Management of severe acute malnutrition in low-income and middle-income countries

Gut microbiota and childhood malnutrition: Understanding the link and exploring therapeutic interventions

Childhood malnutrition is a metabolic condition that affects the physical and mental well-being of children and leads to resultant disorders in maturity. The development of childhood malnutrition is influenced by a number of physiological and environmental factors including metabolic stress, infections, diet, genetic variables, and gut microbiota. The imbalanced gut microbiota is one of the main environmental risk factors that significantly influence host physiology and childhood malnutrition progression. In this review, we have evaluated the gut microbiota association with undernutrition and overnutrition in children, and then the quantitative and qualitative significance of gut dysbiosis in order to reveal the impact of gut microbiota modification using probiotics, prebiotics, synbiotics, postbiotics, fecal microbiota transplantation, and engineering biology methods as new therapeutic challenges in the management of disturbed energy homeostasis. Understanding the host-microbiota interaction and the remote regulation of other organs and pathways by gut microbiota can improve the effectiveness of new therapeutic approaches and mitigate the negative consequences of childhood malnutrition.

Simplified treatment protocols improve recovery of children with severe acute malnutrition in South Sudan: results from a mixed methods study

BACKGROUND

As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes.

METHODS

A mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols.

RESULTS

Very few (1.6%; n = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI - 30.2, - 26.5) and 5.1 days (CI - 6.2, - 4.0); the full adapted protocol had a decrease of 3.0 (CI - 5.1, - 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18-3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45-2.19); and fully adapted protocol AOR = 2.41 (CI 1.69-3.45).

CONCLUSIONS

This study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing.

Open-heart surgery in preterm infants: A single-center experience

Background

Open-heart surgery is challenging in preterm neonates and infants, and its feasibility in low-resource settings has not been defined. We describe our institutional experience with open-heart surgeries performed on consecutive preterm infants.

Materials Methods and Results

This was a single-center retrospective cohort from a tertiary hospital in Southern India and included consecutive preterm neonates (<37 weeks) admitted for open-heart surgery. This report is limited to babies who were <3 months at the surgery. The salient features of the 15 preterm included twin gestation: 7 (46.7%); median gestational age at birth: 35 weeks (28-36 weeks); median corrected gestational age at surgery: 37 weeks (33-40 weeks); birth weight: 1.75 kg (1.0-2.6 kg); weight at surgery: 1.8 kg (1.2-2.9 kg); and small for gestational age: 12 (80%). The heart defects included transposition of the great arteries (7), total anomalous pulmonary venous return (3), large ventricular septal defect (VSD) (1), and VSD with coarctation of the aorta (4). Eleven (73%) were mechanically ventilated preoperatively and five had preoperative sepsis. The mean cardiopulmonary bypass time was 169.7 ± 61.5 min, and cross-clamp time was 99.7 ± 43.8 min. There was no inhospital mortality; one baby expired during follow-up at 1 month. Postoperative mechanical ventilation duration was 126.50 h (84.25-231.50 h), and intensive care unit stay was 13.5 days (9-20.8). The total hospital stay was 39 days (11-95 days). Two children (13.3%) had postoperative sepsis.

Conclusion

Through collaborative multidisciplinary management, excellent outcomes are feasible in low-resource environments for selected preterm neonates undergoing corrective open-heart operations.

Critical Review of Tuberculosis Diagnosis in Children from Papua New Guinea Presenting to Health Facilities in the Torres Strait Islands, Australia

Paediatric tuberculosis can be challenging to diagnose, and various approaches are used in different settings. A retrospective review was conducted on Papua New Guinea (PNG) children with presumptive TB who presented for health care in the Torres Strait Islands, Australia, between 2016 and 2019. We compared diagnostic algorithms including the modified Keith Edwards TB Score, The Union Desk Guide, and the new World Health Organization (WHO) algorithm, with diagnostic practices used in the remote Torres Strait Islands. Of the 66 children with presumptive TB, 7 had bacteriologically confirmed TB. The majority (52%) were under 5 years (median age 61 months), and 45% were malnourished. There was moderate agreement across the diagnostic methods (K = 0.34; 95% CI 0.23-0.46), with the highest concordance observed between The Union Desk Guide and the WHO's algorithm (K = 0.61). Local TB physicians might have over-diagnosed presumed lymph node TB while under-diagnosing TB overall. Enhancing the precision and promptness of paediatric TB diagnosis using practical tools is pivotal to decrease TB-related child mortality, notably in isolated regions like the Torres Strait and the Western Province of PNG.

Inflammation: the driver of poor outcomes among children with severe acute malnutrition?

Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.

Growth and Body Composition 5 y After Treatment for Severe Acute Malnutrition: A 5-y Prospective Matched Cohort Study in Ethiopian Children

BACKGROUND

Short-term anthropometric outcomes are well documented for children treated for severe acute malnutrition (SAM). However, anthropometric recovery may not indicate restoration of healthy body composition.

OBJECTIVES

This study aimed to evaluate long-term associations of SAM with growth and body composition of children 5 y after discharge from community-based management of acute malnutrition (CMAM).

METHODS

We conducted a 5-y prospective cohort study, enrolling children aged 6 to 59 mo discharged from CMAM (post-SAM) (n = 203) and nonmalnourished matched controls (n = 202) from Jimma Zone, Ethiopia in 2013. Anthropometry and body composition (bioelectrical impedance) were assessed. Multiple linear regression models tested differences in height-for-age (HAZ), weight-for-age (WAZ), and body mass index-for-age (BAZ) z-scores; height-adjusted fat-free mass index (FFMI); and FM index (FMI) between groups.

RESULTS

Post-SAM children had higher stunting prevalence than controls at discharge (82.2% compared with 36.0%; P < 0.001), 1 y (80.2% compared with 53.7%; P < 0.001), and 5 y postdischarge (74.2% compared with 40.8%; P < 0.001). Post-SAM children remained 5 cm shorter throughout follow-up, indicating no HAZ catch-up. No catch-up in WAZ or BAZ was observed. Post-SAM children had lower hip (-2.05 cm; 95% CI: -2.73, -1.36), waist (-0.92 cm; CI: -1.59, -0.23) and mid-upper arm (-0.64 cm; CI: -0.90, -0.42) circumferences and lower-limb length (-1.57 cm; 95% CI: -2.21, -0.94) at 5 y postdischarge. They had larger waist-hip (0.02 cm; 95% CI: 0.008, 0.033) and waist-height (0.013 cm; 95% CI: 0.004, 0.021) ratios, and persistent deficits in FFMI at discharge and 6 mo and 5 y postdischarge (P < 0.001 for all). No difference was detected in head circumference, sitting height, or FMI.

CONCLUSIONS

Five y after SAM treatment, children maintained deficits in HAZ, WAZ, BAZ, and FFMI, with preservation of FMI, sitting height, and head circumference at the expense of lower-limb length, indicating a "thrifty growth" pattern. Research is urgently needed to identify effective clinical and public health interventions to mitigate these consequences of malnutrition.

Incidence of tuberculosis and its predictors among under-five children with severe acute malnutrition in North Shoa, Amhara region, Ethiopia: a retrospective follow-up study

Introduction

Although tuberculosis (TB) is one of the significant public health challenges in severely malnourished children throughout the globe, it is a severe issue for countries such as Ethiopia, with significant resource limitations. Few studies have examined the incidence of tuberculosis and its predictors among children under five years of age with severe acute malnutrition in developing countries, and there is a paucity of data. This study aimed to estimate the incidence of tuberculosis and its predictors among under-five children with severe acute malnutrition (SAM) in North Shoa, Amhara region, Ethiopia.

Methods

An institution-based retrospective follow-up study was conducted between January 20, 2017, and June 20, 2019. The sample size was calculated using STATA, which yields a total of 345 charts that were selected with systematic random sampling. Data entry was performed using Epi-data version 4.2 and analyzed with STATA 14. Kaplan-Meier survival curves were computed. Cox proportional hazard models were fitted to detect the determinants of tuberculosis. The hazard ratio with a 95% confidence interval was subsequently calculated. Variables with p-values < 0.05 were considered statistically significant.

Results

The incidence rate of tuberculosis among children under five years of age with SAM was 4.6 per 100 person-day observations (95% CI: 3.29, 8.9). Predictors of TB were a history of contact with known TB cases [AHR: 1.4 (95% CI: 1.00, 2.8], HIV/AIDS [AHR: 3.71 (95% CI: 2.10, 8.71)], baseline pneumonia [AHR: 2.10 (1.76,12)], not supplying zinc at baseline [AHR: 3.1 (1.91, 4.70)], and failed appetite taste at the diagnosis of SAM [AHR: 2.4 (1.35, 3.82)].

Conclusions

In this study, the incidence rate of TB was high. Not supplying zinc at baseline, failed appetite taste at the diagnosis of SAM, history of contact with known TB cases, and baseline pneumonia were significant predictors of TB. Prioritizing regular TB screenings, nutritional support, and zinc supplementation for under-five children with SAM should be implemented to reduce the risk of TB.

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.

A qualitative assessment of facility readiness and barriers to the facility-based management of childhood severe acute malnutrition in the public healthcare settings in Bangladesh

OBJECTIVE

To assess facility readiness and identify barriers to the facility-based management of childhood severe acute malnutrition (SAM) in public healthcare settings.

DESIGN

Qualitative methods were applied to assess readiness and identify different perspectives on barriers to the facility-based management of children with SAM. Data collection was done using in-depth interviews, key informant interviews, exit interviews and pre-tested observation tools.

SETTINGS

Two tertiary care and four district hospitals in Rangpur and Sylhet Divisions of Bangladesh.

PARTICIPANTS

Healthcare professionals and caregivers of children with SAM.

RESULTS

Anthropometric tools, glucometer, medicines, F-75, F-100 and national guidelines for facility-based management of childhood SAM were found unavailable in some of the hospitals. Sitting and sleeping arrangements for the caregivers were absent in all of the chosen facilities. We identified a combination of health system and contextual barriers that inhibited the facility-based management of SAM. The health system barriers include inadequate manpower, rapid turnover of staff, increased workload, lack of training and lack of adherence to management protocol. The major facility barriers were insufficient space and unavailability of required equipment, medicines and foods for hospitalised children with SAM. The reluctance of caregivers to complete the treatment regimen, their insufficient knowledge regarding proper feeding, increased number of attendants and poverty of parents were the principal contextual barriers.

CONCLUSIONS

The study findings provide insights on barriers that are curbing the facility-based management of SAM and emphasise policy efforts to develop feasible interventions to reduce the barriers and ensure the preparedness of the facilities for effective service delivery.

Determinants of wasting among children aged 6-59 months in North-East Ethiopia: a community-based case-control study

OBJECTIVE

Childhood acute malnutrition, in the form of wasting defined by Weight-for-Height Z-Scores, is a major public health concern. It is one of the main reasons for the death of children in developing countries like Ethiopia. Accordingly, this study aimed to assess determinants of wasting among children aged 6-59 months in Meket district, North Wollo zone, North-East Ethiopia.

SETTING

The study was conducted among communities in Meket district, North Wollo zone, North-East Ethiopia.

PARTICIPANTS

A total of 327 (109 cases and 218 controls) children aged 6-59 months participated in the study. Children from 6 months to 59 months of age who match the definition of case/wasted/ and control/not wasted were eligible for the study. However, children who had physical deformities which make anthropometric measurements inconvenient were excluded from the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcome measure was wasting.

RESULT

The mean ages of the cases and controls were 21.77±11.41 months and 20.13±11.39 months, respectively. Factors that were significantly associated with wasting were: maternal decision making on the use of household money (adjusted odd ratio (AOR)=3.04, 95% CI 1.08 to 7.83), complementary feeding started in a month (AOR=3.02, 95% CI 1.097 to 6.97), food diversity score (AOR=2.64, 95% CI 1.64 to 5.23), frequency of complementary feeding (AOR=6.68, 95% CI 3.6 to 11.25) and history of acute respiratory infections (ARIs) 2 weeks preceding the survey (AOR=3.21, 95% CI 1.07 to 7.86).

CONCLUSION

Our result implies that the right time to introduce complementary foods, the frequency of feeding and also the amount of food consumed were some of the crucial factors that needed to be changed in child nutrition to reduce wasting. Furthermore, within the framework of our study, the empowerment of women in the decision-making process and the prevention of ARI should be seen as a necessary benchmark for acute malnutrition.

Concordance Between Indices of Malnutrition: Mid-Upper Arm Circumference V/S Weight for the Height Z Score in Different Age Groups in Karachi, Pakistan

Objective

To compare the WHO cut-off of the mid-upper arm circumference (MUAC) with the weight for height z-score (WHZ) in different age groups of children (6 months to 59 months of age) with acute malnutrition in Pakistan.

Methodology

A cross-sectional study was carried out in the pediatric unit of Ziauddin Medical University and Hospital on malnourished children from six to 59 months of age to compare two different indices of malnutrition, MUAC and WHZ. A total of 450 children with WHZ of <-2SD and <-3SD were included in the study after excluding children with failure to thrive due to chronic illness, congenital defects, and immune deficiencies/malabsorption.

Results

The study revealed a significant mean difference in weight, height, and MUAC among the participants (0.030, 0.053, and 0.02). The sensitivity of MUAC at <11.5 cm was highest in the 12-24-month age group with a decline at 24-48 months while specificity was highest at six to 12 months of age, which shows a mixed response.

Conclusion

The result revealed variation in the cut-off value of MUAC in different age groups; the best specificity of MUAC was found at six to 12 months of age and the best sensitivity at 12-24 months of age.

Infant Nutrition in Low- and Middle-Income Countries

The burden of infant malnutrition is greatest in low- and middle-income countries (LMICs). Infant malnutrition is defined based on distinct subcategories, among them stunting (low-height-for-age) and wasting (low-weight-for-height). Some experts are shifting more toward understanding the interplay between these overlapping phenotypes and other confounding factors such as maternal nutrition and environmental hygiene. Current guidelines emphasize appropriate breastfeeding and nutrition within the 1000 days from conception to a child's second birthday to optimize early development. Future research directed toward better biomarkers of malnutrition before acute clinical symptoms develop will help direct targeted efforts toward at-risk populations.

Subclinical Kwashiorkor in Adults: A New Age Paradigm

Childhood protein-energy undernutrition (PEU) is a well-recognized problem and therefore a lot of work has been done to identify and manage paediatric PEU. Though there have been several reports of low protein consumption in adults from developing countries, PEU and its subtle forms (subclinical PEU) are not yet recognized as adult disorders. Physicians and public perception do not favour easy recognition and action. In this review, the authors provide a scoping review of the existing literature on this entity providing insights into its recognition, pathogenesis and management. Adult subclinical PEU is an enormous under-recognized challenge that can have detrimental consequences if not recognized and corrected in time. PEU has grave health and economic impact on the patient and society. Therefore, it is important to recognize subclinical PEU and prevent its progression to full-blown form.

Spatial Variations and Determinants of Acute Malnutrition Among Under-Five Children in Ethiopia: Evidence from 2019 Ethiopian Demographic Health Survey

Background and aims:

Childhood acute malnutrition, in the form of wasting defined by a severe weight loss as a result of acute food shortage and/or illness. It is a critical public health problem that needs urgent attention in developing countries, like Ethiopia. Despite its variation between localities, the risk factors and its geospatial variation were not addressed enough across the various corner of the country. Therefore, the current study was undertaken to assess spatial variation and factors associated with acute malnutrition among under-five children in Ethiopia.

Methods:

A total weighted sample of 4 955 under-five children were included from the 2019 Demographic and Health Survey. Getis-Ord spatial statistical tool used to identify the hot and cold spot areas of severe and acute malnutrition. A multilevel multivariable logistic regression model using was used to examine predictors of acute malnutrition. In the multivariable multilevel analysis, Adjusted Odds Ratio with 95% CI was used to declare significant determinants of acute malnutrition among children.

Result:

Among 4 955 under-five children, 7% of them were wasted and 1% of them were severely wasted in Ethiopia during the 2019 national demographic survey. The distribution was followed some spatial geo-locations where most parts of Somali were severely affected (RR = 1.46, P37 value <0.001), and the distribution affected few areas of Afar, Gambella, and Benishangul Gumz regions. Factors that significantly associated with childhood wasting were: gender(male)1.9 (1.3–2.7), age (above 36 months) 0.5 (0.2–0.9), wealth index(richest) 0.5 (0.2–0.8), and water source (unimproved source) 1.5 (1.0–2.3).

Conclusions:

Our finding implies, the distribution of childhood wasting was not random. Regions like Afar, Somali, and pocket areas in Gambella and SNNP should be considered as priority areas nutritional interventions for reducing acute malnutrition. The established socio-demographic and economic characteristics can be also used to develop strategies.

Starvation and Its Effects on the Gut

There is growing awareness that intestinal dysfunction determines the clinical outcomes of situations as diverse as undernourished children in urban tropical slums and undernourished surgical patients in intensive care units. As experimental starvation in humans has only rarely been studied, and largely not using current biomedical research tools, we must draw inference from disparate clinical and experimental observations as to the derangements present in the starved gut. There is good evidence of intestinal atrophy and achlorhydria in starvation and severe undernutrition. Historical reports from concentration camps and conflict settings consistently reported a noncontagious phenomenon called "hunger diarrhea," but in settings where starved individuals are isolated from others (prisoners on hunger strike, anorexia nervosa) diarrhea is not a feature. Changes in intestinal permeability and absorption have been infrequently studied in experimental starvation; available data suggest that short-term starvation reduces sugar absorption but not permeability. Severe acute malnutrition in children is associated with severe changes in the intestinal mucosa. Experimental animal models may help explain some observations in humans. Starved rats develop a hypersecretory state and intestinal barrier defects. Starved pigs demonstrate prolongation of rotavirus diarrhea and reproduce some of the absorptive and barrier defects observed in malnourished children. However, there remains much to be learned about the effects of starvation on the gut. Given the high prevalence of undernutrition in hospitals and disadvantaged communities, the lack of attention to the interaction between undernutrition and gastrointestinal damage is surprising and needs to be corrected. Current sophisticated cellular and molecular techniques now provide the opportunity to create fresh understanding of gastrointestinal changes in pure undernutrition, using volunteer studies and samples from anorexia nervosa.

Food intake and infectious diseases among malnutrition toddlers in rural area of Muna Regency

OBJECTIVE

This study aims to look at the relationship between food intake and infectious diseases with the incidence of malnutrition in rural toddlers.

METHODS

The study was conducted using a cross-sectional study design. Daily food intake was collected using the Food Frequency Questionnaire (FFQ) method. Measurement of body weight and body length is done by enumerators who have been trained.

RESULTS

This study found that there was a significant relationship between food intake and nutritional status of children under five years because p-value <0.05, with RR=3.17 (95% CI=1.22-8.25), there was a relationship which is meaningful between infectious diseases and nutritional status because of the p-value <0.05, with a RR value of 2.6 (95% CI=1.01-6.73).

CONCLUSION

Food intake among malnutrition children was much lower than the recommended daily allowance. Infectious diseases are found prevalent among malnutrition children.

Ready-to-use therapeutic foods for the treatment of malnourished children and infants

PURPOSE OF REVIEW

Ready-to-use therapeutic foods (RUTF) allow effective community-based management of severe acute malnutrition (SAM). Current interest focuses on their optimal composition and use.

RECENT FINDINGS

Studies of alternative RUTF have yielded differing results. Partial soybean, sorghum flour, and whey protein replacement RUTF were inferior to standard RUTF. In contrast, soy-based RUTF was as effective as milk-based RUTF and an alternative RUTF with added oats lead to superior recovery in comparison to standard RUTF.Reducing the dose of RUTF in the later phases of SAM recovery resulted in small reductions in the growth of uncertain clinical significance.Although iron and vitamin A status improve during treatment with standard RUTF, a significant proportion of children remained deficient. Alternative soya, maize, and sorghum-based formulas with no milk protein may improve recovery of iron status compared to standard RUTF.Finally, in children with SAM, plasma essential fatty acids and conversion to long-chain polyunsaturated fatty acids are reduced. Despite the improvement, these parameters remain lower than in normal children after 3 months.

SUMMARY

New RUTF formulations may provide a cost-effective alternative to standard RUTF. Future research should focus on addressing micronutrient deficiency, lipid metabolism, and long-term recovery.

Severe acute malnutrition morphological patterns in children under five

Current methods for infant and child nutritional assessment rely on anthropometric measurements, whose implementation faces technical challenges in low- and middle-income countries. Anthropometry is also limited to linear measurements, ignoring important body shape information related to health. This work proposes the use of 2D geometric morphometric techniques applied to a sample of Senegalese participants aged 6–59 months with an optimal nutritional condition or with severe acute malnutrition to address morphometric variations due to nutritional status. Significant differences in shape and size body changes were described according to nutritional status, resulting age, sex and allometric effect crucial factors to establish nutritional morphological patterns. The constructed discriminant functions exhibited the best classification rates in the left arm. A landmark-based template registering body shape could be useful to both assess acute malnutrition and better understand the morphological patterns that nutritional status promotes in children during their first 5 years of growth and development.

Length of stay to recover from severe acute malnutrition and associated factors among under-five years children admitted to public hospitals in Aksum, Ethiopia

Background

Severe acute malnutrition is defined by <70% weight for length/height, by visible severe wasting, by the presence of pitting edema, and in children 6 to 59 months of age, mid upper arm circumference <110 mm. Severe acute malnutrition remains to be a worldwide problem, claiming lives of millions of children, especially in sub-Saharan Africa and south Asia. Though the Ethiopian national guideline states the total length of stay in therapeutic feeding units should not be more than four weeks, there is huge difference, varying from 8 to 47 days of stay. Therefore, the objective of this study was to assess length of stay to recover from severe acute malnutrition and associated factors among under five children hospitalized to the public hospitals in Aksum Town.

Methods

Sample size was calculated using STATA version 12.0. A retrospective cohort study was conducted using pretested questionnaire in the public hospitals in Aksum on children aged 0–59 months. Cleaned data was entered to Epi info version 7.1.4 and then exported into SPSS version 21 for analysis. Bivariable and multivariable analyses were performed using Kaplan Meier and Cox regression models. During bivariable analysis, variables with p-value < 0.05 were selected for multivariable analysis to identify independent factors associated with length of stay.

Results

A total of 564 participants enrolled to the study. The rate of recovery was 56% with median length of stay of 15 days (95% CI: 14.1, 15.9). The independent predictors of length of stay to recovery were presence of diarrhea at admission (AHR = 0.573, 95% CI: 0.415–0.793), being HIV positive (AHR = 0.391, 95% CI: 0.194–0.788), palmar pallor (AHR = 0.575, 95% CI: 0.416–0.794), presence of other co-morbidities at admission (AHR = 0.415, 95% CI: 0.302–0.570) and not being treated with plumpy nut (AHR = 0.368, 95% CI: 0.262–0.518).

Conclusions

Length of stay is in the acceptable range of the international and national set of standards. Nevertheless, the recovery rate was lower compared to the Sphere standard. Presence of diarrhea, palmar pallor, HIV other co-morbidities and not treated with plumpy nut were found independent protective factors for recovery from sever acute malnutrition.

Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi

BACKGROUND

Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the 'WHO 10 Steps' and mortality in children with SAM is not fully understood.

METHODS

Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6-36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients' charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the 'WHO 10 Steps' were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression.

RESULTS

Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1% vs 3.8%, p < 0.001). Compared with independent assessment anthropometrics, clinicians appropriately documented SAM on admission in 39.5%. The following factors were independently associated with mortality: kwashiorkor [adjusted odds ratio (aOR) 5.14, 95% confidence interval (CI) 1.27-20.78], shock (aOR 18.54, 95% CI 3.87-88.90), HIV-positive (aOR 5.32, 95% CI 1.76-16.09), SAM documented on admission (aOR 2.41, 95% CI 1.11-5.22), documentation of blood glucose within 24 hrs (aOR 3.97, 95% CI 1.90-8.33) and IV fluids given without documented shock (aOR 3.13, 95% CI 1.16-8.44).

CONCLUSION

HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.

Plasma proteomics reveals markers of metabolic stress in HIV infected children with severe acute malnutrition

HIV infection affects up to 30% of children presenting with severe acute malnutrition (SAM) in Africa and is associated with increased mortality. Children with SAM are treated similarly regardless of HIV status, although mechanisms of nutritional recovery in HIV and/or SAM are not well understood. We performed a secondary analysis of a clinical trial and plasma proteomics data among children with complicated SAM in Kenya and Malawi. Compared to children with SAM without HIV (n = 113), HIV-infected children (n = 54) had evidence (false discovery rate (FDR) corrected p < 0.05) of metabolic stress, including enriched pathways related to inflammation and lipid metabolism. Moreover, we observed reduced plasma levels of zinc-α-2-glycoprotein, butyrylcholinesterase, and increased levels of complement C2 resembling findings in metabolic syndrome, diabetes and other non-communicable diseases. HIV was also associated (FDR corrected p < 0.05) with higher plasma levels of inflammatory chemokines. Considering evidence of biomarkers of metabolic stress, it is of potential concern that our current treatment strategy for SAM regardless of HIV status involves a high-fat therapeutic diet. The results of this study suggest a need for clinical trials of therapeutic foods that meet the specific metabolic needs of children with HIV and SAM.

Effect of Malnutrition on Hearing Loss in Children

OBJECTIVE

To characterize the relation between protein-calorie malnutrition (PCM) and hearing loss (HL) in children.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral hospital.

PATIENTS

Children in the Audiological and Genetic Database with a diagnosis of protein-calorie malnutrition, marasmus, and/or kwashiorkor.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Prevalence, type, severity (4-tone pure-tone average, PTA), and progression of HL.

RESULTS

Of 770 children with PCM, 57.8% had HL, compared to 45.5% of children without PCM (p < 0.001). Severely malnourished children had significantly higher odds of moderate-profound HL (aOR 2.27, 95% CI 1.47-3.43), high-frequency HL (aOR 1.82, 95% CI 1.21-2.75), and sensorineural or mixed HL (aOR 1.60, 95% CI 1.05-2.41) compared to children without PCM. Severely malnourished children had significantly worse initial (35.0 dB vs 25.0 dB, p < 0.001), and final median PTA (31.3 dB vs 20.0 dB, p < 0.001) compared to children without PCM. Additionally, HL in children who were moderately and severely malnourished was significantly less likely to improve (aOR 0.47, 95% CI 0.25-0.82 and aOR 0.4, 95% CI 0.2-0.9) when compared to those without PCM.

CONCLUSIONS

Given the greater prevalence and severity of hearing loss, children with PCM should be considered an at-risk group for poor audiological outcomes, and clinical practice should focus on early treatment and intervention for malnourished children. Routine audiological evaluation should be considered in this population.

Edematous severe acute malnutrition is characterized by hypomethylation of DNA

Edematous severe acute childhood malnutrition (edematous SAM or ESAM), which includes kwashiorkor, presents with more overt multi-organ dysfunction than non-edematous SAM (NESAM). Reduced concentrations and methyl-flux of methionine in 1-carbon metabolism have been reported in acute, but not recovered, ESAM, suggesting downstream DNA methylation changes could be relevant to differences in SAM pathogenesis. Here, we assess genome-wide DNA methylation in buccal cells of 309 SAM children using the 450 K microarray. Relative to NESAM, ESAM is characterized by multiple significantly hypomethylated loci, which is not observed among SAM-recovered adults. Gene expression and methylation show both positive and negative correlation, suggesting a complex transcriptional response to SAM. Hypomethylated loci link to disorders of nutrition and metabolism, including fatty liver and diabetes, and appear to be influenced by genetic variation. Our epigenetic findings provide a potential molecular link to reported aberrant 1-carbon metabolism in ESAM and support consideration of methyl-group supplementation in ESAM.

Nutritional, clinical and immunological status of children at HIV diagnosis in the continental region of Equatorial Guinea

OBJECTIVE

To evaluate the nutritional, clinical and immunological status of children at HIV diagnosis in the continental region of Equatorial Guinea.

METHODS

Children <18 years diagnosed with HIV between 2009 and 2017 were included. Clinical, immunological and nutritional data were collected. Weight-for-height, weight-for-age and height-for-age Z-scores were calculated using WHO Child Growth Standards. The population was assessed in two equal periods (2009-2013 and 2014-2017) from the time of diagnosis.

RESULTS

A total of 213 children were diagnosed with HIV (49.3% males), median age 3.8 years (IQR: 1.5-8.2). A total of 121 cases (56.8%) were at WHO clinical stage III, and 53 (24.9%) were at WHO clinical stage IV. CDC immunological stage II was diagnosed in 51/130 (39.2%) and CDC stage III in 44/130 (33.8%). About 56.2% of children were underweight (weight-for-age <-2 SD); 20.1% moderately and 36.1% severely so. About 27.6% of children were wasted (weight-for-height <-2 SD); 11.9% moderately and 15.7% severely so. About 56.3% of children were stunted (height-for-age <-2 SD); 20.7% moderately and 35.6% severely so. The prevalence of wasting was higher in children ≤5 years than in children >5 years (36.4% vs. 19.1%, P = 0.026). In the second period, the prevalence of moderate-severe immunodeficiency decreased (87.2% to 67.0%, P = 0.018), without significant differences in the other nutritional or clinical data. Severe underweight was a risk factor for moderate-severe immunodeficiency (aOR: 4 [95% CI: 1.4-11.4], P = 0.010).

CONCLUSIONS

We highlight a high proportion of malnutrition at the time of HIV diagnosis in Guinea´s paediatric population. Early diagnosis of HIV infection is a priority, achievable by training Guinea´s physicians to suspect HIV early, introducing HIV molecular diagnostic techniques and ensuring intensive nutritional treatment.

Community management of acute malnutrition (CMAM) programme in Pakistan effectively treats children with uncomplicated severe wasting

Severe wasting is the most widespread form of severe acute malnutrition, affecting an estimated 17 million children globally. This analysis assesses the effectiveness of Pakistan's community management of acute malnutrition (CMAM) programme. We conducted a retrospective case series analysis of 32,458 children aged 6–59 months who were admitted to the programme with a mid‐upper arm circumference (MUAC) < 115 mm (January 1–December 31, 2014). We found that at admission, 59.6% of the children were girls and 87.4% were in the age group 6–23 months old. While in the programme, 120 children (0.4%) died, 3,456 (10.6%) defaulted, and 28,882 (89.0%) were discharged after a mean length of stay of 69.3 ± 25.7 days. Children's mean weight gain while in the programme was 3.2 ± 2.7 g/kg body weight/day. At discharge, 28,499 children (98.7% of discharged) had recovered (MUAC ≥ 125 mm). The odds of death were significantly higher among children with weight‐for‐height (WHZ) < −3 and/or height‐for‐age (HAZ) < −2 at admission. The odds of recovery on the basis of MUAC ≥125 mm were higher among children with HAZ ≥ −2 at admission. The odds of recovery on the basis of WHZ ≥ −2 were significantly higher among children with WHZ ≥ −3 and/or HAZ < −2 at admission. Pakistan's CMAM programme is effective in achieving good survival and recovery rates. Population‐level impact could be increased by giving priority to children 6–23 months old and children with multiple anthropometric failure and by scaling up CMAM in the provinces and areas where the risk, prevalence, and/or burden of severe acute malnutrition is highest.

Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age

BACKGROUND

Management of severe acute malnutrition (SAM) in children comprises two potential phases: stabilisation and rehabilitation. During the initial stabilisation phase, children receive treatment for dehydration, electrolyte imbalances, intercurrent infections and other complications. In the rehabilitation phase (applicable to children presenting with uncomplicated SAM or those with complicated SAM after complications have been resolved), catch-up growth is the main focus and the recommended energy and protein requirements are much higher. In-hospital rehabilitation of children with SAM is not always desirable or practical - especially in rural settings - and home-based care can offer a better solution. Ready-to-use therapeutic food (RUTF) is a widely used option for home-based rehabilitation, but the findings of our previous review were inconclusive.

OBJECTIVES

To assess the effects of home-based RUTF used during the rehabilitation phase of SAM in children aged between six months and five years on recovery, relapse, mortality and rate of weight gain.

SEARCH METHODS

We searched the following databases in October 2018: CENTRAL, MEDLINE, Embase, six other databases and three trials registers. We ran separate searches for cost-effectiveness studies, contacted researchers and healthcare professionals in the field, and checked bibliographies of included studies and relevant reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs, where children aged between six months and five years with SAM were, during the rehabilitation phase, treated at home with RUTF compared to an alternative dietary approach, or with different regimens and formulations of RUTF compared to each other. We assessed recovery, deterioration or relapse and mortality as primary outcomes; and rate of weight gain, time to recovery, anthropometrical changes, cognitive development and function, adverse outcomes and acceptability as secondary outcomes.

DATA COLLECTION AND ANALYSIS

We screened for eligible studies, extracted data and assessed risk of bias of those included, independently and in duplicate. Where data allowed, we performed a random-effects meta-analysis using Review Manager 5, and investigated substantial heterogeneity through subgroup and sensitivity analyses. For the main outcomes, we evaluated the quality of the evidence using GRADE, and presented results in a 'Summary of findings' table per comparison.

MAIN RESULTS

We included 15 eligible studies (n = 7976; effective sample size = 6630), four of which were cluster trials. Eight studies were conducted in Malawi, four in India, and one apiece in Kenya, Zambia, and Cambodia. Six studies received funding or donations from industry whereas eight did not, and one study did not report the funding source.The overall risk of bias was high for six studies, unclear for three studies, and low for six studies. Among the 14 studies that contributed to meta-analyses, none (n = 5), some (n = 5) or all (n = 4) children were stabilised in hospital prior to commencement of the study. One small study included only children known to be HIV-infected, another study stratified the analysis for 'recovery' according to HIV status, while the remaining studies included HIV-uninfected or untested children. Across all studies, the intervention lasted between 8 and 16 weeks. Only five studies followed up children postintervention (maximum of six months), and generally reported on a limited number of outcomes.We found seven studies with 2261 children comparing home-based RUTF meeting the World Health Organization (WHO) recommendations for nutritional composition (referred to in this review as standard RUTF) with an alternative dietary approach (effective sample size = 1964). RUTF probably improves recovery (risk ratio (RR) 1.33; 95% confidence interval (CI) 1.16 to 1.54; 6 studies, 1852 children; moderate-quality evidence), and may increase the rate of weight gain slightly (mean difference (MD) 1.12 g/kg/day, 95% CI 0.27 to 1.96; 4 studies, 1450 children; low-quality evidence), but we do not know the effects on relapse (RR 0.55, 95% CI 0.30 to 1.01; 4 studies, 1505 children; very low-quality evidence) and mortality (RR 1.05, 95% CI 0.51 to 2.16; 4 studies, 1505 children; very low-quality evidence).Two quasi-randomised cluster trials compared standard, home-based RUTF meeting total daily nutritional requirements with a similar RUTF but given as a supplement to the usual diet (213 children; effective sample size = 210). Meta-analysis showed that standard RUTF meeting total daily nutritional requirements may improve recovery (RR 1.41, 95% CI 1.19 to 1.68; low-quality evidence) and reduce relapse (RR 0.11, 95% CI 0.01 to 0.85; low-quality evidence), but the effects are unknown for mortality (RR 1.36, 95% CI 0.46 to 4.04; very low-quality evidence) and rate of weight gain (MD 1.21 g/kg/day, 95% CI - 0.74 to 3.16; very low-quality evidence).Eight studies randomised 5502 children (effective sample size = 4456) and compared standard home-based RUTF with RUTFs of alternative formulations (e.g. using locally available ingredients, containing less or no milk powder, containing specific fatty acids, or with added pre- and probiotics). For recovery, it made little or no difference whether standard or alternative formulation RUTF was used (RR 1.03, 95% CI 0.99 to 1.08; 6 studies, 4188 children; high-quality evidence). Standard RUTF decreases relapse (RR 0.84, 95% CI 0.72 to 0.98; 6 studies, 4188 children; high-quality evidence). However, it probably makes little or no difference to mortality (RR 1.00, 95% CI 0.80 to 1.24; 7 studies, 4309 children; moderate-quality evidence) and may make little or no difference to the rate of weight gain (MD 0.11 g/kg/day, 95% CI -0.32 to 0.54; 6 studies, 3807 children; low-quality evidence) whether standard or alternative formulation RUTF is used.

AUTHORS' CONCLUSIONS

Compared to alternative dietary approaches, standard RUTF probably improves recovery and may increase rate of weight gain slightly, but the effects on relapse and mortality are unknown. Standard RUTF meeting total daily nutritional requirements may improve recovery and relapse compared to a similar RUTF given as a supplement to the usual diet, but the effects on mortality and rate of weight gain are not clear. When comparing RUTFs with different formulations, the current evidence does not favour a particular formulation, except for relapse, which is reduced with standard RUTF. Well-designed, adequately powered, pragmatic RCTs with standardised outcome measures, stratified by HIV status, and that include diarrhoea as an outcome, are needed.

The functional biology of peanut allergens and possible links to their allergenicity

Peanut is one of the most common food triggers of fatal anaphylaxis worldwide although peanut allergy affects only 1%-2% of the general population. Peanuts are the source of highly potent allergenic proteins. It is emerging that the allergenicity of certain proteins is linked to their biological function. Peanut is an unusual crop in that it flowers aboveground but produces its seed-containing pods underground. This so-called geocarpic fruiting habit exposes pods and seeds during their development to soilborne pathogens and pests. Pest damage can also open routes of entry for opportunistic fungi such as Aspergillus. Although seed proteins have primary functions in nutrient reservoirs, lipid storage bodies, or the cytoskeleton, they have also evolved to act as part of the plant's defense system to enhance fitness and survival of the species. When interacting with pathogens or pests, these proteins modify and damage cells' membranes, interact with immune receptors, and modulate signaling pathways. Moreover, following exposure, the immune system of predisposed individuals reacts to these proteins with the production of specific IgE. This review explores the evolutionary biology of peanut and its seed proteins and highlights possible links between the proteins' biological function and their allergenicity.

A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial

BACKGROUND

Children with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase.

METHODS AND FINDINGS

In a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2-5 days), which was similar between randomized groups (0.23 [95% CI -0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite.

CONCLUSIONS

Empirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02246296.

Severe malnutrition in infants aged <6 months-Outcomes and risk factors in Bangladesh: A prospective cohort study

Severe acute malnutrition (SAM) affects ~4 million infants under 6 months (u6m) worldwide, but evidence underpinning their care is "very low" quality. To inform future research and policy, the objectives of our study were to identify risk factors for infant u6m SAM and describe the clinical and anthropometric outcomes of treatment with current management strategies. We conducted a prospective cohort study in infants u6m in Barisal district, Bangladesh. One group of 77 infants had SAM (weight-for-length Z-score [WLZ] <-3 and/or bipedal oedema); 77 others were "non-SAM" (WLZ ≥-2 to <+2, no oedema, mid-upper-arm circumference ≥125 mm). All were enrolled at 4-8 weeks of age and followed up at 6 months. Maternal education and satisfaction with breastfeeding were among factors associated with SAM. Duration of exclusive breastfeeding was shorter at enrolment (3·9 ± 2.1 vs. 5.7 ± 2.2 weeks, P < 0.0001) and at age 6 months (13.2 ± 8.9 vs. 17.4 ± 7.9 weeks; P = 0.003) among SAM infants. Despite referral, only 13 (17%) reported for inpatient care, and at 6 months, 18 (23%) infants with SAM still had SAM, and 3 (3.9%) died. In the non-SAM group, one child developed SAM, and none died. We conclude that current treatment strategies have limited practical effectiveness: poor uptake of inpatient referral being the main reason. World Health Organization recommendations and other intervention strategies of outpatient-focused care for malnourished but clinically stable infants u6m need to be tested. Breastfeeding support is likely central to future treatment strategies but may be insufficient alone. Better case definitions of nutritionally at-risk infants are also needed.

Comparative Rice Bran Metabolomics across Diverse Cultivars and Functional Rice Gene⁻Bran Metabolite Relationships

Rice (Oryza sativa L.) processing yields ~60 million metric tons of bran annually. Rice genes producing bran metabolites of nutritional and human health importance were assessed across 17 diverse cultivars from seven countries using non-targeted metabolomics, and resulted in 378–430 metabolites. Gambiaka cultivar had the highest number and Njavara had the lowest number of metabolites. The 71 rice bran compounds of significant variation by cultivar included 21 amino acids, seven carbohydrates, two metabolites from cofactors and vitamins, 33 lipids, six nucleotides, and two secondary metabolites. Tryptophan, α-ketoglutarate, γ-tocopherol/β-tocopherol, and γ-tocotrienol are examples of bran metabolites with extensive cultivar variation and genetic information. Thirty-four rice bran components that varied between cultivars linked to 535 putative biosynthetic genes using to the OryzaCyc 4.0, Plant Metabolic Network database. Rice genes responsible for bran composition with animal and human health importance is available for rice breeding programs to utilize in crop improvement.

Useful Tools for Food Aid: Linear Programming and Protein Quality Tools

The development of a superior treatment option for severe acute malnutrition (SAM) which allowed for home-based therapy put in place constraints that are crucial for ensuring the feasibility and nutritional integrity of the treatment. Soon after the initial success of ready-to-use therapeutic food (RUTF), there were attempts to modify the formulation for cost and other areas of acceptability. While alternative formulations have been taken on in clinical trials, they have been inferior to the standard RUTF recipe. Linear programming (LP) technology, however, has streamlined the formulation process allowing the user to account for the crucial constraints required to maintain the feasibility and nutritional integrity of standard RUTF. With the aid of an LP tool and other functional tools for assessing nutrient quality, nutrition researchers can use innovative approaches in food development that could potentially revolutionize food aid products.

Perceptions of Acute Malnutrition and Its Management in Infants Under 6 Months of Age: A Qualitative Study in Rural Bangladesh

BACKGROUND

World Health Organization guidelines advise community-based care (CBC) for "uncomplicated" severe acute malnutrition (SAM) infants <6 months old (u6m), whereas current national protocols refer to inpatient care. Our aim was to inform and shape future management strategies by understanding caregivers' and different stakeholders' perceptions on malnutrition among infants u6m on barriers/facilitators to future CBC.

METHODS

The methods used in this study are as follows: in-depth interviews and focus group discussions (FGDs) in southern Bangladesh, thematic analysis of transcripts, and sample size by data saturation.

RESULTS

We conducted 5 FGDs with 29 caregivers, 4 with 29 health care workers, 4 key informant interviews each with community leaders and health supervisors. Five themes emerged. 1) Identification of SAM infants and care-seeking behavior: malnutrition was not noticed until severe, caregivers focused on clinical symptoms. Both allopathic and traditional healers were consulted. (2) Perceived causes of infant malnutrition: underlying illness, poor feeding practices, poverty, and local superstitions. (3) Views and preferences on treatment: hospitals and doctors were perceived as offering the best treatment, health care workers were also important, and respondents highlighted the need care of the caregiver/mother along with the infant. (4) Perceived benefits and risks of CBC: lower cost and greater accessibility were appreciated but worried about quality. (5) Community networks: wider family and social support networks were considered important aspects of care.

CONCLUSIONS

There is considerable potential for CBC but needs to be better and earlier identification of at-risk infants, strengthening of health systems to avoid community options being perceived as "second best," engagement with families and communities to tackle "upstream" determinants of SAM, and care for mother-infant pairs.

Developmental and behavioural problems in children with severe acute malnutrition in Malawi: A cross-sectional study

Background

Early childhood development provides an important foundation for the development of human capital. Although there is a clear relation between stunting and child development outcomes, less information is available about the developmental and behavioural outcomes of children with severe acute malnutrition (SAM). Particularly an important research gap exists in Sub–Saharan Africa where there is a high prevalence of SAM and a high rate of co–occurring HIV (human immune deficiency virus) infection. Our first objective was to assess the prevalence and severity of developmental and behavioural disorders on a cohort of children admitted to an inpatient nutritional rehabilitation centre in Malawi. Our second objective was to compare the developmental and behavioural profiles of children with the two main phenotypes of SAM: kwashiorkor and marasmus.

Methods

This was a cross–sectional observational study including all children hospitalized with complicated SAM in Blantyre, Malawi over an 8–month period from February to October 2015. At discharge, children were assessed with the well-validated Malawi Developmental Assessment Tool (MDAT) for gross motor, fine motor, language and social development. In children ≥24 months, emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ).

Results

150 children (55% boys) with SAM were recruited; mean age of 27.2 months (standard deviation 17.9), 27 children (18%) had pre–existing neurodisabilities (ND) and 34 (23%) had a co–occurring human immune deficiency virus (HIV) infection. All children with SAM experienced profound delays in the gross and fine motor, language and social domains. Linear regression analysis demonstrated that children with kwashiorkor scored 0.75 standard deviations lower (95% confidence interval –1.43 to –0.07) on language MDAT domain than children with marasmus when adjusted for covariates. The prosocial behaviour score of the SDQ was low in children with SAM, indicating a lack of sensitive behaviour in social interactions.

Conclusions

Children with SAM have severe developmental delays after a hospital admission. Our results indicate that there might be a significant difference in developmental attainment between children with kwashiorkor and with marasmus. Future studies exploring longer–term outcomes and testing possible intervention strategies are urgently needed.

Additional Common Bean in the Diet of Malawian Children Does Not Affect Linear Growth, but Reduces Intestinal Permeability

Background

Chronic malnutrition, as manifested by linear growth faltering, is pervasive among rural African children. Improvements in complementary feeding may decrease the burden of environmental enteric dysfunction (EED) and thus improve growth in children during the critical first 1000 d of development.

Objective

We tested the hypothesis that systematically including common bean or cowpea into complementary feeding would reduce EED and growth faltering among children in rural Malawi.

Methods

This was a double-blind clinical trial in which children 12-23 mo of age were randomly assigned to receive complementary feeding with 1 of 3 foods: roasted cowpea or common bean flour, or an isoenergetic amount of corn-soy blend as a control food for 48 wk. Children aged 12-23 mo received 155 kcal/d and thereafter until 35 mo received 200 kcal/d. The primary outcomes were change in length-for-age z score (LAZ) and improvements in a biomarker of EED, the percentage of lactulose (%L) excreted as part of the lactulose:mannitol dual-sugar absorption test. Anthropometric measurements and urinary %L excretion were compared between the 2 intervention groups and the control group separately with the use of linear mixed model analyses for repeated measures.

Results

A total of 331 children completed the clinical trial. Compliance with the study interventions was excellent, with >90% of the intervention flour consumed as intended. No significant effects on LAZ, change in LAZ, or weight-for-length z score were observed due to either intervention legume, compared to the control. %L was reduced with common bean consumption (effect estimate was -0.07 percentage points of lactulose, P = 0.0007). The lactulose:mannitol test was not affected by the legume intervention.

Conclusion

The addition of common bean to complementary feeding of rural Malawian children during the second year of life led to an improvement in a biomarker of gut health, although this did not directly translate into improved linear growth. This trial was registered at clinicaltrials.gov as NCT02472301.

Management of Ebola Virus Disease in Children

The West African outbreak of 2013 to 2016 was the largest Ebola epidemic in history. With tens of thousands of patients treated during this outbreak, much was learned about how to optimize clinical care for children with Ebola. In anticipation of inevitable future outbreaks, a firsthand summary of the major aspects of pediatric Ebola case management in austere settings is presented. Emphasis is on early and aggressive critical care, including fluid resuscitation, electrolyte repletion, antimicrobial therapy, and nutritional supplementation.

Lactoferrin and lysozyme to reduce environmental enteric dysfunction and stunting in Malawian children: study protocol for a randomized controlled trial

Background

Chronic childhood malnutrition, as manifested by stunted linear growth, remains a persistent barrier to optimal child growth and societal development. Environmental enteric dysfunction (EED) is a significant underlying factor in the causal pathway to stunting, delayed cognitive development, and ultimately morbidity and mortality. Effective therapies against EED and stunting are lacking and further clinical trials are warranted to effectively identify and operationalize interventions.

Methods/design

A prospective randomized placebo-controlled parallel-group randomized controlled trial will be conducted to determine if a daily supplement of lactoferrin and lysozyme, two important proteins found in breast milk, can decrease the burden of EED and stunting in rural Malawian children aged 12–23 months old. The intervention and control groups will have a sample size of 86 subjects each. All field and laboratory researchers will be blinded to the assigned intervention group, as will the subjects and their caregivers. The percentage of ingested lactulose excreted in the urine (Δ%L) after 4 h will be used as the biomarker for EED and linear growth as the measure of chronic malnutrition (stunting). The primary outcomes of interest will be change in Δ%L from baseline to 8 weeks and to 16 weeks. Intention-to-treat analyses will be used.

Discussion

A rigorous clinical trial design will be used to assess the biologically plausible use of lactoferrin and lysozyme as dietary supplements for children at high risk for EED. If proven effective, these safe proteins may serve to markedly reduce the burden of childhood malnutrition and improve survival.

Trial Registration

Clinicaltrials.gov, NCT02925026. Registered on 4 October 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2278-8) contains supplementary material, which is available to authorized users.

Severe childhood malnutrition

The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.

Integration of childhood TB into guidelines for the management of acute malnutrition in high burden countries

Introduction: Childhood tuberculosis (TB) and undernutrition are major global public health challenges. In 2015, although an estimated 1 million children aged <15 years developed TB, the majority of the cases remain undiagnosed, partly due to a lack of awareness and capacity by providers who serve as the first point of care for sick children. This calls for better integration of TB with child health and nutrition services. TB can cause or worsen undernutrition, and undernutrition increases the risk of TB. Methods: Guidelines for the management of acute malnutrition from 17 high TB burden countries were reviewed to gather information on TB symptom screening, exposure history, and treatment. Results: Seven (41%) countries recommend routine TB screening among children with acute malnutrition, and six (35%) recommend obtaining a TB exposure history. Conclusion: TB screening is not consistently included in guidelines for acute malnutrition in high TB burden countries. Routine TB risk assessment, especially history of TB exposure, among acutely malnourished children, combined with improved linkages with TB services, would help increase TB case finding and could impact outcomes. Operational research on how best to integrate services at different levels of the health care system is needed.

Effects of unconditional cash transfers on the outcome of treatment for severe acute malnutrition (SAM): a cluster-randomised trial in the Democratic Republic of the Congo

BACKGROUND

Cash transfer programs (CTPs) aim to strengthen financial security for vulnerable households. This potentially enables improvements in diet, hygiene, health service access and investment in food production or income generation. The effect of CTPs on the outcome of children already severely malnourished is not well delineated. The objective of this study was to test whether CTPs will improve the outcome of children treated for severe acute malnutrition (SAM) in the Democratic Republic of the Congo over 6 months.

METHODS

We conducted a cluster-randomised controlled trial in children with uncomplicated SAM who received treatment according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. Analyses were by intention to treat.

RESULTS

The hazard ratio of reaching full recovery from SAM was 35% higher in the intervention group than the control group (adjusted hazard ratio, 1.35, 95% confidence interval (CI) = 1.10 to 1.69, P = 0.007). The adjusted hazard ratios in the intervention group for relapse to moderate acute malnutrition (MAM) and SAM were 0.21 (95% CI = 0.11 to 0.41, P = 0.001) and 0.30 (95% CI = 0.16 to 0.58, P = 0.001) respectively. Non-response and defaulting were lower when the households received cash. All the nutritional outcomes in the intervention group were significantly better than those in the control group. After 6 months, 80% of cash-intervened children had re-gained their mid-upper arm circumference measurements and weight-for-height/length Z-scores and showed evidence of catch-up. Less than 40% of the control group had a fully successful outcome, with many deteriorating after discharge. There was a significant increase in diet diversity and food consumption scores for both groups from baseline; the increase was significantly greater in the intervention group than the control group.

CONCLUSIONS

CTPs can increase recovery from SAM and decrease default, non-response and relapse rates during and following treatment. Household developmental support is critical in food insecure areas to maximise the efficiency of SAM treatment programs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02460848 . Registered on 27 May 2015.

Severe malnutrition in children in Papua New Guinea: effect of a multi-faceted intervention to improve quality of care and nutritional outcomes

BACKGROUND AND AIMS

Severe malnutrition remains a major problem in Papua New Guinea; it is associated with 11% of paediatric hospital admissions and 33% of all child deaths, with a case fatality rate around 20%. This article aims to evaluate the effectiveness of a multi-faceted intervention for improving care for children with severe malnutrition.

METHODS

Severe malnutrition was defined as weight-for-age (WFA) <-3 Z-scores with severe wasting or mid upper arm circumference <115 mm or generalised oedema owing to malnutrition. The intervention included training for health-care workers on WHO guidelines for severe malnutrition, ward-round checklists, posters and support for nurses to provide better patient nutrition. Three point prevalence surveys were conducted; one before the intervention and two afterwards at 3-month intervals. The main outcomes were weight change since admission, energy intake and the proportion of the calculated required energy intake in the previous 24 hours. Each stage of the WHO guidelines for severe malnutrition management was assessed for adherence.

RESULTS

There were significant improvements in the WHO steps for the management of severe malnutrition. At pre-intervention baseline, children received a median of 356 ml/day (IQR 178-450): 31% (95% CI 21-48) of their estimated daily energy requirements for weight. In the first follow-up survey, children received a median of 820 (IQR 600-1110) ml/day: 98% (95% CI 67-100) of daily energy requirements; and in the second follow-up survey they received 780 (IQR 480-900) ml/day: 86% (95% CI 46-100%) of daily requirement (P<0.001 both for volume received and percentage of energy requirements). Median weight gain prior to the intervention was 1.55 g/kg/day (IQR -4.3-6.0) which increased to 5.56 g/kg/day (IQR -3.7-12.0) and 10.19 g/kg/day (IQR 0-16.0) in the first and second follow-up surveys, respectively (P=0.013).

CONCLUSION

Implementation of a multi-faceted intervention to improve the management of children with severe malnutrition was associated with improved quality of care and improved weight gain.

Bacteremia caused by multidrug-resistant bacteria among hospitalized malnourished children in Mwanza, Tanzania: a cross sectional study

BACKGROUND

Severe malnutrition has been known to increase susceptibility and severity of infections. Bacteremia in malnourished children has been found to increase morbidity and mortality especially if is due to multidrug resistant bacteria. Here, we report the prevalence of bacteremia among children under 5 years of age and the antibiotic susceptibility pattern of the isolates; the information that can be used by clinicians to guide on the empirical antibiotic treatment.

FINDINGS

A total of 402 malnourished children were investigated for bacteremia. The median age of enrolled children were 17 (IQR 12-31) months. Severe malnutrition was observed in 19.1% of malnourished underfives. The point prevalence of bacteremia among malnourished children was 56/402 (13.9%; 95% CI 10.3-17.3). The prevalence of bacteremia was significantly higher among severely malnourished children than in children with moderate/mild malnutrition (18.0 vs. 10.7%, P = 0.03). Mortality was significantly associated with bacteremia among severely malnourished children (OR 2.77, 95% CI 1.02-6.98, P = 0.02). Pseudomonas spp. 20/56 (35.7%) were the most frequent isolates while Staphylococcus aureus and Streptococcus pneumoniae were isolated in 8/56 (14.2%) and 5/56 (8.9%) respectively. Rates of resistance for gram negative bacteria were; ampicillin (100%), amoxicillin/clavulanic acid (85.7%), gentamicin (23.8%), ceftriaxone (23.8%), ceftazidime (23.8%) meropenem (4.7%) and ciprofloxacin (2.4%). methicillin resistant S. aureus strains were confirmed in 4/8 (50%) of S. aureus isolates and 60% of S. pneumoniae isolates were resistant to 1 µg oxacillin.

CONCLUSION

Bacteremia due to multi drug resistant isolates is common among severely malnourished children under 5 years of age. There is a need to review empirical antibiotic treatment coupled with antibiotic stewardship to prevent mortality and morbidity of severely malnourished children under 5 years of age.

Physical therapy guideline for children with malnutrition in low income countries: clinical commentary

Physical therapy intervention along with nutritional rehabilitation has recently become an inevitable combo after recent evidences suggesting a strong interaction between malnutrition and neuro-muscular disabilities which contribute to a significant burden in global settings. Recent studies confirm that appropriate physical assessment of neuro-musculo skeletal system, developmental assessment or cognitive tools along with nutritional assessments followed by exercise rehabilitation will yield positive results in children with malnutrition. There is an obvious need to make available a simple physical therapy exercise guidelines with simple measure and exercise to be used in resource limited settings of developing countries. The purpose of this clinical commentary is to summarize simple assessment tools to evaluate activity impairment, participation restriction, gross motor activity and simple physical therapy intervention program for children with disability secondary to malnutrition.

Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Retrospective Analysis of Three Years of a Programme in Lusaka

BACKGROUND

While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka.

PROGRAMME ACTIVITIES AND ANALYSIS

Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression.

FINDINGS

1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM (RR of SAM 10.9; 95%CI 3.4,34.8; P<0.0001), and higher in children with HIV infection (RR 5.2, 95%CI 2.9, 9.0; P<0.0001). In multivariate analysis, HIV (OR 5.2; 95%CI 2.6, 10.1; P<0.0001), MUAC <11.5 cm (OR 4.1; 95%CI 2.2, 7.4; P<0.0001) and the first year of the programme (OR 1.9; 95%CI 1.0, 3.4; P = 0.04) all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality (RR 0.23; 95%CI 0.10, 0.57; P = 0.0008).

INTERPRETATION

Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.

Including whey protein and whey permeate in ready-to-use supplementary food improves recovery rates in children with moderate acute malnutrition: a randomized, double-blind clinical trial

BACKGROUND

The utility of dairy ingredients in the supplementary foods used in the treatment of childhood moderate acute malnutrition (MAM) remains unsettled.

OBJECTIVE

We evaluated the effectiveness of a peanut-based ready-to-use supplementary food (RUSF) with soy protein compared with a novel RUSF containing dairy ingredients in the form of whey permeate and whey protein concentrate in the treatment of children with MAM.

DESIGN

We conducted a randomized, double-blind clinical effectiveness trial involving rural Malawian and Mozambican children 6-59 mo of age with MAM treated with either soy RUSF or a novel whey RUSF treatment of ~75 kcal · kg(-1) · d(-1) for up to 12 wk.

RESULTS

The proportion of children that recovered from MAM was significantly higher in the group that received whey RUSF (960 of 1144; 83.9%) than in the group that received soy RUSF (874 of 1086; 80.5%; P < 0.04; risk difference 3.4%, 95% CI: 0.3%, 6.6%). Children who consumed whey RUSF also demonstrated better growth markers, with a higher mean midupper arm circumference (MUAC) at the time of discharge (P < 0.009), greater MUAC gain during the course of treatment (P < 0.003), higher mean weight-for-height z score at discharge (P < 0.008), and greater weight gain (P < 0.05). No significant differences were identified in length gain or time to recovery between the 2 groups.

CONCLUSION

This study highlights the importance of milk protein in the treatment of MAM, because the use of a novel whey RUSF resulted in higher recovery rates and improved growth than did soy RUSF, although the whey RUSF supplement provided less total protein and energy than the soy RUSF. This study was registered at clinicaltrials.gov as NCT01790048.

Evaluation of validity of Integrated Management of Childhood Illness guidelines in identifying edema of nutritional causes among Egyptian children

OBJECTIVE

The aim of this study was to assess the validity of the Integrated Management of Childhood Illness (IMCI) algorithm to detect edematous type of malnutrition in Egyptian infants and children ranging in age from 2 months to 5 years.

MATERIALS AND METHODS

This study was carried out by surveying 23 082 children aged between 2 months and 5 years visiting the pediatric outpatient clinic, Ain Shams University Hospital, over a period of 6 months. Thirty-eight patients with edema of both feet on their primary visit were enrolled in the study. Every child was assessed using the IMCI algorithm 'assess and classify' by the same physician, together with a systematic clinical evaluation with all relevant investigations.

RESULTS

Twenty-two patients (57.9%) were proven to have nutritional etiology. 'Weight for age' sign had a sensitivity of 95.5%, a specificity of 56%, and a diagnostic accuracy of 78.95% in the identification of nutritional edema among all cases of bipedal edema. Combinations of IMCI symptoms 'pallor, visible severe wasting, fever, diarrhea', and 'weight for age' increased the sensitivity to 100%, but with a low specificity of 38% and a diagnostic accuracy of 73.68%.

CONCLUSION AND RECOMMENDATIONS

Bipedal edema and low weight for age as part of the IMCI algorithm can identify edema because of nutritional etiology with 100% sensitivity, but with 37% specificity. Revisions need to be made to the IMCI guidelines published in 2010 by the Egyptian Ministry of Health in the light of the new WHO guidelines of 2014.