 times more at risk, children from homes with the lowest wealth index are at 1⋅4 times more risk, and children from food insecure families were 2⋅61 times more likely to require long-term treatment for MUAC. In the present study, the time to cure severe acute malnutrition by MUAC is determined as 10 weeks. Moreover, family size, low wealth index, and household food insecurity were risks to delay in cure time MUAC.
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21
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Wrabel M, Stokes‐Walters R, King S, Funnell G, Stobaugh H. Programmatic adaptations to acute malnutrition screening and treatment during the COVID-19 pandemic. MATERNAL & CHILD NUTRITION 2022; 18:e13406. [PMID: 35929509 PMCID: PMC9480950 DOI: 10.1111/mcn.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
The COVID-19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community-based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid-upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow-up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well-accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID-19 disruptions; however, challenges included long-term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme. Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi-year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences.
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Affiliation(s)
| | | | - Sarah King
- Action Against Hunger USAWashington, DCUSA
| | | | - Heather Stobaugh
- Action Against Hunger USAWashington, DCUSA
- Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
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22
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Bliznashka L, Grantz KH, Botton J, Berthé F, Garba S, Hanson KE, Grais RF, Isanaka S. Burden and risk factors for relapse following successful treatment of uncomplicated severe acute malnutrition in young children: Secondary analysis from a randomised trial in Niger. MATERNAL & CHILD NUTRITION 2022; 18:e13400. [PMID: 35866201 PMCID: PMC9480908 DOI: 10.1111/mcn.13400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/22/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
This study aimed to quantify the burden of relapse following successful treatment for uncomplicated severe acute malnutrition (SAM) and to identify associated risk factors in rural Niger. We used data from 1490 children aged 6−59 months discharged as recovered from an outpatient nutritional programme for SAM and followed for up to 12 weeks after admission. Postdischarge SAM relapse was defined as weight‐for‐height Z‐score <−3, mid‐upper arm circumference (MUAC) <115 mm or bipedal oedema after having been discharged as recovered. Postdischarge hospitalisation was defined as admission to inpatient SAM treatment or hospitalisation for any cause after having been discharged as recovered. We used multivariate log‐binomial models to identify independent risk factors. After programmatic discharge, 114 (8%) children relapsed to SAM and 89 (6%) were hospitalised. Factors associated with SAM relapse were discharge during the lean season (relative risk [RR] = 1.80 [95% confidence interval [CI] = 1.22−2.67]) and larger household size (RR = 1.56 [95% CI = 1.01−2.41]), whereas older child age (RR = 0.94 [95% CI = 0.88−1.00]), higher child MUAC at discharge (RR = 0.93 [95% CI = 0.87−1.00]) and maternal literacy (RR = 0.54 [95% CI = 0.29−0.98]) were protective factors. Discharge during the lean season (RR = 2.27 [95% CI = 1.46−3.51]) was independently associated with postdischarge hospitalisation. Future nutritional programmes in the context of Niger may consider modification of anthropometric discharge criteria or the provision of additional home support or follow‐up during the lean season as potential interventions to prevent relapse. More research including postdischarge follow‐up is needed to better understand the sustainability of treatment outcomes after discharge and the type of intervention that may best sustain recovery over time. Clinical Trial Registration: ClinicalTrials.gov number, NCT01613547. Following successful discharge from a community‐based nutritional programme for severe acute malnutrition (SAM) treatment in rural Niger, the prevalence of SAM relapse was 8% and the prevalence of postdischarge hospitalisation was 6% within 12 weeks from admission. Factors associated with SAM relapse were child age at programme admission, child mid‐upper arm circumference (MUAC) at discharge, discharge from the nutritional programme during the lean season, and maternal literacy. Anthropometry at discharge was a primary risk factor for relapse. MUAC at discharge performed better than weight‐for‐height Z‐score (WHZ) in classifying SAM relapse cases. ‘Optimal’ cut‐offs, defined using the Liu method which maximises the product of the sensitivity and specificity, were MUAC of 121 mm with 66% sensitivity and 67% specificity and WHZ of −1.38 with 54% sensitivity and 57% specificity. Future programmes may consider additional support or follow‐up of children at high risk of postdischarge relapse or hospitalisation, including those discharged during the lean season. Modification of current anthropometric discharge criteria may also be explored as an actionable target to further reduce the risk of relapse.
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Affiliation(s)
- Lilia Bliznashka
- Global Academy of Agriculture and Food Systems University of Edinburgh Edinburgh United Kingdom
| | - Kyra H. Grantz
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Jérémie Botton
- Faculty of Pharmacy University Paris‐Sud, University Paris‐Saclay Châtenay‐Malabry France
| | | | | | | | | | - Sheila Isanaka
- Department of Research Epicentre Paris France
- Department of Nutrition Harvard T. H., Chan School of Public Health Boston Massachusetts USA
- Department of Global Health and Population Harvard T. H., Chan School of Public Health Boston Massachusetts USA
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23
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Alam J, Islam MR, Fahim SM, Gazi MA, Ahmed T. Role of L-Carnitine supplementation on rate of weight gain and biomarkers of Environmental Enteric Dysfunction in children with severe acute malnutrition: A protocol for a double-blinded randomized controlled trial. PLoS One 2022; 17:e0275291. [PMID: 36178918 PMCID: PMC9524645 DOI: 10.1371/journal.pone.0275291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 09/09/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) and environmental enteric dysfunction (EED) are highly prevalent among children residing in resource-limited countries like Bangladesh. L-carnitine may play a role in improving the growth and ameliorating the EED among nutritionally vulnerable children. OBJECTIVE To investigate the role of L-carnitine supplementation on the rate of weight gain, duration of hospital stays, and EED biomarkers among children with severe acute malnutrition. METHODS This study is a double-blinded, placebo-controlled, randomized clinical trial aiming to enroll diarrheal children with SAM between 9-24 months of both sexes attending the nutritional rehabilitation unit (NRU) of Dhaka Hospital of icddr,b. It is an ongoing trial including two arms where one arm receives L-carnitine supplementation, and the other arms receive a placebo for 15 days in addition to the existing standard treatment of SAM. The primary outcome is the rate of weight gain, and the secondary outcomes include duration of hospital stay and EED biomarkers. Outcomes are assessed at baseline and 15 days of post-intervention. We hypothesize that the L- carnitine supplementation for 15 days in children with SAM will improve the rate of weight gain and biomarkers of EED. TRIAL REGISTRATION ClinicalTrials.gov # NCT05083637. Date of registration: October 19, 2021.
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Affiliation(s)
- Jinat Alam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Ridwan Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Office of the Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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24
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Tsegaye AT, Pavlinac PB, Turyagyenda L, Diallo AH, Gnoumou BS, Bamouni RM, Voskuijl WP, van den Heuvel M, Mbale E, Lancioni CL, Mupere E, Mukisa J, Lwanga C, Atuhairwe M, Chisti MJ, Ahmed T, Shahid AS, Saleem AF, Kazi Z, Singa BO, Amam P, Masheti M, Berkley JA, Walson JL, Tickell KD. The Role of Food Insecurity and Dietary Diversity on Recovery from Wasting among Hospitalized Children Aged 6-23 Months in Sub-Saharan Africa and South Asia. Nutrients 2022; 14:3481. [PMID: 36079736 PMCID: PMC9460249 DOI: 10.3390/nu14173481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Current guidelines for the management of childhood wasting primarily focus on the provision of therapeutic foods and the treatment of medical complications. However, many children with wasting live in food-secure households, and multiple studies have demonstrated that the etiology of wasting is complex, including social, nutritional, and biological causes. We evaluated the contribution of household food insecurity, dietary diversity, and the consumption of specific food groups to the time to recovery from wasting after hospital discharge. Methods: We conducted a secondary analysis of the Childhood Acute Illness Network (CHAIN) cohort, a multicenter prospective study conducted in six low- or lower-middle-income countries. We included children aged 6−23 months with wasting (mid-upper arm circumference [MUAC] ≤ 12.5 cm) or kwashiorkor (bipedal edema) at the time of hospital discharge. The primary outcome was time to nutritional recovery, defined as a MUAC > 12.5 cm without edema. Using Cox proportional hazards models adjusted for age, sex, study site, HIV status, duration of hospitalization, enrollment MUAC, referral to a nutritional program, caregiver education, caregiver depression, the season of enrollment, residence, and household wealth status, we evaluated the role of reported food insecurity, dietary diversity, and specific food groups prior to hospitalization on time to recovery from wasting during the 6 months of posthospital discharge. Findings: Of 1286 included children, most participants (806, 63%) came from food-insecure households, including 170 (13%) with severe food insecurity, and 664 (52%) participants had insufficient dietary diversity. The median time to recovery was 96 days (18/100 child-months (95% CI: 17.0, 19.0)). Moderate (aHR 1.17 [0.96, 1.43]) and severe food insecurity (aHR 1.14 [0.88, 1.48]), and insufficient dietary diversity (aHR 1.07 [0.91, 1.25]) were not significantly associated with time to recovery. Children who had consumed legumes and nuts prior to diagnosis had a quicker recovery than those who did not (adjusted hazard ratio (aHR): 1.21 [1.01,1.44]). Consumption of dairy products (aHR 1.13 [0.96, 1.34], p = 0.14) and meat (aHR 1.11 [0.93, 1.33]), p = 0.23) were not statistically significantly associated with time to recovery. Consumption of fruits and vegetables (aHR 0.78 [0.65,0.94]) and breastfeeding (aHR 0.84 [0.71, 0.99]) before diagnosis were associated with longer time to recovery. Conclusion: Among wasted children discharged from hospital and managed in compliance with wasting guidelines, food insecurity and dietary diversity were not major determinants of recovery.
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Affiliation(s)
| | | | | | - Abdoulaye H. Diallo
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Blaise S. Gnoumou
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Roseline M. Bamouni
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Wieger P. Voskuijl
- Amsterdam UMC, University of Amsterdam, Amsterdam Centre for Global Child Health & Emma Children’s Hospital, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Meta van den Heuvel
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Emmie Mbale
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 265, Malawi
| | - Christina L. Lancioni
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA
| | - Ezekiel Mupere
- Uganda-CWRU Research Collaboration, Kampala P.O. Box 663, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala P.O. Box 7072, Uganda
| | - John Mukisa
- Uganda-CWRU Research Collaboration, Kampala P.O. Box 663, Uganda
| | | | | | - Mohammod J. Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Abu S.M.S.B. Shahid
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Ali F. Saleem
- Department of Pediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Zaubina Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | | | - Pholona Amam
- Kenya Medical Research Institute, Nairobi 54840, Kenya
| | - Mary Masheti
- Kenya Medical Research Institute, Nairobi 54840, Kenya
| | - James A. Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi 80108, Kenya
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi 184742, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LG, UK
| | - Judd L. Walson
- Departments of Global Health, University of Washington, Seattle, WA 98195, USA
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi 184742, Kenya
| | - Kirkby D. Tickell
- Departments of Global Health, University of Washington, Seattle, WA 98195, USA
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King S, D'Mello-Guyett L, Yakowenko E, Riems B, Gallandat K, Mama Chabi S, Mohamud FA, Ayoub K, Olad AH, Aliou B, Marshak A, Trehan I, Cumming O, Stobaugh H. A multi-country, prospective cohort study to measure rate and risk of relapse among children recovered from severe acute malnutrition in Mali, Somalia, and South Sudan: a study protocol. BMC Nutr 2022; 8:90. [PMID: 36002905 PMCID: PMC9404649 DOI: 10.1186/s40795-022-00576-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Community-Based Management of Acute Malnutrition (CMAM) model transformed the treatment of severe acute malnutrition (SAM) by shifting treatment from inpatient facilities to the community. Evidence shows that while CMAM programs are effective in the initial recovery from SAM, recovery is not sustained for some children requiring them to receive treatment repeatedly. This indicates a potential gap in the model, yet little evidence is available on the incidence of relapse, the determinants of the phenomena, or its financial implications on program delivery. METHODS This study is a multi-country prospective cohort study following "post-SAM" children (defined as children following anthropometric recovery from SAM through treatment in CMAM) and matched community controls (defined as children not previously experiencing acute malnutrition (AM)) monthly for six months. The aim is to assess the burden and determinants of relapse to SAM. This study design enables the quantification of relapse among post-SAM children, but also to determine the relative risk for, and excess burden of, AM between post-SAM children and their matched community controls. Individual -, household-, and community-level information will be analyzed to identify potential risk-factors for relapse, with a focus on associations between water, sanitation, and hygiene (WASH) related exposures, and post-discharge outcomes. The study combines a microbiological assessment of post-SAM children's drinking water, food, stool via rectal swabs, dried blood spots (DBS), and assess for indicators of enteric pathogens and immune function, to explore different exposures and potential associations with treatment and post-treatment outcomes. DISCUSSION This study is the first of its kind to systematically track children after recovery from SAM in CMAM programs using uniform methods across multiple countries. The design allows the use of results to: 1) facilitate understandings of the burden of relapse; 2) identify risk factors for relapse and 3) elucidate financial costs associated with relapse in CMAM programs. This protocol's publication aims to support similar studies and evaluations of CMAM programs and provides opportunities for comparability of an evidence-based set of indicators for relapse to SAM.
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Affiliation(s)
- Sarah King
- Action Against Hunger, New York, NY, USA
| | - Lauren D'Mello-Guyett
- Environmental Health Group, Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Karin Gallandat
- Environmental Health Group, Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Khamisa Ayoub
- Nutrition Department, Ministry of Health for the Republic of South Sudan, Juba, South Sudan
| | - Ahmed Hersi Olad
- Research Department, Federal Ministry of Health for the Federal Republic of Somalia, Mogadishu, Somalia
| | - Bagayogo Aliou
- Nutrition Sub-Directorate, General Directorate of Health and Public Hygiene, Ministry of Health and Social Development for the Republic of Mali, Bamako, Mali
| | | | - Indi Trehan
- Departments of Pediatrics, Global Health, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Oliver Cumming
- Environmental Health Group, Department for Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Heather Stobaugh
- Action Against Hunger, New York, NY, USA. .,Tufts University, Boston, MA, USA.
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Oldenburg CE, Hinterwirth A, Ourohiré M, Dah C, Ouédraogo M, Sié A, Boudo V, Chen C, Ruder K, Zhong L, Lebas E, Nyatigo F, Arnold BF, O’Brien KS, Doan T. Gut Resistome after Antibiotics among Children with Uncomplicated Severe Acute Malnutrition: A Randomized Controlled Trial. Am J Trop Med Hyg 2022; 107:59-64. [PMID: 35895362 PMCID: PMC9294673 DOI: 10.4269/ajtmh.22-0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/27/2022] [Indexed: 08/19/2023] Open
Abstract
A broad-spectrum antibiotic, typically amoxicillin, is included in many country guidelines as part of the management of uncomplicated severe acute malnutrition (SAM) in children without overt clinical symptoms of infection. Alternative antibiotics may be beneficial for children with SAM without increasing selection for beta-lactam resistance. We conducted a 1:1 randomized controlled trial of single dose azithromycin versus a 7-day course of amoxicillin for SAM. Children 6-59 months of age with uncomplicated SAM (mid-upper arm circumference < 11.5 cm and/or weight-for-height Z-score < -3) were enrolled in Boromo District, Burkina Faso, from June through October 2020. Rectal swabs were collected at baseline and 8 weeks after treatment and processed using DNA-Seq. We compared the resistome at the class level in children randomized to azithromycin compared with amoxicillin. We found no evidence of a difference in the distribution of genetic antibiotic resistance determinants to any antibiotic class 8 weeks after treatment. There was no difference in genetic macrolide resistance determinants (65% azithromycin, 65% placebo, odds ratio, OR, 1.00, 95% confidence interval, CI, 0.43-2.34) or beta-lactam resistance determinants (82% azithromycin, 83% amoxicillin, OR 0.94, 95% CI, 0.33-2.68) at 8 weeks. Although presence of genetic antibiotic resistance determinants to macrolides and beta-lactams was common, we found no evidence of a difference in the gut resistome 8 weeks after treatment. If there are earlier effects of antibiotics on selection for genetic antibiotic resistance determinants, the resistome may normalize by 8 weeks.
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Affiliation(s)
- Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Armin Hinterwirth
- Francis I Proctor Foundation, University of California, San Francisco, California
| | | | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Cindi Chen
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Kevin Ruder
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Lina Zhong
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Fanice Nyatigo
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Benjamin F. Arnold
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Kieran S. O’Brien
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Thuy Doan
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
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Patterson GT, Osorio EY, Peniche A, Dann SM, Cordova E, Preidis GA, Suh JH, Ito I, Saldarriaga OA, Loeffelholz M, Ajami NJ, Travi BL, Melby PC. Pathologic Inflammation in Malnutrition Is Driven by Proinflammatory Intestinal Microbiota, Large Intestine Barrier Dysfunction, and Translocation of Bacterial Lipopolysaccharide. Front Immunol 2022; 13:846155. [PMID: 35720380 PMCID: PMC9204284 DOI: 10.3389/fimmu.2022.846155] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/20/2022] [Indexed: 12/12/2022] Open
Abstract
Acute malnutrition, or wasting, is implicated in over half of all deaths in children under five and increases risk of infectious disease. Studies in humans and preclinical models have demonstrated that malnutrition is linked to an immature intestinal microbiota characterized by increased prevalence of Enterobacteriaceae. Observational studies in children with moderate acute malnutrition (MAM) have also observed heightened systemic inflammation and increased circulating bacterial lipopolysaccharides (LPS; endotoxin). However, the mechanisms that underpin the systemic inflammatory state and endotoxemia, and their pathophysiological consequences, remain uncertain. Understanding these pathophysiological mechanisms is necessary to design targeted treatments that will improve the unacceptable rate of failure or relapse that plague current approaches. Here we use a mouse model of MAM to investigate the mechanisms that promote inflammation in the malnourished host. We found that mice with MAM exhibited increased systemic inflammation at baseline, increased translocation of bacteria and bacterial LPS, and an exaggerated response to inflammatory stimuli. An exaggerated response to bacterial LPS was associated with increased acute weight loss. Remarkably, intestinal inflammation and barrier dysfunction was found in the cecum and colon. The cecum showed a dysbiotic microbiota with expansion of Gammaproteobacteria and some Firmicutes, and contraction of Bacteroidetes. These changes were paralleled by an increase in fecal LPS bioactivity. The inflammatory phenotype and weight loss was modulated by oral administration of non-absorbable antibiotics that altered the proportion of cecal Gammaproteobacteria. We propose that the heightened inflammation of acute malnutrition is the result of changes in the intestinal microbiota, intestinal barrier dysfunction in the cecum and colon, and increased systemic exposure to LPS.
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Affiliation(s)
- Grace T Patterson
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States
| | - Elvia Y Osorio
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Alex Peniche
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Sara M Dann
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States.,Center for Tropical Diseases, University of Texas Medical Branch, Galveston, TX, United States
| | - Erika Cordova
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Geoffrey A Preidis
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Ji Ho Suh
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Ichiaki Ito
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States
| | - Omar A Saldarriaga
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Michael Loeffelholz
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, United States
| | - Nadim J Ajami
- The Alkek Center for Metagenomics and Microbiome Research, Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States
| | - Bruno L Travi
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Center for Tropical Diseases, University of Texas Medical Branch, Galveston, TX, United States
| | - Peter C Melby
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States.,Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, United States.,Center for Tropical Diseases, University of Texas Medical Branch, Galveston, TX, United States
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28
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Kambale RM, Francisca IN. Optimising the management of acute malnutrition. THE LANCET GLOBAL HEALTH 2022; 10:e453-e454. [DOI: 10.1016/s2214-109x(22)00087-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022] Open
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29
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Bwakura‐Dangarembizi M, Dumbura C, Amadi B, Chasekwa B, Ngosa D, Majo FD, Sturgeon JP, Chandwe K, Kapoma C, Bourke CD, Robertson RC, Nathoo KJ, Ntozini R, Norris SA, Kelly P, Prendergast AJ. Recovery of children following hospitalisation for complicated severe acute malnutrition. MATERNAL & CHILD NUTRITION 2022; 18:e13302. [PMID: 34939325 PMCID: PMC8932709 DOI: 10.1111/mcn.13302] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
Nutritional recovery and hospital readmission following inpatient management of complicated severe acute malnutrition (SAM) are poorly characterised. We aimed to ascertain patterns and factors associated with hospital readmission, nutritional recovery and morbidity, in children discharged from hospital following management of complicated SAM in Zambia and Zimbabwe over 52‐weeks posthospitalization. Multivariable Fine‐Gray subdistribution hazard models, with death and loss to follow‐up as competing risks, were used to identify factors associated with hospital readmission; negative binomial regression to assess time to hospitalisation and ordinal logistic regression to model factors associated with nutritional recovery. A total of 649 children (53% male, median age 18.2 months) were discharged to continue community nutritional rehabilitation. All‐cause hospital readmission was 15.4% (95% CI 12.7, 18.6) over 52 weeks. Independent risk factors for time to readmission were cerebral palsy (adjusted subhazard ratio (aSHR): 2.96, 95% CI 1.56, 5.61) and nonoedematous SAM (aSHR: 1.64, 95%CI 1.03, 2.64). Unit increases in height‐for‐age Z‐score (HAZ) (aSHR: 0.82, 95% CI 0.71, 0.95) and enrolment in Zambia (aSHR: 0.52, 95% CI 0.28, 0.97) were associated with reduced subhazard of time to readmission. Young age, SAM at discharge, nonoedematous SAM and cerebral palsy were associated with poor nutritional recovery throughout follow‐up. Collectively, nonoedematous SAM, ongoing SAM at discharge, cerebral palsy and low HAZ are independent risk factors for readmission and poor nutritional recovery following complicated SAM. Children with these high‐risk features should be prioritised for additional convalescent care to improve long‐term outcomes. One‐in‐six children managed for SAM were readmitted into hospital over the first year after discharge and one‐in‐eight remained undernourished by 52 weeks of follow‐up. Nonoedematous SAM, ongoing SAM at the time of discharge and underlying cerebral palsy were independent risk factors for hospital readmission and poor nutritional recovery. Low HAZ was a risk factor for hospital readmission and poor nutritional recovery. Postdischarge care should focus on children with disability, nonoedematous SAM at initial hospitalisation and have ongoing SAM at the time of discharge. Stunting should be considered in the management of children with SAM.
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Affiliation(s)
- Mutsa Bwakura‐Dangarembizi
- University of Zimbabwe College of Health Sciences Harare Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- University of Witwatersrand Johannesburg South Africa
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Jonathan P. Sturgeon
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Claire D. Bourke
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Ruairi C. Robertson
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Kusum J. Nathoo
- University of Zimbabwe College of Health Sciences Harare Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | | | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
- Blizard Institute, Queen Mary University of London London UK
| | - Andrew J. Prendergast
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
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30
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Optimizing prevention and community-based management of severe malnutrition in children. PLoS Med 2022; 19:e1003924. [PMID: 35231022 PMCID: PMC8887723 DOI: 10.1371/journal.pmed.1003924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Zulfiqar A. Bhutta discusses prevention and treatment strategies for optimization of community-based management of severe acute malnutrition in children.
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31
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O’Brien KS, Sié A, Dah C, Ourohiré M, Ouedraogo M, Boudo V, Arzika A, Lebas E, Nyatigo F, Godwin W, Kelly JD, Arnold BF, Oldenburg CE. Comparing Azithromycin to Amoxicillin in the Management of Uncomplicated Severe Acute Malnutrition in Burkina Faso: A Pilot Randomized Trial. Am J Trop Med Hyg 2022; 106:930-938. [PMID: 35008055 PMCID: PMC8922483 DOI: 10.4269/ajtmh.21-1023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/12/2021] [Indexed: 11/07/2022] Open
Abstract
Azithromycin is a promising alternative to amoxicillin in the management of uncomplicated severe acute malnutrition (SAM) as it can be administered as a single dose and has efficacy against several pathogens causing infectious disease and mortality in children under 5. In this pilot trial, we aimed to establish the feasibility of a larger randomized controlled trial and provide preliminary evidence comparing the effect of azithromycin to amoxicillin on weight gain in children with uncomplicated SAM. We enrolled children 6-59 months old with uncomplicated SAM at six healthcare centers in Burkina Faso. Participants were randomized to a single dose of azithromycin or a 7-day course of amoxicillin and followed weekly until nutritional recovery and again at 8 weeks. Apart from antibiotics, participants received standard of care, which includes ready-to-use therapeutic food. Primary feasibility outcomes included enrollment potential, refusals, and loss to follow-up. The primary clinical outcome was weight gain (g/kg/day) over 8 weeks. Outcome assessors were masked. Between June and October 2020, 312 children were screened, 301 were enrolled with zero refusals, and 282 (93.6%) completed the 8-week visit. Average weight gain was 2.5 g/kg/day (standard deviation [SD] 2.0) in the azithromycin group and 2.6 (SD 1.7) in the amoxicillin group (mean difference -0.1, 95% CI -0.5 to 0.3, P = 0.63). Fewer adverse events were reported in the azithromycin group (risk ratio 0.50, 95% CI 0.31-0.82, P = 0.006). With strong enrollment and follow-up, a fully powered trial in this setting is feasible.
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Affiliation(s)
- Kieran S. O’Brien
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ahmed Arzika
- Centre de Recherche et Interventions en Santé Publique, Niamey, Niger
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Fanice Nyatigo
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - William Godwin
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - J. Daniel Kelly
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Benjamin F. Arnold
- Francis I Proctor Foundation, University of California, San Francisco, California;,Department of Ophthalmology, University of California, San Francisco, California
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California;,Department of Ophthalmology, University of California, San Francisco, California;,Department of Epidemiology & Biostatistics, University of California, San Francisco, California,Address correspondence to Catherine E. Oldenburg, Francis I. Proctor Foundation, University of California, San Francisco, 490 Illinois St., 2nd floor, San Francisco, CA 94158. E-mail:
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32
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Grimbeek A, Saloojee H. Clinical and growth outcomes of severely malnourished children following hospital discharge in a South African setting. PLoS One 2022; 17:e0262700. [PMID: 35061836 PMCID: PMC8782382 DOI: 10.1371/journal.pone.0262700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background Data on outcomes of children with severe acute malnutrition (SAM) following treatment are scarce with none described from any upper-middle-income country. This study established mortality, clinical outcomes and anthropometric recovery of children with SAM six months following hospital discharge. Methods A prospective cohort study was conducted in children aged 3–59 months enrolled on discharge from two hospitals in the Tshwane district of South Africa between April 2019 and January 2020. The primary outcome was mortality at six months. Secondary outcomes included relapse rates, type(s) and frequency of morbidities experienced and the anthropometric changes in children with SAM following hospital discharge. Standard programmatic support included nutritional supplements. Results Forty-three children were enrolled with 86% of participants followed up to six months. Only a third of the participants had normal anthropometry at hospital discharge–a quarter still had ongoing SAM. There were no deaths, although four children (9%) were re-hospitalised including two for complicated SAM. Mean weight-for-length z-scores (WLZ) and wasting rates improved at one month but deteriorated by three months. At three months, six children (14%) either had ongoing or relapsed SAM–a SAM incidence rate of 20 per 1000 person-months despite more than half of the participants still receiving nutritional supplements at the time. Risk factors associated with persistent malnutrition at three months included a low WLZ on admission (relative risk [RR] 3.3, 95% confidence interval [95%CI] 1.2–9.2), being discharged from hospital before meeting WHO SAM treatment discharge criteria (RR 5.3, 95%CI 1.3–14.8) or having any illness by three months (RR 8.6, 95%CI 1.3–55.7). Conclusion Post-discharge mortality and morbidity was lower than in other less resourced settings. However, anthropometric recovery was poorer than expected. Modifying discharge criteria, optimising the use of available nutritional supplements and better integration with community-based health and social services may improve outcomes for children with SAM post-hospitalisation.
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Affiliation(s)
- Angelika Grimbeek
- Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Haroon Saloojee
- Division of Community Paediatrics, Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
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Kumar P, Sinha RK, Daniel A, Shah H, Sriswan R, Kokane A, Mohapatra A, Kashyap V, Goel AK, Kumar V, Kiran A, Arlappa N, Joshi A, Nayak RR, Singh M, Salasibew M, Ghosh S, Pawar SM, Mishra P, Tiwari K, Bhattacharjee S, Saiyed F, Patel TS, Nayak PK, Sahoo SK, Prajapati M, Sinha S, de Wagt A. Effectiveness of community-based treatment programs for treatment of uncomplicated severe acute malnourished children aged 6-59 months using locally produced nutrient dense foods: protocol for a multicentric longitudinal quasi-experimental study. BMC Nutr 2021; 7:85. [PMID: 34906257 PMCID: PMC8672603 DOI: 10.1186/s40795-021-00489-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 11/29/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) is a major underlying cause of mortality among children. Around one third of the world's acutely malnourished children live in India. The WHO recommends community-based management of acute malnutrition (CMAM) for managing children with SAM. In India, different states are implementing community-based SAM treatment programme, hereinafter called CSAM, using varieties of locally produced nutrient dense food items with different nutrient compositions. The study will assess the effectiveness of these state specific CSAM interventions. METHODS The longitudinal quasi-experimental study will be undertaken in two purposively selected blocks of one district each in the four intervention states and one comparison state. From each state, 200 SAM children identified using weight-for-length/height z-score (WHZ) < - 3 criteria will be enrolled in the study. Their anthropometric data and skinfold thickness will be taken on admission, at sixth week and at discharge by trained field investigators. Other child details, incidence of morbidity and socio-economic details will be collected on admission. To assess food consumption pattern including consumption of locally produced nutrient dense food supplements, dietary assessment, using 24-h dietary recall will be conducted on admission, at sixth week and at discharge. In addition, body composition parameters will be assessed for a sub-set of children using bio-electrical impedance analysis on admission and at discharge to analyse changes in total body water, fat-free mass, and fat mass. Post discharge, all study participants will be followed up monthly until 6 months. Atleast 10% of the sample will be checked for quality assessment. The study's primary outcome is cure rate defined as children attaining WHZ ≥ -2. Secondary outcomes include mean weight gain, mean length of stay, body composition parameters, relapse and mortality rates. Additionally, process evaluation and cost effectiveness analysis will be conducted. DISCUSSION There is a shortage of robust evidence regarding the effectiveness of locally produced nutrient dense food supplements provided as part of the CSAM intervention in India. This study will contribute to evidence on effective strategies to manage children with uncomplicated SAM in India. The study protocol has all necessary ethical approvals. Written informed consent will be obtained from caregivers of the children. TRIAL REGISTRATION The study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 ) Date of registration 24/09/2020.
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Affiliation(s)
- Praveen Kumar
- Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001 India
| | - Rajesh Kumar Sinha
- National Centre of Excellence for Management of Children with Severe Acute Malnutrition (NCoE-SAM), Kalawati Saran Children’s Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001 India
| | - Abner Daniel
- UNICEF India Country Office, 73, Lodi Estate, New Delhi, 110003 India
| | - Hemang Shah
- Children’s Investment Fund Foundation, The Crescent, Level 3, Lado Sarai, New Delhi, 110030 India
| | - Raja Sriswan
- ICMR-National Institute of Nutrition, Beside Tarnaka Metro Station, Osmania University, PO, Hyderabad, Telangana 500007 India
| | - Arun Kokane
- All India Institute of Medical Sciences, Saket Nagar, AIIMS Campus, Saket Nagar, BaghSwaniya, Bhopal, Madhya Pradesh 462020 India
| | - Aditya Mohapatra
- Annex Building, SIHFW, BiraMaharana Ln, Nilakantha Nagar, Nayapalli, Bhubaneswar, Odisha 751012 India
| | - Vivek Kashyap
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand 834001 India
| | - Anil Kumar Goel
- AIIMS Campus, Gate No, 1, Great Eastern Rd, opposite Gurudwara, Tatibandh, Raipur, Chhattisgarh 492099 India
| | - Virendra Kumar
- Lady Hardinge Medical College and associated Kalawati Saran Children’s Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001 India
| | - Asha Kiran
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand 834001 India
| | - N. Arlappa
- ICMR-National Institute of Nutrition, Beside Tarnaka Metro Station, Osmania University, PO, Hyderabad, Telangana 500007 India
| | - Ankur Joshi
- All India Institute of Medical Sciences, Saket Nagar, AIIMS Campus, Saket Nagar, BaghSwaniya, Bhopal, Madhya Pradesh 462020 India
| | - Rashmi Ranjan Nayak
- Department of Women and Child Development and Mission Shakti, Government of Odisha, Mission Shakti Bhawan, At-Gandamunda, PO-Baramunda, Bhubaneswar, Odisha Pin-751030 India
| | - Manjula Singh
- Children’s Investment Fund Foundation, The Crescent, Level 3, Lado Sarai, New Delhi, 110030 India
| | - Mihretab Salasibew
- Children’s Investment Fund Foundation, The Crescent, Level 3, Lado Sarai, New Delhi, 110030 India
| | - Samik Ghosh
- Children’s Investment Fund Foundation, The Crescent, Level 3, Lado Sarai, New Delhi, 110030 India
| | - Sameer Manikrao Pawar
- UNICEF, Plot No.41-42, Polytechnic Colony, Shyamla Hills, Bhopal, Madhya Pradesh 462013 India
| | - Preetu Mishra
- UNICEF, VISHWA Complex, Ground Floor, Near IICM, Kanke Road, Ranchi, Jharkhand 834006 India
| | - Khyati Tiwari
- UNICEF, Flat No. 1104, Block B, Indis One City, KPHB, Hyderabad, Telangana 500072 India
| | | | | | - Tarun Shrikrishna Patel
- UNICEF, Plot No.41-42, Polytechnic Colony, Shyamla Hills, Bhopal, Madhya Pradesh 462013 India
| | - Pritish Kumar Nayak
- UNICEF, VISHWA Complex, Ground Floor, Near IICM, Kanke Road, Ranchi, Jharkhand 834006 India
| | | | | | - Shikha Sinha
- National Centre of Excellence for Management of Children with Severe Acute Malnutrition (NCoE-SAM), Kalawati Saran Children’s Hospital, C-604 Connaught Circus, DIZ Area, Connaught Place, New Delhi, 110001 India
| | - Arjan de Wagt
- UNICEF India Country Office, 73, Lodi Estate, New Delhi, 110003 India
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Mutunga M, Rutishauser-Perera A, Laillou A, Prak S, Berger J, Wieringa FT, Bahwere P. The relationship between wasting and stunting in Cambodian children: Secondary analysis of longitudinal data of children below 24 months of age followed up until the age of 59 months. PLoS One 2021; 16:e0259765. [PMID: 34794170 PMCID: PMC8601787 DOI: 10.1371/journal.pone.0259765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 10/27/2021] [Indexed: 01/22/2023] Open
Abstract
The interrelationship between wasting and stunting has been poorly investigated. We assessed the association between two indicators of linear growth, height-for-age Z-score (HAZ) change and occurrence of accelerated linear growth, and selected indicators of wasting and wasting reversal in 5,172 Cambodian children aged less than 24 months at enrolment in the 'MyHealth' study. The specific objectives were to evaluate the relationship between temporal changes in wasting and 1) change in HAZ and 2) episodes of accelerated linear growth. At enrolment, the stunting and wasting prevalence were 22.2 (21.0;23.3) % and 9.1 (8.1;10.1) %, respectively, and reached 41.4 (39.3;43.6) %, and 12.4 (11.5;13.3) % respectively, two years later. Between 14-19% of stunted children were also wasted throughout the whole study period. For each centimetre increase in Mid-Upper Arm Circumference (MUAC) from the previous assessment, the HAZ increased by 0.162 (0.150; 0.174) Z-score. We also observed a delayed positive association between the weight for height Z score (WHZ) unit increase and HAZ change of +0.10 to +0.22 units consistent with a positive relationship between linear growth and an increase in WHZ occurring with a lag of approximately three months. A similar positive correlation was observed for the occurrence of an episode of accelerated linear growth. These results show that interventions to prevent and treat wasting can contribute to stunting reduction and call for integrated wasting and stunting programming.
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Affiliation(s)
- Mueni Mutunga
- United Nations Children’s Fund (UNICEF) East Asia Pacific Regional Office, Bangkok, Thailand
| | | | - Arnaud Laillou
- United Nations Children’s Fund (UNICEF), Addis Ababa, Ethiopia
| | - Sophonneary Prak
- National Nutrition Program, Maternal and Child Health Center, Phnom Penh, Cambodia
| | - Jacques Berger
- Institut de Recherche pour le De´veloppement, Montpellier, France
| | | | - Paluku Bahwere
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de santé publique, Université Libre de Bruxelles, Brussels, Belgium
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Das K, Das S, Mohapatra S, Swain A, Mohakud NK. Risk and Adverse Outcome Factors of Severe Acute Malnutrition in Children: A Hospital-Based Study in Odisha. Cureus 2021; 13:e18364. [PMID: 34737917 PMCID: PMC8557996 DOI: 10.7759/cureus.18364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/05/2022] Open
Abstract
Background Malnutrition is prevalent in 41% of children less than five years old in developing countries. Objective To determine the clinical spectrum, identify the risk factors, and find out the factors responsible for the adverse outcomes of severe acute malnutrition (SAM) in children. Methods In this prospective cohort, children aged one month to five years with SAM from October 2016 to September 2018 were enrolled. Clinical profile, contributing factors, treatment, and outcome of cases (n=198) were noted. Results SAM was diagnosed in 323 (1.6%) of admitted cases. The unimmunized children were 123 (62.1%). Common co-morbidities were acute gastroenteritis (n=89, 44.9%), respiratory tract infection (n=88, 44.4%), and septicemia (n=54, 26.7%). Children not on exclusive breastfeeding (n=157, 79.1%), early complementary feeding (<6 months) (n=157, 88.2%), bottle-feeding (n=138, 77.55%), low birth weight (157, 79.1%), living in kutcha houses (115, 58.2%), and unavailability of safe drinking water (131, 66.4%) were the significant risk factors. Pneumonia, diarrhea, nutritional edema, hypothermia, and circulatory shock at the time of admission were responsible for adverse outcomes. One hundred and eighty-three (92.4%) children were cured and discharged and 15 (7.6%) children died. Conclusions Wrong feeding practices and unavailability of safe drinking water have an important bearing on the development of SAM children. Pneumonia, diarrhea, nutritional edema, hypothermia, and circulatory shock at the time of admission were responsible for adverse outcomes.
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Affiliation(s)
- Kedarnath Das
- Paediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
| | - Swarnalata Das
- Paediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Arakhita Swain
- Paediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
| | - Nirmal K Mohakud
- Paediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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Braitstein P, DeLong A, Ayuku D, Ott M, Atwoli L, Galárraga O, Sang E, Hogan J. Association of Care Environment With HIV Incidence and Death Among Orphaned, Separated, and Street-Connected Children and Adolescents in Western Kenya. JAMA Netw Open 2021; 4:e2125365. [PMID: 34529063 PMCID: PMC8446813 DOI: 10.1001/jamanetworkopen.2021.25365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In 2015, there were nearly 140 million orphaned children globally, particularly in low- and middle-income regions, and millions more for whom the street is central to their everyday lives. A total of 16.6 million children were orphaned because of deaths associated with HIV/AIDS, of whom 90% live in sub-Saharan Africa. Although most orphaned and separated children and adolescents in this region are cared for by extended family, the large number of children requiring care has produced a proliferation of institutional care. Few studies have investigated the association between care environment and physical health among orphaned and separated youths in sub-Saharan Africa. OBJECTIVE To examine the association of care environment with incident HIV and death among orphaned and separated children and adolescents who were living in charitable children's institutions, family-based settings, and street settings in western Kenya over almost 10 years. DESIGN, SETTING, AND PARTICIPANTS The Orphaned and Separated Children's Assessments Related to Their Health and Well-Being (OSCAR) project was an observational prospective cohort study conducted in Uasin Gishu County, Kenya. The cohort comprised 2551 orphaned, separated, and street-connected children from communities within 8 administrative locations, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 charitable children's institutions (institutional settings), and a convenience sample of 100 children who were practicing self-care on the streets (street settings). Participants were enrolled from May 31, 2010, to April 24, 2013, and were followed up until November 30, 2019. EXPOSURES Care environment (family-based, institutional, or street setting). MAIN OUTCOMES AND MEASURES Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death. RESULTS Among 2551 participants, 1230 youths were living in family-based settings, 1230 were living in institutional settings, and 91 were living in street settings. Overall, 1321 participants (51.8%) were male, with a mean (SD) age at baseline of 10.4 (4.8) years. Most participants who were living in institutional (1047 of 1230 youths [85.1%]) or street (71 of 91 youths [78.0%]) settings were double orphaned (ie, both parents had died). A total of 59 participants acquired HIV infection or died during the study period. After adjusting for sex, age, and baseline HIV status, living in a charitable children's institution was not associated with death (adjusted hazard ratio [AHR], 0.26; 95% CI, 0.07-1.02) or incident HIV (AHR, 1.49; 95% CI, 0.46-4.83). Compared with living in a family-based setting, living in a street setting was associated with death (AHR, 5.46; 95% CI, 2.30-12.94), incident HIV (AHR, 17.31; 95% CI, 5.85-51.25), and time to incident HIV or death (AHR, 7.82; 95% CI, 3.48-17.55). CONCLUSIONS AND RELEVANCE In this study, after adjusting for potential confounders, no association was found between care environment and HIV incidence or death among youths living in institutional vs family-based settings. However, living in a street setting vs a family-based setting was associated with both HIV incidence and death. This study's findings suggest that strengthening of child protection systems and greater investment in evidence-based family support systems that improve child and adolescent health and prevent youth migration to the street are needed for safe and beneficial deinstitutionalization to be implemented at scale.
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Affiliation(s)
- Paula Braitstein
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
| | - Allison DeLong
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Mary Ott
- Department of Pediatrics, Faculty of Medicine, Indiana University, Indianapolis
| | - Lukoye Atwoli
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Dean’s Office, Aga Khan University Medical College, East Africa, Nairobi, Kenya
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Edwin Sang
- Academic Model Providing Access to Healthcare (AMPATH) Program, Eldoret, Kenya
| | - Joseph Hogan
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
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Renzaho AMN, Dachi G, Tesfaselassie K, Abebe KT, Kassim I, Alam Q, Shaban NS, Shiweredo T, Vinathan H, Jaiswal C, Abraham HM, Miluwa KA, Mahumud RA, Ategbo E, Ndiaye B, Ayoya MA. Assessing the Impact of Integrated Community-Based Management of Severe Wasting Programs in Conflict-Stricken South Sudan: A Multi-Dimensional Approach to Scalability of Nutrition Emergency Response Programs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179113. [PMID: 34501705 PMCID: PMC8431605 DOI: 10.3390/ijerph18179113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/16/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022]
Abstract
Community-based management of severe wasting (CMSW) programs have solely focused on exit outcome indicators, often omitting data on nutrition emergency preparedness and scalability. This study aimed to document good practices and generate evidence on the effectiveness and scalability of CMSW programs to guide future nutrition interventions in South Sudan. A total of 69 CMSW program implementation documents and policies were authenticated and retained for analysis, complemented with the analyses of aggregated secondary data obtained over five (2016-2020 for CMSW program performance) to six (wasting prevention) years (2014-2019). Findings suggest a strong and harmonised coordination of CMSW program implementation, facilitated timely and with quality care through an integrated and harmonised multi-agency and multidisciplinary approach. There were challenges to the institutionalisation and ownership of CMSW programs: a weak health system, fragile health budget that relied on external assistance, and limited opportunities for competency-based learning and knowledge transfer. Between 2014 and 2019, the prevalence of wasting fluctuated according to the agricultural cycle and remained above the emergency threshold of 15% during the July to August lean season. However, during the same period, under-five and crude mortality rates (10,000/day) declined respectively from 1.17 (95% confidence interval (CI): 0.91, 1.43) and 1.00 (95% CI: 0.75, 1.25) to 0.57 (95% CI: 0.38, 0.76) and 0.55 (95% CI: 0.39, 0.70). Both indicators remained below the emergency thresholds, hence suggesting that the emergency response was under control. Over a five-year period (2016-2020), a total of 1,105,546 children (52% girls, 48% boys) were admitted to CMSW programs. The five-year pooled performance indicators (mean [standard deviations]) was 86.4 (18.9%) for recovery, 2.1 (7.8%) for deaths, 5.2 (10.3%) for defaulting, 1.7 (5.7%) for non-recovery, 4.6 (13.5%) for medical transfers, 2.2 (4.7%) for relapse, 3.3 (15.0) g/kg/day for weight gain velocity, and 6.7 (3.7) weeks for the length of stay in the program. In conclusion, all key performance indicators, except the weight gain velocity, met or exceeded the Humanitarian Charter and Minimum Standards in Humanitarian Response. Our findings demonstrate the possibility of implementing robust and resilient CMSAM programs in protracted conflict environments, informed by global guidelines and protocols. They also depict challenges to institutionalisation and ownership.
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Affiliation(s)
- Andre M. N. Renzaho
- Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, NSW 2560, Australia
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC 3004, Australia
- Correspondence: ; Tel.: +612-4620-3506
| | - Gilbert Dachi
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Kibrom Tesfaselassie
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Kiross Tefera Abebe
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Ismail Kassim
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Qutab Alam
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Nawal Sadick Shaban
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Tesfatsion Shiweredo
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Hari Vinathan
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Chandrakala Jaiswal
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Hellen Martin Abraham
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | | | - Rashidul Alam Mahumud
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia;
| | - Eric Ategbo
- UNICEF South Sudan, Totto Chan Compound, Juba P.O. Box 45, Sudan; (G.D.); (K.T.); (K.T.A.); (I.K.); (Q.A.); (N.S.S.); (T.S.); (H.V.); (C.J.); (H.M.A.); (E.A.)
| | - Biram Ndiaye
- UNICEF Somalia, RA International Compound, Aden Adde International Airport Area, Mogadishu, Somalia; (B.N.); (M.A.A.)
| | - Mohamed Ag Ayoya
- UNICEF Somalia, RA International Compound, Aden Adde International Airport Area, Mogadishu, Somalia; (B.N.); (M.A.A.)
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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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Guesdon B, Katwal M, Poudyal AK, Bhandari TR, Counil E, Nepali S. Anthropometry at discharge and risk of relapse in children treated for severe acute malnutrition: a prospective cohort study in rural Nepal. Nutr J 2021; 20:32. [PMID: 33820545 PMCID: PMC8021301 DOI: 10.1186/s12937-021-00684-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background There is a dearth of evidence on what should be the optimal criteria for discharging children from severe acute malnutrition (SAM) treatment. Programs discharging children while they are still presenting varying levels of weight-for-height (WHZ) or mid-upper-arm circumference (MUAC) deficits, such as those implemented under the current national protocol in Nepal, are opportunities to fill this evidence gap. Methods We followed a cohort of children discharged as cured from SAM treatment in Parasi district, Nepal. Relapse as SAM, defined as the occurrence of WHZ<-3 or MUAC < 115 mm or nutritional edema, was investigated through repeated home visits, during six months after discharge. We assessed the contribution of remaining anthropometric deficits at discharge to relapse risk through Cox regressions. Results Relapse as SAM during follow-up was observed in 33 % of the cohort (35/108). Being discharged before reaching the internationally recommended criteria was overall associated with a large increase in the risk of relapse (HR = 3.3; p = 0.006). Among all anthropometric indicators at discharge, WHZ<-2 led to a three-fold increase in relapse risk (HR = 3.2; p = 0.003), while MUAC < 125 mm significantly raised it only in the older children. WHZ<-2 at discharge came up as the only significant predictor of relapse in multivariate analysis (HR = 2.8, p = 0.01), even among children with a MUAC ≥ 125 mm. Of note, more than 80 % of the events of relapse as SAM would have been missed if WHZ had not been monitored and used in the definition of relapse. Conclusions Our results suggest that the priority for SAM management programs should be to ensure that children reach a high level of WHZ at discharge, at least above or equal to the WHO recommended cut-off. The validity of using a single MUAC cut-off such as 125 mm as a suitable discharge criterion for all age groups is questioned. Further follow-up studies providing a complete assessment of nutritional status at discharge and not based on a restricted MUAC-only definition of relapse as SAM would be urgently needed to set evidence-based discharge criteria. These studies are also required to assess programs currently discounting or omitting WHZ for identification and management of SAM.
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Affiliation(s)
- Benjamin Guesdon
- Action Against Hunger
- Action Contre la Faim (ACF) - France, 14-16 Boulevard Douaumont, 75854, Paris, France.
| | - Manisha Katwal
- Action Against Hunger
- Action Contre la Faim (ACF)- Nepal, Kathmandu, Nepal
| | - Amod Kumar Poudyal
- Central Department of Public Health, Institute of Medicine (IOM), Tribhuvan University (TU), Kirtipur, Nepal
| | - Tusli Ram Bhandari
- Department of Public Health, School of Health and Allied Sciences, Pokhara University (PoU), Pokhara, Nepal
| | - Emilie Counil
- Institut national d'études démographiques (INED), F-93322, Aubervilliers, France
| | - Sujay Nepali
- Action Against Hunger
- Action Contre la Faim (ACF)- Nepal, Kathmandu, Nepal
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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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Njunge JM, Gonzales GB, Ngari MM, Thitiri J, Bandsma RH, Berkley JA. Systemic inflammation is negatively associated with early post discharge growth following acute illness among severely malnourished children - a pilot study. Wellcome Open Res 2021; 5:248. [PMID: 33969227 PMCID: PMC8080977 DOI: 10.12688/wellcomeopenres.16330.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Rapid growth should occur among children with severe malnutrition (SM) with medical and nutritional management. Systemic inflammation (SI) is associated with death among children with SM and is negatively associated with linear growth. However, the relationship between SI and weight gain during therapeutic feeding following acute illness is unknown. We hypothesised that growth post-hospital discharge is associated with SI among children with SM. Methods: We conducted secondary analysis of data from HIV-uninfected children with SM (n=98) who survived and were not readmitted to hospital during one year of follow-up. We examined the relationship between changes in absolute deficits in weight and mid-upper-arm circumference (MUAC) from enrolment at stabilisation to 60 days and one year later, and untargeted plasma proteome, targeted cytokines/chemokines, leptin, and soluble CD14 using multivariate regularized linear regression. Results: The mean change in absolute deficit in weight and MUAC was -0.50kg (standard deviation; SD±0.69) and -1.20cm (SD±0.89), respectively, from enrolment to 60 days later. During the same period, mean weight and MUAC gain was 3.3g/kg/day (SD±2.4) and 0.22mm/day (SD±0.2), respectively. Enrolment interleukins; IL17-alpha and IL-2, and serum amyloid P were negatively associated with weight and MUAC gain during 60 days. Lipopolysaccharide binding protein and complement component 2 were negatively associated with weight gain only. Leptin was positively associated with weight gain. Soluble CD14, beta-2 microglobulin, and macrophage inflammatory protein 1 beta were negatively associated with MUAC gain only. Glutathione peroxidase 3 was positively associated with weight and MUAC gain during one year. Conclusions: Early post-hospital discharge weight and MUAC gain were rapid and comparable to children with uncomplicated SM treated in the community. Higher concentrations of SI markers were associated with less weight and MUAC gain, suggesting inflammation negatively impacts recovery from wasting. This finding warrants further research on reducing inflammation on growth among children with SM.
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Affiliation(s)
- James M. Njunge
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gerard Bryan Gonzales
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Moses M. Ngari
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Robert H.J. Bandsma
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James A. Berkley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Noble CCA, Sturgeon JP, Bwakura-Dangarembizi M, Kelly P, Amadi B, Prendergast AJ. Postdischarge interventions for children hospitalized with severe acute malnutrition: a systematic review and meta-analysis. Am J Clin Nutr 2021; 113:574-585. [PMID: 33517377 PMCID: PMC7948836 DOI: 10.1093/ajcn/nqaa359] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/06/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Children hospitalized with severe acute malnutrition (SAM) have poor long-term outcomes following discharge, with high rates of mortality, morbidity, and impaired neurodevelopment. There is currently minimal guidance on how to support children with SAM following discharge from inpatient treatment. OBJECTIVES This systematic review and meta-analysis aimed to examine whether postdischarge interventions can improve outcomes in children recovering from complicated SAM. METHODS Systematic searches of 4 databases were undertaken to identify studies of interventions delivered completely or partially after hospital discharge in children aged 6-59 mo, following inpatient treatment of SAM. The main outcome of interest was mortality. Random-effects meta-analysis was undertaken where ≥2 studies were sufficiently similar in intervention and outcome. RESULTS Ten studies fulfilled the inclusion criteria, recruiting 39-1781 participants in 7 countries between 1975 and 2015. Studies evaluated provision of zinc (2 studies), probiotics or synbiotics (2 studies), antibiotics (1 study), pancreatic enzymes (1 study), and psychosocial stimulation (4 studies). Six studies had unclear or high risk of bias in ≥2 domains. Compared with standard care, pancreatic enzyme supplementation reduced inpatient mortality (37.8% compared with 18.6%, P < 0.05). In meta-analysis there was some evidence that prebiotics or synbiotics reduced mortality (RR: 0.72; 95% CI: 0.51, 1.00; P = 0.049). Psychosocial stimulation reduced mortality in meta-analysis of the 2 trials reporting deaths (RR: 0.36; 95% CI: 0.15, 0.87), and improved neurodevelopmental scores in ≥1 domain in all studies. There was no evidence that zinc reduced mortality in the single study reporting deaths. Antibiotics reduced infectious morbidity but did not reduce mortality. CONCLUSIONS Several biological and psychosocial interventions show promise in improving outcomes in children following hospitalization for SAM and require further exploration in larger randomized mortality trials. This study was registered with PROSPERO as CRD42018111342 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=111342).
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Affiliation(s)
- Christie C A Noble
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jonathan P Sturgeon
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Paul Kelly
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, United Kingdom
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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Lelijveld N, Musyoki E, Adongo SW, Mayberry A, Wells JC, Opondo C, Kerac M, Bailey J. Relapse and post-discharge body composition of children treated for acute malnutrition using a simplified, combined protocol: A nested cohort from the ComPAS RCT. PLoS One 2021; 16:e0245477. [PMID: 33534818 PMCID: PMC7857614 DOI: 10.1371/journal.pone.0245477] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/01/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Severe and moderate acute malnutrition (SAM and MAM) affect more than 50 million children worldwide yet 80% of these children do not access care. The Combined Protocol for Acute Malnutrition Study (ComPAS) trial assessed the effectiveness of a simplified, combined SAM/MAM protocol for children aged 6-59 months and found non-inferior recovery compared to standard care. To further inform policy, this study assessed post-discharge outcomes of children treated with this novel protocol in Kenya. METHODS Six 'combined' protocol clinics treated SAM and MAM children using an optimised mid-upper arm circumference (MUAC)-based dose of ready-to-use therapeutic food (RUTF). Six 'standard care' clinics treated SAM with weight-based RUTF rations; MAM with ready-to-use supplementary food (RUSF). Four months post-discharge, we assessed anthropometry, recent history of illness, and body composition by bioelectrical impedance analysis. Data was analysed using multivariable linear regression, adjusted for age, sex and allowing for clustering by clinic. RESULTS We sampled 850 children (median age 18 months, IQR 15-23); 44% of the original trial sample in Kenya. Children treated with the combined protocol had similar anthropometry, fat-free mass, fat mass, skinfold thickness z-scores, and frequency of common illnesses 4 months post-discharge compared the standard protocol. Mean subscapular skinfold z-scores were close to the global norm (standard care: 0.24; combined 0.27). There was no significant difference in odds of relapse between protocols (SAM, 3% vs 3%, OR = 1.0 p = 0.75; MAM, 10% vs 12%, OR = 0.90 p = 0.34). CONCLUSIONS Despite the lower dosage of RUTF for most SAM children in the combined protocol, their anthropometry and relapse rates at 4 months post-discharge were similar to standard care. MAM children treated with RUTF had similar body composition to those treated with RUSF and neither group exhibited excess adiposity. These results add further evidence that a combined protocol is as effective as standard care with no evidence of adverse effects post-discharge. A simplified, combined approach could treat more children, stretch existing resources further, and contribute to achieving Sustainable Development Goal Two.
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Affiliation(s)
- Natasha Lelijveld
- No Wasted Lives, Action Against Hunger, London, United Kingdom
- Emergency Nutrition Network, Oxford, United Kingdom
- * E-mail:
| | | | | | - Amy Mayberry
- No Wasted Lives, Action Against Hunger, London, United Kingdom
| | - Jonathan C. Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street, Institute of Child Health, University College London, London, United Kingdom
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marko Kerac
- Department of Population Health, Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jeanette Bailey
- Department of Population Health, Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, United Kingdom
- International Rescue Committee, New York City, New York, United States of America
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Laillou A, Baye K, Meseret Z, Darsene H, Rashid A, Chitekwe S. Wasted Children and Wasted Time: A Challenge to Meeting the Nutrition Sustainable Development Goals with a High Economic Impact to Ethiopia. Nutrients 2020; 12:E3698. [PMID: 33266008 PMCID: PMC7760409 DOI: 10.3390/nu12123698] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 11/08/2022] Open
Abstract
Despite some progress in the reduction of the prevalence of child wasting in Ethiopia, the pace of progress has been slow. Despite millions of dollars being spent on the treatment of wasting every year, the increased frequency and magnitude of environmental and anthropogenic shocks has halted progress. This study aimed to present the trends of child wasting in Ethiopia and estimate the economic losses related to the slow progress towards meeting the sustainable development goal (SDG) targets. Weather shocks and civil unrest between 2015 and 2018 have halted progress. We used a "consequence model" to apply the coefficient risk-deficit on economic losses established in the global scientific literature to the Ethiopian health, demographic, and economic data to estimate economic losses related to child wasting. The impact of wasting on the national economy of Ethiopia is estimated to be 157.8-230.2 million United States dollars (USD), annually. The greatest contributor to the economic burden (43.5-63.5% of the burden depending on the discount rate) is the cost of supplies and human resources to treat wasting. To reach the 2030 SDGs, Ethiopia should increase its annual average reduction rate (AARR) in the numbers of child (<59 months) wasting from 0.1% to 5.4%. This will avert the wasting in 7.9 million cases and prevent additional economic costs of up to 803.7 million USD over the next decade. Increasing the reach of therapeutic interventions, but also identifying and implementing wasting prevention interventions, will be critical if the SDG targets are to be met and the opportunity of the children to thrive is not to be wasted.
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Affiliation(s)
- Arnaud Laillou
- United Nations Children’s Fund (UNICEF), Addis Ababa 12000, Ethiopia; (A.R.); (S.C.)
| | - Kaleab Baye
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa 12000, Ethiopia;
| | - Zelalem Meseret
- Department for Maternal, Child Health and Nutrition, Federal Ministry of Health, Addis Ababa 12000, Ethiopia; (Z.M.); (H.D.)
| | - Hiwot Darsene
- Department for Maternal, Child Health and Nutrition, Federal Ministry of Health, Addis Ababa 12000, Ethiopia; (Z.M.); (H.D.)
| | - Abdulai Rashid
- United Nations Children’s Fund (UNICEF), Addis Ababa 12000, Ethiopia; (A.R.); (S.C.)
| | - Stanley Chitekwe
- United Nations Children’s Fund (UNICEF), Addis Ababa 12000, Ethiopia; (A.R.); (S.C.)
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45
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Njunge JM, Gonzales GB, Ngari MM, Thitiri J, Bandsma RH, Berkley JA. Systemic inflammation is negatively associated with early post discharge growth following acute illness among severely malnourished children - a pilot study. Wellcome Open Res 2020; 5:248. [PMID: 33969227 PMCID: PMC8080977 DOI: 10.12688/wellcomeopenres.16330.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2020] [Indexed: 11/03/2023] Open
Abstract
Background: Rapid growth should occur among children with severe malnutrition (SM) when medically and nutritionally treated. Systemic inflammation (SI) is associated with death among children with SM and is negatively associated with linear growth. However, the relationship between SI and weight gain during therapeutic feeding following acute illness is unknown. We hypothesised that growth in the first 60 days post-hospital discharge is associated with SI among children with SM. Methods: We conducted secondary analysis of data from HIV-uninfected children with SM (n=98) who survived and were not readmitted to hospital during one year of follow up. We examined the relationship between changes in absolute deficits in weight and mid-upper-arm circumference (MUAC) from enrolment at stabilisation to 60 days later and untargeted plasma proteome, targeted cytokines/chemokines, leptin, and soluble CD14 (sCD14) using multivariate regularized linear regression. Results: The mean change in absolute deficit in weight and MUAC was -0.50kg (standard deviation; SD±0.69) and -1.20cm (SD±0.89), respectively, from enrolment to 60 days later. During the same period, mean weight and MUAC gain was 3.3g/kg/day (SD±2.4) and 0.22mm/day (SD±0.2), respectively. Enrolment inflammatory cytokines interleukin 17 alpha (IL17α), interleukin 2 (IL2), and serum amyloid P (SAP) were negatively associated with weight and MUAC gain. Lipopolysaccharide binding protein (LBP) and complement component 2 were negatively associated with weight gain only. Leptin was positively associated with weight gain. sCD14, beta-2 microglobulin (β2M), and macrophage inflammatory protein 1 beta (MIP1β) were negatively associated with MUAC gain only. Conclusions: Early post-hospital discharge weight and MUAC gain were rapid and comparable to children with uncomplicated SM treated with similar diet in the community. Higher concentrations of SI markers were associated with less weight and MUAC gain, suggesting inflammation negatively impacts recovery from wasting. This finding warrants further research on the role of inflammation on growth among children with SM.
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Affiliation(s)
- James M. Njunge
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gerard Bryan Gonzales
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Moses M. Ngari
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Robert H.J. Bandsma
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James A. Berkley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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46
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Trehan I. The past informs the future: inpatient mortality in severe childhood malnutrition. Am J Clin Nutr 2020; 112:911-912. [PMID: 32885811 DOI: 10.1093/ajcn/nqaa231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Indi Trehan
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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47
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Adegoke O, Arif S, Bahwere P, Harb J, Hug J, Jasper P, Mudzongo P, Nanama S, Olisenekwu G, Visram A. Incidence of severe acute malnutrition after treatment: A prospective matched cohort study in Sokoto, Nigeria. MATERNAL AND CHILD NUTRITION 2020; 17:e13070. [PMID: 32761792 PMCID: PMC7729648 DOI: 10.1111/mcn.13070] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/22/2020] [Accepted: 07/16/2020] [Indexed: 01/06/2023]
Abstract
Severe acute malnutrition (SAM) among children in Nigeria is tackled through the outpatient therapeutic programme (OTP) of the Community-based Management of Acute Malnutrition (CMAM) programme. CMAM is evidently effective in resolving SAM, but little evidence exists on the remaining risk of SAM relapse for children discharged as cured from the OTP. We aimed to measure and compare the 6-month incidence of SAM among OTP-cured and community control children and identify factors associated with SAM relapse. We conducted a prospective matched cohort study that tracked 553 OTP-cured and 526 control children in Sokoto State, Northern Nigeria. Outcomes and covariates were measured fortnightly in up to 12 home visits. We used multivariate Cox and accelerated failure time models to identify significant risk correlates, where the covariates to be tested for correlation with relapse were selected using domain knowledge and automatic feature selection methods. SAM incidence rates were 52 times higher in the OTP-cured cohort (0.204/100 child-days) than in the community control cohort (0.004/100 child-days). Children with lower mid-upper arm circumference at OTP admission, with lower height/length-for-age z-scores, whose household head did not work over the full year, who lived in an area previously affected by environmental shocks, who were female and who had diarrhoea before the visit had a significantly higher relapse risk. Our study shows that OTP-cured children remain at a significantly excess risk of SAM. To improve long-term health outcomes of these children, programmes adopting a CMAM approach should strengthen follow-up care and be integrated with other preventive services.
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Affiliation(s)
| | | | - Paluku Bahwere
- Valid International, Oxford, UK.,Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Jana Harb
- Oxford Policy Management, Oxford, UK
| | - Julia Hug
- Oxford Policy Management, Oxford, UK
| | | | - Paul Mudzongo
- United Nations Children's Fund (UNICEF) Nigeria, Abuja, Nigeria
| | - Simeon Nanama
- United Nations Children's Fund (UNICEF) Nigeria, Abuja, Nigeria
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The recovery rate from severe acute malnutrition among under-five years of children remains low in sub-Saharan Africa. A systematic review and meta-analysis of observational studies. PLoS One 2020; 15:e0229698. [PMID: 32187182 PMCID: PMC7080262 DOI: 10.1371/journal.pone.0229698] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/11/2020] [Indexed: 11/19/2022] Open
Abstract
Background Globally, Severe Acute Malnutrition (SAM) has been reduced by only 11% over the past 20 years and continues to be a significant cause of morbidity and mortality. So far, in Sub-Saharan Africa, several primary studies have been conducted on recovery rate and determinants of recovery from SAM in under-five children. However, comprehensive reviews that would have a shred of strong evidence for designing interventions are lacking. So, this review and meta-analysis was conducted to bridge this gap. Methods A systematic review of observational studies published in the years between 1/1/2000 to 12/31/2018 was conducted following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. Two reviewers have been searched and extracted data from CINAHL (EBSCO), MEDLINE (via Ovid), Emcare, PubMed databases, and Google scholar. Articles' quality was assessed using the Newcastle-Ottawa Scale by two independent reviewers, and only studies with fair to good quality were included in the final analysis. The review presented the pooled recovery rate from SAM and an odds ratio of risk factors affecting recovery rate after checking for heterogeneity and publication bias. The review has been registered in PROSPERO with protocol number CRD42019122085. Result Children with SAM from 54 primary studies (n = 140,148) were included. A pooled rate of recovery was 71.2% (95% CI: 68.5–73.8; I2 = 98.9%). Children who received routine medication (Pooled Odds ratio (POR):1.85;95% CI: 1.49–2.29; I2 = 0.0%), older age (POR: 1.99;95% CI: 1.29–3.08; I2 = 80.6%), and absence of co-morbidity (POR:3.2;95% CI: 2.15–4.76; I2 = 78.7%) had better odds of recovery. This systematic review and meta-analysis suggestes HIV infected children had lower recovery rate from SAM (POR; 0.19; 95% CI: 0.09–0.39; I2 = 42.9%) compared to those non-infected. Conclusion The meta-analysis deciphers that the pooled recovery rate was below the SPHERE standard, and further works would be needed to improve the recovery rate. So, factors that were identified might help to revise the plan set by the countries, and further research might be required to explore health fascilities fidelity to the WHO SAM management protocol.
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49
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Frison S, Angood C, Khara T, Bahwere P, Black RE, Briend A, Connell N, Fenn B, Isanaka S, James P, Kerac M, Mayberry A, Myatt M, Dolan C. Prevention of child wasting: Results of a Child Health & Nutrition Research Initiative (CHNRI) prioritisation exercise. PLoS One 2020; 15:e0228151. [PMID: 32049994 PMCID: PMC7015423 DOI: 10.1371/journal.pone.0228151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/09/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND An estimated 49.5 million children under five years of age are wasted. There is a lack of robust studies on effective interventions to prevent wasting. The aim of this study was to identify and prioritise the main outstanding research questions in relation to wasting prevention to inform future research agendas. METHOD A research prioritisation exercise was conducted following the Child Health and Nutrition Research Initiative method. Identified research gaps were compiled from multiple sources, categorised into themes and streamlined into forty research questions by an expert group. A survey was then widely circulated to assess research questions according to four criteria. An overall research priority score was calculated to rank questions. FINDINGS The prioritised questions have a strong focus on interventions. The importance of the early stages of life in determining later experiences of wasting was highlighted. Other important themes included the identification of at-risk infants and young children early in the progression of wasting and the roles of existing interventions and the health system in prevention. DISCUSSION These results indicate consensus to support more research on the pathways to wasting encompassing the in-utero environment, on the early period of infancy and on the process of wasting and its early identification. They also reinforce how little is known about impactful interventions for the prevention of wasting. CONCLUSION This exercise provides a five-year investment case for research that could most effectively improve on-the-ground programmes to prevent child wasting and inform supportive policy change.
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Affiliation(s)
- Severine Frison
- Emergency Nutrition Network, Oxford, United Kingdom
- Department of Infectious Disease and Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Chloe Angood
- Emergency Nutrition Network, Oxford, United Kingdom
| | - Tanya Khara
- Emergency Nutrition Network, Oxford, United Kingdom
| | | | - Robert E. Black
- Institute for International Programs, Bloomsbury School of Public Health, Johns Hopkins University, Baltimore, United States of America
| | - André Briend
- Center for Child Health Research, Tampere University, Tampere, Finland
| | - Nicki Connell
- Eleanor Crook Foundation, Washington DC, United States of America
| | - Bridget Fenn
- Emergency Nutrition Network, Oxford, United Kingdom
| | - Sheila Isanaka
- Department of Nutrition, Harvard School of Public Health, Boston, United States of America
- Department of Global Health and Population, Harvard School of Public Health, Boston, United States of America
- Department of Research, Epicentre, Paris, France
| | - Philip James
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amy Mayberry
- No Wasted Lives and Action Against Hunger UK, London, United Kingdom
| | - Mark Myatt
- Brixton Health, Llwyngwril Gwynedd, United Kingdom
| | - Carmel Dolan
- Emergency Nutrition Network, Oxford, United Kingdom
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50
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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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