Nutritional evaluation and growth of infants in a Rwandan neonatal follow-up clinic

The impact of growth monitoring and promotion on health indicators in children under five years of age in low- and middle-income countries

BACKGROUND

Undernutrition in the critical first 1000 days of life is the most common form of childhood malnutrition, and a significant problem in low- and middle-income countries (LMICs). The effects of undernutrition in children aged under five years are wide-ranging and include increased susceptibility to and severity of infections; impaired physical and cognitive development, which diminishes school and work performance later in life; and death. Growth monitoring and promotion (GMP) is a complex intervention that comprises regular measurement and charting of growth combined with promotion activities. Policymakers, particularly in international aid agencies, have differing and changeable interpretations and perceptions of the purpose of GMP. The effectiveness of GMP as an approach to preventing malnutrition remains a subject of debate, particularly regarding the added value of growth monitoring compared with promotion alone.

OBJECTIVES

To evaluate the effectiveness of child growth monitoring and promotion for identifying and addressing faltering growth, improving infant and child feeding practices, and promoting contact with and use of health services in children under five years of age in low- and middle-income countries.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 3 November 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cohort studies, and controlled before-after studies that compared GMP with standard care or nutrition education alone in non-hospitalised children aged under five years.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to conduct a narrative synthesis. Our primary outcomes were anthropometric indicators, infant and child feeding practices, and health service usage. Secondary outcomes were frequency and severity of childhood illnesses, and mortality. We used GRADE to assess the certainty of evidence for each primary outcome.

MAIN RESULTS

We included six studies reported in eight publications. We grouped the findings according to intervention. Community-based growth monitoring and promotion (without supplementary feeding) versus standard care We are unsure if GMP compared to standard care improves infant and child feeding practices, as measured at 24 months by the proportion of infants who have fluids other than breast milk introduced early (49.7% versus 70.5%; 1 study; 4296 observations; very low-certainty evidence). We are unsure if GMP improves health service usage, as measured at 24 months by the proportion of children who receive vitamin A (72.5% versus 62.9%; 1 study; 4296 observations; very low-certainty evidence) and the proportion of children who receive deworming (29.2% versus 14.6%; 1 study; 4296 observations; very low-certainty evidence). No studies reported selected anthropometric indicators (weight-for-age z-score or height-for-age z-score) at 12 or 24 months, infant and child feeding practices at 12 months, or health service usage at 12 months. Community-based growth monitoring and promotion (with supplementary feeding) versus standard care Two studies (with 569 participants) reported the mean weight-for-age z-score at 12 months, providing very low-certainty evidence: in one study, there was little or no difference between GMP and standard care (mean difference (MD) -0.07, 95% confidence interval (CI) -0.19 to 0.06); in the other study, mean weight-for-age z-score worsened in both groups, but we were unable to calculate a relative effect. GMP versus standard care may make little to no difference to the mean height-for-age z-score at 12 months (MD -0.15, 95% CI -0.34 to 0.04; 1 study, 337 participants; low-certainty evidence). Two studies (with 564 participants) reported a range of outcome measures related to infant and child feeding practices at 12 months, showing little or no difference between the groups (very low-certainty evidence). No studies reported health service usage at 12 or 24 months, feeding practices at 24 months, or selected anthropometric indicators at 24 months.

AUTHORS' CONCLUSIONS

There is limited uncertain evidence on the effectiveness of GMP for identifying and addressing faltering growth, improving infant and child feeding practices, and promoting contact with and use of health services in children aged under five years in LMICs. Future studies should explore the reasons for the apparent limited impact of GMP on key child health indicators. Reporting of GMP interventions and important outcomes must be transparent and consistent.

Complementary Feeding Practices and Childhood Malnutrition in South Africa: The Potential of Moringa Oleifera Leaf Powder as a Fortificant: A Narrative Review

Poor complementary feeding is a common practice in developing regions, including South Africa (SA), and is one of the main contributing factors to childhood malnutrition. This paper reviews the literature on complementary feeding practices in SA and the potential of fortifying home-prepared complementary foods with Moringa oleifera to improve their nutritional composition. Studies that investigated complementary feeding practices, indigenous crops, nutritional benefits of Moringa oleifera, and the use of MOLP as a fortificant both locally and globally were included in this review. In SA, maize meal and commercial cereal are the most commonly used complementary infant foods. The diet consumed by children from vulnerable households commonly has insufficient nutrients. Foods consumed are generally high in starch and low in other essential nutrients, including good-quality protein. Impoverished individuals consume poor-quality foods as they are unable to afford a diversified diet with food from different food groups, such as protein, fruits, and vegetables. In SA, various programs have been implemented to reduce the incidence of childhood malnutrition. However, childhood malnutrition remains on the rise. This shows a need for complementary food-based strategies that can be implemented and sustained at a household level. This can be conducted through the use of accessible indigenous crops such as Moringa oleifera. Moringa oleifera contains essential nutrients such as proteins, amino acids, vitamins, and minerals. Therefore, it could possibly be used as a home-prepared complementary food fortificant to enhance nutritional composition. Before complementary foods can be fortified with Moringa oleifera, popular home-prepared complementary foods must be identified.

Evaluation of an mHealth tool to improve nutritional assessment among infants under 6 months in paediatric development clinics in rural Rwanda: Quasi-experimental study

Infants born preterm, low birthweight or with other perinatal complications require frequent and accurate growth monitoring for optimal nutrition and growth. We implemented an mHealth tool to improve growth monitoring and nutritional status assessment of high risk infants. We conducted a pre-post quasi-experimental study with a concurrent control group among infants enrolled in paediatric development clinics in two rural Rwandan districts. During the pre-intervention period (August 2017-January 2018), all clinics used standard paper-based World Health Organization (WHO) growth charts. During the intervention period (August 2018-January 2019), Kirehe district adopted an mHealth tool for child growth monitoring and nutritional status assessment. Data on length/height; weight; length/height-for-age (L/HFA), weight-for-length/height (WFL/H) and weight-for-age (WFA) z-scores; and interval growth were tracked at each visit. We conducted a 'difference-in-difference' analysis to assess whether the mHealth tool was associated with greater improvements in completion and accuracy of nutritional assessments and nutritional status at 2 and 6 months of age. We observed 3529 visits. mHealth intervention clinics showed significantly greater improvements on completeness for corrected age (endline: 65% vs. 55%; p = 0.036), L/HFA (endline: 82% vs. 57%; p ≤ 0.001), WFA (endline: 93% vs. 67%; p ≤ 0.001) and WFL/H (endline: 90% vs. 59%; p ≤ 0.001) z-scores compared with control sites. Accuracy of growth monitoring did not improve. Prevalence of stunting, underweight and inadequate interval growth at 6-months corrected age decreased significantly more in the intervention clinics than in control clinics. Results suggest that integrating mHealth nutrition interventions is feasible and can improve child nutrition outcomes. Improved tool design may better promote accuracy.

Neurodevelopmental outcomes of preterm babies during infancy in Eastern Uganda: a prospective cohort study

Background

Complications due to prematurity are a threat to child survival and full developmental potential particularly in low-income settings.

Objective

The aim of the study was to determine the neurodevelopmental outcomes among preterm infants and identify any modifiable factors associated with neurodevelopmental disability (NDD)

Methods

We recruited 454 babies (242 preterms with birth weight <2.5 kg, and 212 term babies) in a cohort study at birth from Iganga hospital between May and July 2018. We followed up the babies at an average age of 7 months (adjusted for prematurity) and assessed 211 preterm and 187 term infants for neurodevelopmental outcomes using the Malawi Developmental Assessment tool. Mothers were interviewed on care practices for the infants. Data were analyzed using STATA version 14.

Results

The study revealed a high incidence of NDD of 20.4% (43/211) among preterm infants compared to 7.5% (14/187) among the term babies, p < 0.001, of the same age. The most affected domain was fine motor (11.8%), followed by language (9.0%). At multivariate analysis, malnutrition and Kangaroo Mother Care (KMC) at home after discharge were the key factors that were significantly associated with NDD among preterm babies. The prevalence of malnutrition among preterm infants was 20% and this significantly increased the odds of developing NDD, OR = 2.92 (95% CI: 1.27–6.71). KMC practice at home reduced the odds of developing NDD, OR = 0.46, (95% CI: 0.21–1.00). Re-admission of preterm infants after discharge (a sign of severe illness) increased the odds of developing NDD but this was not statistically significant, OR = 2.33 (95% CI: 0.91–5.94).

Conclusion

Our study has shown that preterm infants are at a high risk of developing NDD, especially those with malnutrition. Health system readiness should be improved to provide follow-up care with emphasis on improving nutrition and continuity of KMC at home.

Nutritional evaluation and growth of infants in a Rwandan neonatal follow-up clinic

Children born preterm, low birth weight (LBW) or with other perinatal risk factors are at high‐risk of malnutrition. Regular growth monitoring and early intervention are essential to promote optimal feeding and growth; however, monitoring growth in preterm infants can be complex. This study evaluated growth monitoring of infants under 6 months enrolled in Paediatric Development Clinics (PDCs) in rural Rwanda. We reviewed electronic medical records (EMR) of infants enrolled in PDCs before age 2 months with their first visit between January 2015 and December 2016 and followed them until age 6 months. Nurse classification of anthropometric measures and nutritional status were extracted from the EMR. Interval growth and length‐for‐age, weight‐for‐length, and weight‐for‐age z‐scores were calculated using World Health Organization anthropometry software as a ‘gold standard’ comparison to nurse classifications. Two hundred and ninety‐four patients enrolled and had 2,033 visits during the study period. Referral reasons included prematurity/LBW (73.8%) and hypoxic ischemic encephalopathy (28.2%). Nurses assessed interval growth at 58.7% of visits, length‐for‐age at 66.4%, weight‐for‐length at 65.6% and weight‐for‐age at 66.4%. Nurses and gold standard assessment agreed on interval growth at 53.3% of visits and length‐for‐age at 63.7%, weight‐for‐length at 78.2% and weight‐for‐age at 66.3%. At 6 months, 46.5% were stunted, 19.9% were wasted and 44.2% were underweight. There were significant challenges to optimizing growth and growth monitoring among high‐risk infants served by PDCs, including incomplete and inaccurate assessments. Developing tools for clinician decision support in assessing growth and providing specialized nutritional counselling are essential to supporting optimal outcomes in this population.