Early development in children with moderate acute malnutrition: A cross-sectional study in Burkina Faso

Predictors of change in early child development among children with stunting: Secondary analysis of a randomized trial in Uganda

Millions of children under 5 years in low- and middle-income countries fail to attain their development potential with accruing short- and long-term consequences. Low length/height for age (stunting) is known to be a key factor, but there is little data on how child characteristics are linked with developmental changes among children with stunting. We assessed the socioeconomic, household, anthropometric, and clinical predictors of change in early child development (ECD) among 1-5-year-old children with stunting. This was a prospective cohort study nested in a randomized trial testing effects of lipid-based nutrient supplementation among children with stunting in Uganda. Development was assessed using the Malawi Development Assessment Tool (MDAT). Multiple linear regression analysis was used to assess for predictors of change. We included 750 children with mean ±SD age of 30.2 ±11.7 months 45% of whom were female. After 12 weeks, total MDAT z-score increased by 0.40 (95%CI: 0.32; 0.48). Moderate vs severe stunting, higher fat-free mass, negative malaria test and no inflammation (serum α-1-acid glycoprotein <1 g/l) at baseline predicted greater increase in ECD scores. Older age and fat mass gain predicted a lesser increase in ECD. Our findings reinforce the link between stunting and development with more severely stunted children having a lesser increase in ECD scores over time. Younger age, freedom from malaria and inflammation, and higher fat-free mass at baseline, as well as less gain of fat mass during follow-up predicted a higher increase in developmental scores in this study. Thus, supporting fat-free mass accretion, focusing on younger children, and infection prevention may improve development among children with stunting.

Early childhood development and nutritional status in urban Ethiopia

Early childhood development (ECD) is crucial for better health and well-being throughout life, but few studies have examined how ECD relates to child malnutrition. This is mainly due to lack of reliable and disaggregated data on ECD. We estimated the prevalence of ECD delays (communication, fine motor, gross motor, problem-solving and personal-social) and examined how different ECD domains were associated with child nutritional status in urban Ethiopia. Using a community-based cross-sectional survey design, 627 mother-child (12-36 months old) pairs were included in the study. The ECD was assessed using the Age and Stage Questionnaire (ASQ-3), and the nutritional status was assessed using anthropometric measurements. The association between the ECD domains and nutritional status was analysed using ordinal logistic regression, adjusting for confounding variables. Delays in ECD domains were common, especially in fine motor domain (41.9%); and more than half of the children were stunted (52.8%). Stunting and underweight were associated with ECD delays, while wasting was not. Accordingly, stunted children were more likely to have worst ECD delays in fine motor (odds ratios [OR] = 1.54; 95% confidence interval [CI]: 1.11; 2.15), gross motor (OR = 1.47; 95% CI: 1.05; 2.04) and problem-solving (OR = 1.41; 95% CI: 1.02; 1.96) domains compared to non-stunted children. Similarly, underweight children were more likely to have worse ECD delays in gross motor (OR = 1.91; 95% CI: 1.20; 3.04) and fine motor (OR = 1.90; 95% CI: 1.15; 3.15) domains compared to normal children. Coordinated and targeted ECD interventions, such as nurturing care, should be promoted and implemented widely to improve ECD outcomes and child nutrition.

Correlates of early child development among children with stunting: A cross-sectional study in Uganda

Many children in low- and middle-income countries are not attaining their developmental potential. Stunting is associated with poor child development, but it is not known which correlates of stunting are impairing child development. We explored potential socioeconomic, nutritional, clinical, and household correlates of early child development among 12-59-month-old children with stunting in a cross-sectional study in Uganda. Development was assessed using the Malawi Development Assessment Tool (MDAT) across four domains of gross and fine motor, language, and social skills. Linear regression analysis was used to assess correlates of development in the four domains and total MDAT score. Of 750 children included, the median [interquartile range] age was 30 [23-41] months, 55% of the children resided in rural settings with 21% from female-headed households and 47% of mothers had no schooling. The mean ± standard deviation height-for-age z-score (HAZ) was -3.02 ± 0.74, 40% of the children had a positive malaria test and 65% were anaemic (haemoglobin < 110 g/L). One-third had children's books at home, majority (96%) used household objects to play with and most of them (70%) used toys as pretence items like those to mimic cooking. After age, sex, and site adjustments, HAZ (0.24, 95% confidence interval [CI]: 0.14-0.33) and head circumference (0.07, 95% CI: 0.02-0.12) were positive correlates of total MDAT score, whereas weight-for-height z-score (WHZ) was not. Current breastfeeding was associated with 0.41 (95% CI: 0.17-0.65) lower total MDAT score. Children from households with a single income earner had 0.22 (95% CI: 0.06-0.37) lower total MDAT score. Furthermore, severe food insecurity, inflammation and positive malaria test were associated with lower scores for motor development. All family care indicator subscales (FCIs) positively correlated with the total MDAT score and this association was independent of household's socioeconomic status. In conclusion, stunting degree, head circumference, number of household income earners and stimulation by improved FCIs correlate with early child development among stunted children. The negative association with prolonged breastfeeding is likely due to reverse causality. Identified correlates may inform initiatives to support children with stunting attain their development potential.

Developmental and Nutritional Changes in Children with Severe Acute Malnutrition Provided with n-3 Fatty Acids Improved Ready-to-Use Therapeutic Food and Psychosocial Support: A Pilot Study in Tanzania

Children with severe acute malnutrition (SAM) are at high risk of impaired development. Contributing causes include the inadequate intake of specific nutrients such as polyunsaturated fatty acids (PUFAs) and a lack of adequate stimulation. We conducted a pilot study assessing developmental and nutritional changes in children with SAM provided with a modified ready-to-use therapeutic food and context-specific psychosocial intervention in Mwanza, Tanzania. We recruited 82 children with SAM (6-36 months) and 88 sex- and age-matched non-malnourished children. We measured child development, using the Malawi Development Assessment Tool (MDAT), measures of family and maternal care for children, and whole-blood PUFA levels. At baseline, the mean total MDAT z-score of children with SAM was lower than non-malnourished children; -2.37 (95% confidence interval: -2.92; -1.82), as were their total n-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) levels. After 8 weeks of intervention, MDAT z-scores improved in all domains, especially fine motor, among children with SAM. Total n-3 and EPA levels increased, total n-6 fatty acids decreased, and DHA remained unchanged. Family and maternal care also improved. The suggested benefits of the combined interventions on the developmental and nutritional status of children with SAM will be tested in a future trial.

Effect of Gut Microbiota-Directed Complementary Food Supplementation on Fecal and Plasma Biomarkers of Gut Health and Environmental Enteric Dysfunction in Slum-Dwelling Children with Moderate Acute Malnutrition

Dietary supplementation with a gut microbiota-directed complementary food (MDCF-2) significantly improved weight gain and repaired gut microbiota, as reported in a recent randomized controlled trial on Bangladeshi children with moderate acute malnutrition (MAM). Environmental enteric dysfunction (EED) is a small bowel disorder, and recent evidence shows that it is linked to growth failure in children. Therefore, we intended to investigate whether supplementation with MDCF-2 has any role in modifying gut health by changing the levels of biomarkers of EED and gut inflammation in children with MAM. We randomly assigned 124 children aged 12-18 months to one of two intervention diets, either MDCF-2 or ready-to-use supplementary food (RUSF). Approximately 50 g of the diet was administered in two feeding sessions daily for 12 weeks. Stool and plasma biomarkers were assessed to evaluate intestinal health. Results showed that the average change in citrulline concentration (µmol/L) significantly increased among children who consumed MDCF-2 compared to those who consumed RUSF (mean difference-in-differences: 123.10; 95% CI: 3.60, 242.61; p = 0.044). The research findings demonstrated that MDCF-2 might have a beneficial effect on improving the gastrointestinal health of malnourished children.

Impact of COVID-19 on Outpatient Malnutrition Centers in Urban and Rural Burkina Faso

Although the numbers of SARS-CoV-2 infections and related deaths are relatively low in sub-Saharan Africa, the pandemic might lead to a high indirect death toll there. We determined the impact of the COVID-19 pandemic on the management of malnourished children in urban and rural areas. We analyzed data from two Centers for Rehabilitation, Education & Nutrition (CRENs), one in the capital and one in a rural center, both run by the Camillian Fathers. We compared data from the year before the pandemic (2019) with the first 2 years during the pandemic (2020/2021). In the urban CREN, there was a sharp reduction in new patients enrolled, from 340 in the pre-pandemic year to 189 during the first pandemic year and 202 in the second year. The follow-up was significantly shorter during the first pandemic year, with a rebound in the second year (pre: 57 days versus 42 and 63 days for the first and second years, respectively). In the rural CREN, the situation was different: The numbers of patients did not show any significant variation between the pre-pandemic year (191) and the first and second pandemic years (223 and 179, respectively). Different perceptions of the pandemic in urban (high, more testing, more COVID) and rural (low, less information and testing) areas may partly explain this difference. The discrepancy between the decreasing numbers of malnourished children in specialized care during the pandemic-especially in the urban area-is contrary to the lockdown-induced increase in food insecurity and warrants attention to avoid an increase in the silent epidemic of malnourished children in Africa.

Associations between Early Life Nutrient Intakes and Brain Maturation Show Developmental Dynamics from Infancy to Toddlerhood: A Neuroimaging Observation Study

BACKGROUND

Myelin imaging has increasingly been applied to study the impact of nutrition on brain development in recent years. Although individual dynamics for nutrient intakes and myelin trajectories previously have been investigated across childhood, the longitudinal interaction between both remains unclear in typically developed children.

OBJECTIVES

The objective of this work was to explore the developmental dynamics of nutrient-myelin interactions from infancy to early childhood using myelin imaging as a marker for brain maturation.

METHODS

Brain neuroimaging (1 scan per child) and dietary nutrient intake data were analyzed for 88 nutrients from 293 children (127 female, 62% White) from a longitudinal cohort study in the United States. A sliding window approach was used to investigate correlations between nutrient intakes and brain myelination over a continuous set of age windows. Image processing techniques (Sobel-filter vertical edge detection) were applied to determine age windows with unique association profiles, providing novel insight into how these relationships change with child age.

RESULTS

We identified 3 nutrient-myelin windows covering the age range of 1-5 y: window 1 from 6 to 20 mo with 60% positive nutrient correlations, window 2 from 20 to 30 mo with 20% positive correlations, and window 3 from 30 to 60 mo with 37% positive correlations. The windows are aligned with reported myelin and white matter dynamics that change in the first 5 y from fast and steep (window 1) to continued but slower growth (window 3), with window 2 possibly representing the inflection period.

CONCLUSIONS

To our knowledge, this is the first study in typically developing children demonstrating the developmental dynamics between early life nutrient intakes and brain maturation in toddlerhood. The knowledge can be applied for identifying targeted and brain-stage-appropriate nutritional interventions for this critical stage of brain development.

The Evolving Need for Neuropsychology in Neurosurgical Settings: Challenges Facing Transformative Care

Clinical neuropsychology has been a valuable asset to neurologic surgery, contributing to lateralization and localization of pathologic brain tissue, identification of eloquent cortex, and evaluation of postoperative neuropsychological functioning. Moreover, neuropsychologists provide empirically driven interventions aimed at supporting preparation and/or recovery of neurosurgery patients. Nonetheless, several challenges may limit the reliability, validity, and generalizability of the assessment data obtained and reduce the usefulness of other neuropsychological services provided. Specifically, linguistic, cultural, educational, and other biases associated with demographic characteristics can lead to a narrowed view of an individual's life experiences, which must be confronted to fulfill the mission of ensuring that all patients have access to care that is appropriate to their needs. Instead of perceiving these challenges as insurmountable barriers, such issues can be viewed as opportunities to catalyze change and foster innovation for the future of neuropsychological care in neurosurgical settings. In addition to reviewing the possible mechanisms of these obstacles, the current article offers tangible solutions at both a macro level (e.g., discipline-wide transformations) and micro level (e.g., individualized patient-centric approaches). Outlined are practical techniques to potentially improve consensus and standardization of methods, advance and globalize research, expand representativeness of measures and practices to serve diverse individuals, and increase treatment adherence through engagement of patients and their families.

Community-based management of acute malnutrition for infants under 6 months of age is safe and effective: analysis of operational data

OBJECTIVE

To assess the effectiveness of outpatient management with ready-to-use and supplementary foods for infants under 6 months (u6m) of age who were unable to be treated as inpatients due to social and economic barriers.

DESIGN

Review of operational acute malnutrition treatment records.

SETTING

Twenty-one outpatient therapeutic feeding clinics in rural Malawi.

PARTICIPANTS

Infants u6m with acute malnutrition treated as outpatients because of barriers to inpatient treatment. The comparison group consisted of acutely malnourished children 6-9 months of age who were being treated at the same time in the same location in the context of two different randomised clinical trials.

RESULTS

A total of 323 infants u6m were treated for acute malnutrition (130 severe and 193 moderate). A total of 357 infants 6-9 months old with acute malnutrition (seventy-four severe and 283 moderate) were included as contemporaneous controls. Among infants u6m with severe acute malnutrition, 98 (75·4 %) achieved nutritional recovery; in comparison, 56 (75·7 %) of those with severe acute malnutrition 6-9 months old recovered. Among infants u6m with moderate acute malnutrition, 157 (81·3 %) recovered; in comparison, 241 (85·2 %) of those aged 6-9 months recovered.

CONCLUSIONS

In a rural Malawian population of infants u6m who had generally already stopped exclusive breast-feeding and were now acutely malnourished, treatment with therapeutic or supplementary foods under the community management of acute malnutrition model was safe and effective. In settings where social and financial factors make hospital admission challenging, consideration should be given to lowering the recommended age of ready-to-use therapeutic and supplementary foods to infants u6m.

Neurodevelopment and Recovery From Wasting

BACKGROUND AND OBJECTIVES

Acute illness with malnutrition is a common indication for hospitalization among children in low- and middle-income countries. We investigated the association between wasting recovery trajectories and neurodevelopmental outcomes in young children 6 months after hospitalization for an acute illness.

METHODS

Children aged 2 to 23 months were enrolled in a prospective observational cohort of the Childhood Acute Illness &amp; Nutrition Network, in Uganda, Malawi, and Pakistan between January 2017 and January 2019. We grouped children on the basis of their wasting recovery trajectories using change in mid-upper arm circumference for age z-score. Neurodevelopment was assessed with the Malawi Developmental Assessment Tool (MDAT development-for-age z-score [DAZ]) at hospital discharge and after 6 months.

RESULTS

We included 645 children at hospital discharge (mean age 12.3 months ± 5.5; 55% male); 262 (41%) with severe wasting, 134 (21%) with moderate wasting, and 249 (39%) without wasting. Four recovery trajectories were identified: high-stable, n = 112; wasted-improved, n = 404; severely wasted-greatly improved, n = 48; and severely wasted-not improved, n = 28. The children in the severely wasted-greatly improved group demonstrated a steep positive MDAT-DAZ recovery slope. This effect was most evident in children with both wasting and stunting (interaction wasted-improved × time × stunting: P &lt; .001). After 6 months, the MDAT DAZ in children with wasting recovery did not differ from community children. In children who never recovered from wasting, there remained a significant delay in MDAT DAZ scores.

CONCLUSIONS

Neurodevelopment recovery occurred in parallel with wasting recovery in children convalescing from acute illness and was influenced by stunting.

Undernutrition and short duration of breastfeeding association with child development: a population-based study

OBJECTIVE

To explore the relationship of undernutrition and the short duration of breastfeeding with child development of children 0-66 months of age residing in Ceará, Brazil.

METHODS

The authors of the present study utilized population-based data from children enrolled in the Study on Maternal and Child Health in Ceará, Brazil (PESMIC). Children's development was assessed with the Ages and Stages Questionnaire third version, validated in Brazil. Undernutrition was accessed through anthropometric measures obtained by trained staff. Breastfeeding information was obtained through the mothers' report and confirmed in the child's governmental booklet. The authors used logistic regressions adjusted for sample clusters used in PESMIC design in a theoretical model for known determinants of child development following the World Health Organization nurturing framework.

RESULTS

A total of 3,566 children were enrolled in the sixth PESMIC study and had their development assessed. The authors found that 8.2%, 3.0%, 2.1%, and 3.6% of children were stunted, underweight, or wasted, at the time of the interview, respectively. All studied factors were associated with a higher prevalence of child development impairment in at least one of the assessed domains. Underweight was the factor with the strongest effect, with an adjusted odds ratio (AOR) of 4,14 (2,26-7,58), p < 0.001. Breastfeeding for up to two months compared to more than six months (AOR 2,08 (1,38-3,12)) was also associated.

CONCLUSIONS

The authors found that undernutrition and short duration of breastfeeding are associated with development outcomes among Brazilian children. As a result, integrated nutritional programs may improve child development outcomes.

Prevalence and associated factors for stunting, underweight and wasting among children under 6 years of age in rural Hunan Province, China: a community-based cross-sectional study

Background

The existing epidemiological data cannot represent the situation of undernutrition among Chinese children, particularly those in rural China. Hence, in this community-based cross-sectional study, the prevalence and associated factors of stunting, underweight and wasting among children (age < 6 years) from rural Hunan Province were analyzed.

Methods

Totally 5529 children aged 0 to 71 months and their caregivers were randomly chosen by multistage stratified cluster sampling from 72 villages from rural Hunan, which were distributed in 24 towns of 12 counties. Data about the children and their mothers, caregivers and family conditions was acquired using unified questionnaire, and the length/height and weight of each child were measured using unified instruments. The prevalence of undernutrition among children was evaluated using the length/height for age, weight for age, weight for length/height, and body mass index for age z scores, which were computed according to the 2006 and 2007 WHO Child Growth Standards.

Results

The prevalence of stunting, underweight, and wasting among the 5529 children were 4.4% (241), 3.9% (217), and 4.0% (221), respectively. The significant associated factors on higher risks of undernutrition in the children were low birth weight, maternal gestational weight gain <10 kg (stunting); low birth weight, maternal gestational weight gain <10 kg, ethnicity of caregivers being minority, large family size (underweight); low birth weight, ethnicity of caregivers being minority, large family size (wasting). High education level of caregivers and high family food expenditure were common protective factors for all three types of undernutrition, except that high family food expenditure was not protective against wasting.

Conclusions

The prevalence of stunting, underweight and wasting is low among rural children under age of 6 years in Hunan. As for the measures, the gestational care and reasonable diet of mothers should be strengthened, and nutritional deficiency during pregnancy be avoided, which will prevent low birth weight. The local economic development and the education level of caregivers need to be further improved, especially for minorities.

Serum cobalamin in children with moderate acute malnutrition in Burkina Faso: Secondary analysis of a randomized trial

BACKGROUND

Among children with moderate acute malnutrition (MAM) the level of serum cobalamin (SC) and effect of food supplements are unknown. We aimed to assess prevalence and correlates of low SC in children with MAM, associations with hemoglobin and development, and effects of food supplements on SC.

METHODS AND FINDINGS

A randomized 2 × 2 × 3 factorial trial was conducted in Burkina Faso. Children aged 6 to 23 months with MAM received 500 kcal/d as lipid-based nutrient supplement (LNS) or corn-soy blend (CSB), containing dehulled soy (DS) or soy isolate (SI) and 0%, 20%, or 50% of total protein from milk for 3 months. Randomization resulted in baseline equivalence between intervention groups. Data on hemoglobin and development were available at baseline. SC was available at baseline and after 3 and 6 months. SC was available from 1,192 (74.1%) of 1,609 children at baseline. The mean (±SD) age was 12.6 (±5.0) months, and 54% were females. Low mid-upper arm circumference (MUAC; <125 mm) was found in 80.4% (958) of the children and low weight-for-length z-score (WLZ; <-2) in 70.6% (841). Stunting was seen in 38.2% (456). Only 5.9% were not breastfed. Median (IQR) SC was 188 (137; 259) pmol/L. Two-thirds had SC ≤222 pmol/L, which was associated with lower hemoglobin. After age and sex adjustments, very low SC (<112 pmol/L) was associated with 0.21 (95% CI: 0.01; 0.41, p = 0.04) and 0.24 (95% CI: 0.06; 0.42, p = 0.01) z-score lower fine and gross motor development, respectively. SC data were available from 1,330 (85.9%) of 1,548 children followed up after 3 months and 398 (26.5%) of the 1,503 children after 6 months. Based on tobit regression, accounting for left censored data, and adjustments for correlates of missing data, the mean (95% CI) increments in SC from baseline to the 3- and 6-month follow-up were 72 (65; 79, p < 0.001) and 26 (16; 37, p < 0.001) pmol/L, respectively. The changes were similar among the 310 children with SC data at all 3 time points. Yet, the increase was 39 (20; 57, p < 0.001) pmol/L larger in children given LNS compared to CSB if based on SI (interaction, p < 0.001). No effect of milk was found. Four children died, and no child developed an allergic reaction to supplements. The main limitation of this study was that only SC was available as a marker of status and was missing from a quarter of the children.

CONCLUSIONS

Low SC is prevalent among children with MAM and may contribute to impaired erythropoiesis and child development. The SC increase during supplementation was inadequate. The bioavailability and adequacy of cobalamin in food supplements should be reconsidered.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN42569496.

Weight-for-Height, Body Fat, and Development in Children in the East Asia and Pacific Region

IMPORTANCE

Weight-for-height z score (WHZ) is a standard indicator of children's nutritional status even though it does not fully reflect body fat.

OBJECTIVE

To examine the combined association of WHZ and body fat with early development in the East Asia and Pacific region.

DESIGN, SETTING, AND PARTICIPANTS

Children from the East Asia-Pacific Early Child Development Scales validation study, with full data available regarding their nutritional status and outcomes, were included in this cross-sectional analysis. In brief, a multilevel stratified random sampling was used to select representative samples from each participating country in the study. WHZ and body fat were independently trichotomized using established references and were combined to form a 9-category exposure variable. Data collection was performed between 2012 and 2014, and the analyses were conducted in June 2021.

MAIN OUTCOMES AND MEASURES

The binary outcome variable of not being developmentally on track (hereafter referred to as poor development) was defined as a score less than the 25th percentile in the following domains: cognitive, language, socioemotional, motor development, and total development score. Poisson regression models were used to analyze the associations between the combined categories and poor development, adjusted for sociodemographic factors.

RESULTS

A total of 6815 children (mean [SD] age, 4.02 [0.8] years; 3434 girls [50.4%]) had full data available and were included in this study. Compared with children with normal weight and normal fat, those with wasting and low body fat had the highest likelihood of total poor development (prevalence ratio, 1.47; 95% CI, 1.28-1.70), followed by those with normal weight but low fat (prevalence ratio, 1.23; 95% CI, 1.11-1.36). Similar associations were found in language, cognitive, and socioemotional development, but not in motor development.

CONCLUSIONS AND RELEVANCE

Poor development was more commonly found in children with low body fat independent of WHZ (wasted or normal weight). Early public health strategies may consider using a combination of WHZ and body fat as an indicator of poor development.

Low linoleic acid foods with added DHA given to Malawian children with severe acute malnutrition improve cognition: a randomized, triple-blinded, controlled clinical trial

BACKGROUND

There is concern that the PUFA composition of ready-to-use therapeutic food (RUTF) for the treatment of severe acute malnutrition (SAM) is suboptimal for neurocognitive recovery.

OBJECTIVES

We tested the hypothesis that RUTF made with reduced amounts of linoleic acid, achieved using high-oleic (HO) peanuts without added DHA (HO-RUTF) or with added DHA (DHA-HO-RUTF), improves cognition when compared with standard RUTF (S-RUTF).

METHODS

A triple-blind, randomized, controlled clinical feeding trial was conducted among children with uncomplicated SAM in Malawi with 3 types of RUTF: DHA-HO-RUTF, HO-RUTF, and S-RUTF. The primary outcomes, measured in a subset of subjects, were the Malawi Developmental Assessment Tool (MDAT) global z-score and a modified Willatts problem-solving assessment (PSA) intention score for 3 standardized problems, measured 6 mo and immediately after completing RUTF therapy, respectively. MDAT domain z-scores, plasma fatty acid content, anthropometry, and eye tracking were secondary outcomes. Comparisons were made between the novel PUFA RUTFs and S-RUTF.

RESULTS

Among the 2565 SAM children enrolled, mean global MDAT z-scores were -0.69 ± 1.19 and -0.88 ± 1.27 for children receiving DHA-HO-RUTF and S-RUTF, respectively (difference 0.19, 95% CI: 0.01, 0.38). Children receiving DHA-HO-RUTF had higher gross motor and social domain z-scores than those receiving S-RUTF. The PSA problem 3 scores did not differ by dietary group (OR: 0.92, 95% CI: 0.67, 1.26 for DHA-HO-RUTF). After 4 wk of treatment, plasma phospholipid EPA and α-linolenic acid were greater in children consuming DHA-HO-RUTF or HO-RUTF when compared with S-RUTF (for all 4 comparisons P values < 0.001), but only plasma DHA was greater in DHA-HO-RUTF than S-RUTF (P < 0.001).

CONCLUSIONS

Treatment of uncomplicated SAM with DHA-HO-RUTF resulted in an improved MDAT score, conferring a cognitive benefit 6 mo after completing diet therapy. This treatment should be explored in operational settings. This trial was registered at clinicaltrials.gov as NCT03094247.

A Microbiota-Directed Food Intervention for Undernourished Children

BACKGROUND

More than 30 million children worldwide have moderate acute malnutrition. Current treatments have limited effectiveness, and much remains unknown about the pathogenesis of this condition. Children with moderate acute malnutrition have perturbed development of their gut microbiota.

METHODS

In this study, we provided a microbiota-directed complementary food prototype (MDCF-2) or a ready-to-use supplementary food (RUSF) to 123 slum-dwelling Bangladeshi children with moderate acute malnutrition between the ages of 12 months and 18 months. The supplementation was given twice daily for 3 months, followed by 1 month of monitoring. We obtained weight-for-length, weight-for-age, and length-for-age z scores and mid-upper-arm circumference values at baseline and every 2 weeks during the intervention period and at 4 months. We compared the rate of change of these related phenotypes between baseline and 3 months and between baseline and 4 months. We also measured levels of 4977 proteins in plasma and 209 bacterial taxa in fecal samples.

RESULTS

A total of 118 children (59 in each study group) completed the intervention. The rates of change in the weight-for-length and weight-for-age z scores are consistent with a benefit of MDCF-2 on growth over the course of the study, including the 1-month follow-up. Receipt of MDCF-2 was linked to the magnitude of change in levels of 70 plasma proteins and of 21 associated bacterial taxa that were positively correlated with the weight-for-length z score (P<0.001 for comparisons of both protein and bacterial taxa). These proteins included mediators of bone growth and neurodevelopment.

CONCLUSIONS

These findings provide support for MDCF-2 as a dietary supplement for young children with moderate acute malnutrition and provide insight into mechanisms by which this targeted manipulation of microbiota components may be linked to growth. (Supported by the Bill and Melinda Gates Foundation and the National Institutes of Health; ClinicalTrials.gov number, NCT04015999.).

Body Composition Changes in Children during Treatment for Moderate Acute Malnutrition: Findings from a 4-Arm Cluster-Randomized Trial in Sierra Leone

BACKGROUND

Measures that better describe "healthy" and sustainable recovery during nutritional treatment of children with moderate acute malnutrition (MAM) are needed.

OBJECTIVES

We compared changes to body composition among children receiving 1 of 4 specialized nutritious food (SNFs) during treatment of MAM and by recovery and relapse outcomes.

METHODS

The study was nested within a prospective, cluster-randomized, community-based, cost-effectiveness trial assessing 4 SNFs to treat children aged 6-59 mo with MAM [midupper arm circumference (MUAC) ≥11.5 cm and <12.5 cm without bipedal edema] in Sierra Leone. Biweekly SNF rations (1 of 3 fortified-blended foods or a lipid-based nutrient supplement) were given until children recovered (MUAC ≥12.5 cm), or up to 7 rations (∼12 wk). Deuterium dilution was used to estimate fat-free mass (FFM) and fat mass (FM) at enrollment and after 4 wk of treatment to ensure similar treatment exposure among the participants. Another MUAC measurement was performed among recovered children 4 wk after program exit to determine whether recovery was sustained. ANOVA, paired t tests, and linear regression models were used to determine significant differences in changes from baseline to 4 wk.

RESULTS

Among 312 analyzed participants, mean baseline weight comprised ∼80% FFM; mean weight gained after 4 wk comprised ∼82% FFM. Changes in FM and FFM among 4 SNFs were similar. Children who recovered gained more weight (241%), FFM (179%), and weight-for-height z score (0.44 compared with 0) compared with those who did not recover; sustainers gained 150% more weight. FM gains were positive among recovered children and sustainers, as well as negative among those who did not recover or sustain recovery, but not significantly different.

CONCLUSIONS

Four SNFs had similar effects on body composition in children after 4 wk of treatment for MAM, showing a healthy pattern of weight gain, the majority being FFM. Differential responses to treatment underscore a need for further research to provide targets for healthy, sustainable recovery. This trial was registered at clinicaltrials.gov as NCT03146897.

Impact of food supplements on early child development in children with moderate acute malnutrition: A randomised 2 x 2 x 3 factorial trial in Burkina Faso

BACKGROUND

Lipid-based nutrient supplements (LNS) and corn-soy blends (CSBs) with varying soy and milk content are used in treatment of moderate acute malnutrition (MAM). We assessed the impact of these supplements on child development.

METHODS AND FINDINGS

We conducted a randomised 2 × 2 × 3 factorial trial to assess the effectiveness of 12 weeks' supplementation with LNS or CSB, with either soy isolate or dehulled soy, and either 0%, 20%, or 50% of protein from milk, on child development among 6-23-month-old children with MAM. Recruitment took place at 5 health centres in Province du Passoré, Burkina Faso between September 2013 and August 2014. The study was fully blinded with respect to soy quality and milk content, while study participants were not blinded with respect to matrix. This analysis presents secondary trial outcomes: Gross motor, fine motor, and language development were assessed using the Malawi Development Assessment Tool (MDAT). Of 1,609 children enrolled, 54.7% were girls, and median age was 11.3 months (interquartile range [IQR] 8.2-16.0). Twelve weeks follow-up was completed by 1,548 (96.2%), and 24 weeks follow-up was completed by 1,503 (93.4%); follow-up was similar between randomised groups. During the study, 4 children died, and 102 children developed severe acute malnutrition (SAM). There was no difference in adverse events between randomised groups. At 12 weeks, the mean MDAT z-scores in the whole cohort had increased by 0.33 (95% CI: 0.28, 0.37), p < 0.001 for gross motor; 0.26 (0.20, 0.31), p < 0.001 for fine motor; and 0.14 (0.09, 0.20), p < 0.001 for language development. Children had larger improvement in language z-scores if receiving supplements with milk (20%: 0.09 [-0.01, 0.19], p = 0.08 and 50%: 0.11 [0.01, 0.21], p = 0.02), although the difference only reached statistical significance for 50% milk. Post hoc analyses suggested that this effect was specific to boys (interaction p = 0.02). The fine motor z-scores were also improved in children receiving milk, but only when 20% milk was added to CSB (0.18 [0.03, 0.33], p = 0.02). Soy isolate over dehulled soy increased language z-scores by 0.07 (-0.01, 0.15), p = 0.10, although not statistically significant. Post hoc analyses suggested that LNS benefited gross motor development among boys more than did CSB (interaction p = 0.04). Differences between supplement groups did not persist at 24 weeks, but MDAT z-scores continued to increase post-supplementation. The lack of an unsupplemented control group limits us from determining the overall effects of nutritional supplementation for children with MAM.

CONCLUSIONS

In this study, we found that child development improved during and after supplementation for treatment of MAM. Milk protein was beneficial for language and fine motor development, while suggested benefits related to soy quality and supplement matrix merit further investigation. Supplement-specific effects were not found post-intervention, but z-scores continued to improve, suggesting a sustained overall effect of supplementation.

TRIAL REGISTRATION

ISRCTN42569496.

Early development in children with moderate acute malnutrition: A cross-sectional study in Burkina Faso

Malnutrition impairs cognitive, communication, and motor development, but it is not known how nutrition and health are associated with development in children with moderate acute malnutrition (MAM). We aimed to describe motor and language development of children with MAM and explore its nutrition and health-related correlates. This cross-sectional study used baseline data from a nutritional trial in children with MAM aged 6-23 months in Burkina Faso. Motor and language skills were assessed using the Malawi Development Assessment Tool (MDAT). Linear mixed models were used to explore potential correlates of MDAT including socio-economic status, anthropometry, body composition, whole-blood polyunsaturated fatty acids (PUFA), haemoglobin (Hb), iron status, and morbidity. We also assessed child and caregiver participation during MDAT procedures and their associations with correlates and development. MDAT data were available for 1.608 children. Mean (95% CI) MDAT z-scores were -0.39 (-0.45, -0.34) for gross motor, 0.54 (0.48, 0.59) for fine motor, and -0.91 (-0.96, -0.86) for language skills. Children with higher mid-upper arm circumference, weight-for-height, height-for-age, fat-free mass, n-3 PUFAs, Hb, and iron status had better MDAT z-scores, whereas children with more fat mass index, anaemia, illness, and inflammation had poorer z-scores. In addition, children living in larger households or with an unmarried mother had poorer MDAT z-scores. Associations between morbidity and z-scores were largely explained by children's poorer participation during MDAT assessment. The identified factors associated with child development may inform interventions needed to stimulate development during or after management of MAM.