Predicators for weight gain in children treated for severe acute malnutrition: a prospective study at nutritional rehabilitation center

Relapse of severe acute malnutrition among children discharged from outpatient therapeutic program in western Ethiopia

BACKGROUND

Children with severe acute malnutrition (SAM) without complication are treated in the outpatient therapeutic program (OTP) and the program has been reported to be effective. However, relapse post-discharge from the program is poorly defined, and scarcely evaluated across programs and research. The objective of this study is to assess the prevalence of SAM among children post-discharge from the OTP and to identify factors associated with SAM relapse in Gambella Region, Western Ethiopia.

METHODS

We conducted a facility-based cross-sectional study among 208 children aged 6-59 months who have been discharged from the OTP as cured. Baseline data were collected from caregivers using structured questionnaire. Child anthropometry and oedema was measured. The association between SAM relapse and the risk factors were assessed using bivariate and multivariable logistic regression models.

RESULTS

The prevalence of SAM relapse was 10.1% (95% CI: 5.8-14.0%). The odds of SAM relapse was significantly higher in children with mothers who had no exposure to education and promotion about infant and young child feeding (IYCF) practices (OR = 5.7; 95% CI: 1.3-12.6), children who were not fully immunized for their age (OR = 8.0; 95% CI: 3.8-23.4), and children with mid-upper arm circumference (MUAC) at discharge of < 12.5 cm (OR = 4.4; 95% CI: 2.1-12.8) than their counterparts.

CONCLUSIONS

To reduce SAM relapse, the OTP programs should avoid premature discharge and consider provision of supplementary food for children with low MUAC at discharge. Further, the OTP discharge criteria should consider both the anthropometric indicators - weight-for-height/length z-score (WHZ) and MUAC - and the absence of bilateral pitting oedema irrespective of the anthropometric indicator that is used during admission. Promotion of nutrition education and improving child immunization services and coverage would help reduce SAM relapse.

Achievement of adequate weight gain among infants and children with complicated severe acute malnutrition receiving treatment in therapeutic feeding centers of South Sudanese refugee camps in Ethiopia

Objectives

This study aimed to assess achievement of adequate weight gain and identify its associated factors among infants and children with complicated severe acute malnutrition admitted in Kule and Tierkidi refugee camps in Gambella, Southwest Ethiopia.

Methods

Records of 332 infants and children with complicated severe acute malnutrition were selected by systematic random sampling. Weight gain was calculated for all participants. Patients who achieved weight gain of >5 g/kg/day were regarded as achieving adequate weight gain. Sociodemographic characteristics, season of admission, patients' anthropometry at admission, source of admission, clinical conditions at admission, types of medications used, length of stay at the centers, and the centers of the treatment were considered as covariates. The adjusted odds ratio and its 95% confidence interval were used to identify factors associated with adequate average weight gain in the multivariable logistic regression.

Results

In total, 72% of the treated patients achieved adequate weight gain. Treatment at Tierkidi center Adjusted Odds Ratio = 5.9, 95% Confidence Interval: (2.0,16.9), treatment with amoxicillin-clavulanate Adjusted Odds Ratio = 4.1, 95% Confidence Interval: (1.7, 10.0), WFH z-score < -3 Adjusted Odds Ratio = 4.1, 95% Confidence Interval: (1.9, 9.0) and length of stay of ⩽7 days Adjusted Odds Ratio = 2.5, 95% Confidence Interval: (1.4, 4.4) were significantly associated with achievement of adequate weight gain.

Conclusion

Seven in ten of treated patients achieved adequate weight gain. However, significant proportion of patients still failed to achieve recommended weight gain in refugee camps. Anthropometric indices, type of antibiotics used for treatment, short length of stay, and the treatment center were associated with achievement of adequate weight gain. We recommend that the local antibiotic sensitivity pattern be studied in order to recommend an appropriate treatment regimen for infants and children. Children requiring longer duration have to be given due focus. Inter-center variations have to be narrowed by strengthening follow-up and supervisory supports.

A Feasibility Study to Examine Clinical Variables of Childhood Malnutrition in Guatemala

Introduction: Guatemala is the country with the highest rate of malnutrition in Latin America and fifth highest worldwide. The objective of this pilot study was to determine the feasibility of examining clinical variables of malnutrition among a subset of children at a Guatemalan Nutrition Rehabilitation Center (NRC). Methods: The study was conducted using a secondary dataset of children admitted and discharged at the NRC in 2018. A total of 42 cases were reviewed. The 12 clinical variables were age, gender, height, weight, nutrition status, referral, diet, secondary diagnoses, medications, supplements, discharge disposition, and time-to-discharge. Results: The two major findings were (a) the lack of access to height and weight at discharge and (b) the inability to verify time-to-recovery. Mean age of participants was 23 months (SD = 12.9). All children were discharged home; median time-to-discharge was 48 days. The Kaplan-Meier analyses indicated that children <2 had slower time-to-discharge (51 days), compared to those older than age 2 (32 days); though not statistically significant. Conclusion: Findings of this study provide valuable data to inform ways NRC leadership can better report child health outcomes. International community-academic partnership could contribute to understanding malnutrition and time-to-recovery.

Analysis of risk and prognostic factors in a population of pediatric patients hospitalized for acute malnutrition at the Chiulo hospital, Angola

Background

Malnutrition is a multifactorial pathology in which genetic, epigenetic, cultural, environmental, socio-economic factors interact with each other. The impact that this disease has on the health of children worldwide is dramatic. Severe acute malnutrition in particular is a disease affecting nearly 20 million preschool children worldwide, most of them in Africa and South East Asia.

Objectives

This work aims to investigate potential prognostic factors in the clinical evolution of acute malnutrition and potential risk factors for the development of the disease.

Methods

Our study was carried out at the “Hospital da Missão Catolica do Chiulo”, in Angola, where the NGO Doctors with Africa CUAMM has been operating since 2000. In the first part of the study we analyzed the characteristics and clinical evolution of 163 patients hospitalized for acute malnutrition at the UEN (Unidade Especial de Nutrição) of the Chiulo Hospital over a period of 6 months, in order to identify potential prognostic factors of the disease. The second part of our study was carried out by administering a questionnaire to a group of caregivers of malnourished children and to a group of caregivers of non-malnourished children admitted to Pediatrics for other causes, with the aim of identifying potential risk factors for the development of malnutrition.

Results and conclusions

The analysis of prognostic factors revealed that the most relevant are the WHZ (weight for height z-score) at the time of admission, the presence of Stunting and the presence of other pathologies or clinical conditions associated with severe acute malnutrition.

The analysis of risk factors has shown that not only food shortages, but also errors in the timing of the suspension of breastfeeding and the timing of the introduction of complementary foods play an important role. Equally important were some family risk factors, including the size of the family unit and the presence of deceased children.

It also emerged that the lack of knowledge of what a child needs to grow up healthy often affects the development of malnutrition. It follows that a useful and low-cost tool for preventing child malnutrition would be large-scale nutrition education campaigns.

Predictors of relapse of acute malnutrition following exit from community-based management program in Amhara region, Northwest Ethiopia: An unmatched case-control study

BACKGROUND

Community-based management of acute malnutrition (CMAM) is an effective program to manage children with acute malnutrition, including both severe and moderate acute malnutrition. However, little is known about continued child nutritional status after discharge from community based management of acute malnutrition programs in Ethiopia.

OBJECTIVE

The study aimed to identify factors associated with relapse of acute malnutrition among children 6-59 months after been discharged recovered from community based management program in South Gondar Zone, Northwest Ethiopia.

METHODS

A case-control study was conducted in three districts of South Gondar Zone by tracing children age 6-59 months who were reported as recovered from the community based management program. Sample size calculated for the first objective of assessing prevalence of severe acute malnutrition among children following discharge as recovery using Epi- Info version 7.1.3.3 StatCalc taking 95% CL, 17.8% post discharge relapse (Ashraf H, et al. (2012), 3% margin of error, design effect of 2 and adding 5% non-response rate was the largest sample size and used to this study. Children with Mid Upper Arm Circumference (MUAC) <12.5cm constituted cases and children with > = 12.5cm served as controls. Data were collected from 10 November 2017 to 30 January 2018 using a survey questionnaire and families were asked to bring children to a health facility for anthropometric measurements, following which data were entered and analyzed. Bivariate and multivariable logistic regression models were utilized to measure association between the risk factors and acute malnutrition.

RESULTS

Overall, 1,273 participants were interviewed. The mean age in months of children was 23.1 (±9.1 SD) for cases and 23.1 (±8.9 SD) for controls. About 40% of the cases and 50% of the controls were female children. The factors associated with acute malnutrition were: male children (AOR = 1.84, 95% CI: 1.42-2.39), living in a food insecure household (AOR = 1.67, 95% CI:1.15-2.44), non-receipt of Vitamin A supplement (AOR = 1.76, 95% CI: 1.28-2.41), prelacteal feeding (AOR = 2.81 (95%CI, 1.57-5.05), distance to water source more than 15 walk (AOR = 1.88, 95% CI:1.32-2.71), less frequent self-reported hand washing (AOR = 1.35, 95% CI:1.05-1.75), mother not having consumed extra food during this pregnancy/lactation (AOR = 1.36, 95% CI: 1.03-1.78), and respondent age above 30 years (AOR = 1.43, 95% CI:1.10-1.87).

CONCLUSION

The key factors contributing to relapse of acute malnutrition were related to childcare and feeding practices. Social and behavior change communication strategies targeting families at risk of undernutrition, along with improved food security and integrated programming are recommended to prevent relapse of acute malnutrition.

Rural children remain more at risk of acute malnutrition following exit from community based management of acute malnutrition program in South Gondar Zone, Amhara Region, Ethiopia: a comparative cross-sectional study

BACKGROUND

Community-based management of acute malnutrition has been reported effective in terms of recovery rate, but recovered children may be at increased risk of developing acute malnutrition after returning to the same household (HH) environment.

OBJECTIVE

Compare the magnitude and factors associated with acute malnutrition among recovered and never treated children in South Gondar Zone, Amhara Region, Ethiopia.

METHOD

A comparative cross-sectional study was conducted in three districts of South Gondar Zone by tracing 720 recovered and an equal number of age matched children who were never treated for acute malnutrition. Parents were asked to bring children to health post for survey data collection, anthropometric measurements, and edema assessment. Data were collected using a survey questionnaire, entered in to EpiData and analyzed using SPSS v20. Anthropometric indices were generated according to the WHO's 2006 Child Growth Standards using WHO Anthro software version 3.2.2. Bivariate and multivariable logistic regression was utilized. Values with P < 0.05 were considered statistically significant and Odds Ratio with 95% CI was used to measure strength of association.

RESULT

A total of 1,440 parents were invited, of which 1,414 participated (98.2% response rate). Mean age in months of children (±SD) was 23.7 (±10.4) for recovered and 23.3 (±10.8) for comparison group. About 49% of recovered and 46% of comparison children were females. A significant difference was observed on magnitude of acute malnutrition between recovered (34.2% (95% CI [30.9-38.0]) and comparison groups (26.7% (95% CI [23.5-30.2]), P = 0.002. Factors associated with acute malnutrition among recovered were district of Ebnat (AOR = 3.7; 95% CI [1.9-7.2]), Tach-Gayint (AOR = 2.4; 95% CI [1.2-4.7]); male child (AOR = 1.4; 95% CI [1.0-2.0]); prelactal feeding (AOR = 2.6; 95% CI [1.3 -5.1]); not feeding colostrum (AOR = 1.5; 95% CI [1.1-2.3]); not consuming additional food during pregnancy/lactation (AOR = 1.6; 95% CI [1.1-2.3]); not given Vitamin A supplement (AOR = 2.1; 95% CI [1.4-3.2]); and safe child feces disposal practice (AOR = 1.7; 95% CI [1.2-2.5]) while district of Tach-Gayint (AOR = 2.5; 95% CI [1.3-4.8]); male child (AOR = 1.5; 95% CI [1.1-2.1]), not feeding colostrum (AOR = 1.7; 95% CI [1.2-2.5]), poor hand washing practice (AOR = 1.6; 95% CI [1.1-2.2]); food insecure HH (AOR = 1.6; 95% CI [1.1-2.4]), birth interval <24 months (AOR = 1.9; 95% CI [1.2-3.2]), and poor access to health facility (AOR = 1.7; 95% CI [1.2-2.4]) were factors associated with acute malnutrition among comparison group.

CONCLUSION

Recovered children were more at risk of acute malnutrition than the comparison group. Nutrition programs should invest in improving nutrition counseling and education; as well as the hygienic practices to protect children against post-discharge relapse of acute malnutrition.

A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia

BACKGROUND

Severe forms of malnutrition have drastic effects on childhood morbidity and mortality in sub-Saharan countries, including Ethiopia. Although few studies have previously estimated treatment outcomes of severe acute malnutrition (SAM) in Ethiopia, the findings were widely varied and inconsistent. This study thus aimed to pool estimates of treatment outcomes and identify predictors of mortality among children with SAM in Ethiopia.

METHODS

A systematic review was carried out to select 21 eligible articles from identified 1013 studies (dating from 2000 to 2018) that estimated treatment outcomes and predictors of mortality among SAM children. Databases including PubMed, CINHAL, Web of Sciences; Cochrane, Psych INFO and Google Scholar were comprehensively reviewed using medical subject headings (MESH) and a priori set criteria PRISMA guideline was used to systematically review and meta-analyze eligible studies. Details of sample size, magnitude of effect sizes, including Hazard Ratio (HRs) and standard errors were extracted. Random-effects model was used to calculate pooled estimates in Stata/se version-14. Cochran's Q, I2, and meta-bias statistics were assessed for heterogeneity and Egger's test for publication bias.

RESULT

Twenty-one studies were included in the final analysis, which comprised 8057 under-five children with SAM in Ethiopia. The pooled estimates of treatment outcomes, in terms of death, recovery, defaulter and transfer out and non-response rates were 10.3% (95% CI: 8.3, 12.3), 70.5% (95% CI: 65.7, 72.2), 13.8% (95% CI: 10.8, 16.9) and 5.1% (95% CI: 3.3, 6.9), respectively. Diarrhea (HR: 1.5, 95% CI: 1.1, 2.2), dehydration (HR: 3.1, 95% CI: 2.3, 4.2) and anemia (HR: 2.2, 95% CI: 1.5, 3.3) were statistically significant predictors of mortality among these children. No publication bias was detected.

CONCLUSION

Treatment outcomes in under-five children with SAM are lower than the World Health Organization (WHO) standard, where mortality is being predicted by comorbidities at admission. Children with SAM need to be treated for diarrhea, dehydration and anemia at the primary point of care to reduce mortality.

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.

Individual and Household Risk Factors for Severe Acute Malnutrition among Under-Five Children in the Analamanga Region, Madagascar

BACKGROUND AND OBJECTIVES

Despite some progress made in the fight against malnutrition in Madagascar, hospitals' mortality due to severe acute malnutrition (SAM) remains high. This study explores the risk factors for SAM among children hospitalized with SAM in the Analamanga region of Madagascar.

METHODS

We conducted an interview based qualitative study of 14 mothers of under-five children with SAM admitted to the hospital's pediatric unit and living in the Analamanga region. Data were analyzed using thematic analysis method.

RESULTS

There were direct, intermediate and basic causes of malnutrition shared with other health care settings. Low health literacy such as limited knowledge and optimistic perception of malnutrition, and lack of health service information resulted in delayed hospital visit for care of SAM. Vulnerable working mothers do not benefit from available community support structure. Mothers are unable to practice what they learned because financial difficulties at the household level occupy their time.

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

Consideration of vulnerable working mothers' access to existing health services and interventions to address health literacy are important to prevent SAM at the community level. Study findings would be of interest to practitioners and policy makers in the region and perhaps in other resource limited settings.

Inpatient management of children with severe acute malnutrition: a review of WHO guidelines

Objective

To understand how the World Health Organization’s (WHO’s) guidelines on the inpatient care of children with complicated severe acute malnutrition may be strengthened to improve outcomes.

Methods

In December 2015, we searched Google scholar and WHO’s website for WHO recommendations on severe acute malnutrition management and evaluated the history and cited evidence behind these recommendations. We systematically searched WHO International Clinical Trials Registry Platform, clinicaltrials.gov and the Controlled Trials metaRegister until 10 August 2015 for recently completed, ongoing, or pending trials.

Findings

WHO’s guidelines provide 33 recommendations on the topic. However, 16 (48.5%) of these recommendations were based solely on expert opinion – unsupported by published evidence. Another 11 (33.3%) of the recommendations were supported by the results of directly relevant research – i.e. either randomized trials (8) or observational studies (3). The other six recommendations (18.2%) were based on studies that were not conducted among children with complicated severe malnutrition or studies of treatment that were not identical to the recommended intervention. Trials registries included 20 studies related to the topic, including nine trials of alternative feeding regimens. Acute medical management and follow-up care studies were minimally represented.

Conclusion

WHO’s guidelines on the topic have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with severe malnutrition is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.