Social, dietary and clinical correlates of oedema in children with severe acute malnutrition: a cross-sectional study

Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

BACKGROUND

We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa.

METHODS

We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART.

RESULTS

PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%.

CONCLUSIONS

Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.

Clinico-biochemical profile of sick children with severe acute malnutrition

Objective

Severe acute malnutrition (SAM) classified as edematous and marasmus, however, Kwashiorker represents the most severe phenotype of edematous malnutrition. The aim of this study was to describe the clinico-biochemical profile in sick children with severe acute malnutrition.

Materials and Methods

This is a descriptive cross-sectional study, which included children aged 6 to 60 months, fulfilling the World Health Organization (WHO) criteria of severe acute malnutrition. We collected data on demography, anthropometry, history, and clinical examination. Investigations included arterial blood gas analysis, serum electrolytes, calcium, serum albumin, and blood sugar. P value < 0.05 was considered significant.

Results

One hundred twenty-two children with SAM were recruited, out of which 65 (53.27%) had edematous malnutrition and 57 (46.7%) had nonedematous malnutrition. Out of total children, 90 (73.77%) were discharged from hospital, 18 (14.7%) died, and 14 (11.4%) were left against medical advice. Out of 122 children with SAM, edematous children were younger (25.7 vs. 34.5 months, P = 0.002). Children with edematous malnutrition were more likely to have pneumonia (P = 0.04), acute gastroenteritis (P < 0.001), hyponatremia (P = 0.04), metabolic acidosis (P = 0.005), and hypocalcemia (P = 0.006) when compared with nonedematous children. Edematous malnutrition has 1.3 and 1.4 times more risk of death and leave against medical advice (LAMA) respectively as compared to nonedematous malnutrition. Mortality was higher in edematous malnutrition (12, 66.6%) than nonedematous malnutrition (6, 33.3%).

Conclusion

Edematous malnutrition was commonly prevalent in 1 to 3 years of children and clinical and biochemical abnormalities frequently co-exist with edematous malnutrition.

Restitution of gut microbiota in Ugandan children administered with probiotics (Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp. lactis BB-12) during treatment for severe acute malnutrition

Severe acute malnutrition (SAM) is a major challenge in low-income countries and gut microbiota (GM) dysbiosis may play a role in its etiology. Here, we determined the GM evolution during rehabilitation from SAM and the impact of probiotics (Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp. lactis BB-12) supplementation. The GM (16S rRNA gene amplicon sequencing) of children admitted to hospital with SAM showed distinct composition over admission (e.g. Klebsiella spp., and Enterobacteriaceae spp.), discharge (e.g. Clostridiaceae spp., Veilonella dispar) and follow-up (e.g. Lactobacillus ruminis, Blautia spp., Faecalibacterium prausnitzii), reaching similar β- and α-diversity as healthy individuals. Children with diarrhea had reduced distribution of Bacteroidaceae, Lachnospiraceae, increased Enterobacteriaceae and Moraxellaceae, and lower α-diversity. Children suffering from edematous SAM had diminished proportion of Prevotellaceae, Lachnospiraceae, Ruminoccaceae and a higher α-diversity when compared to non-edematous SAM. Supplementation of probiotics did not influence β-diversity upon discharge or follow-up, but it increased (p < .05) the number of observed species [SE: > 4.5]. Children where the probiotic species were detected had lower cumulative incidence (p < .001) of diarrhea during the follow-up period compared to children receiving placebo and children receiving probiotics, but where the probiotics were not detected. The GM of children with non-edematous and edematous SAM differ in composition, which might have implications for future GM targeted treatments. Probiotics treatment reduced the cumulative incidence of diarrhea during the outpatient phase, with the strongest effect in children where the administered probiotics could be detected in the GM.

Predictive Model for the Risk of Severe Acute Malnutrition in Children

BACKGROUND

The nutritional status is the best indicator of the well-being of the child. Inadequate feeding practices are the main factors that affect physical growth and mental development. The aim of this study was to develop a predictive score of severe acute malnutrition (SAM) in children under 5 years of age.

METHODS

It was a case-control study. The case group (n = 263) consisted of children aged 6 to 59 months admitted to hospital for SAM that was defined by a z-score weight/height < -3 SD or presence of edema of malnutrition. We performed a univariate and multivariate analysis. Discrimination score was assessed using the ROC curve and the calibration of the score by Hosmer-Lemeshow test.

RESULTS

Low birth weight, history of recurrent or chronic diarrhea, daily meal's number less than 3, age of breastfeeding's cessation less than 6 months, age of introduction of complementary diets less than 6 months, maternal age below 25 years, parity less than 5, family history of malnutrition, and number of children under 5 over 2 were predictive factors of SAM. Presence of these nine criteria affects a certain number of points; a score <6 points defines children at low risk of SAM, a score between 6 and 8 points defines a moderate risk of SAM, and a score >8 points presents a high risk of SAM. The area under ROC curve of this score was 0.9685, its sensitivity was 93.5%, and its specificity was 93.1%.

CONCLUSION

We propose a simple and efficient prediction model for the risk of occurrence of SAM in children under 5 years of age in developing countries. This predictive model of SAM would be a useful and simple clinical tool to identify people at risk, limit high rates of malnutrition, and reduce disease and child mortality registered in developing countries.

The role of dietary diversity in the response to treatment of uncomplicated severe acute malnutrition among children in Niger: a prospective study

Background

Community-based treatment of severe acute malnutrition (SAM) has proven to be safe and cost-effective, although identifying additional factors that can increase recovery and decrease treatment failure may improve program effectiveness. We examine the association of dietary diversity and clinical and program treatment outcomes among children treated for uncomplicated SAM in Niger.

Methods

Two thousand four hundred twelve children were enrolled in a randomized trial of routine amoxicillin in the treatment of uncomplicated SAM from 2012 to 2014. All children received ready to use therapeutic food (RUTF) and standard clinical care. Child dietary diversity was assessed using a 7-day food frequency questionnaire and 8-food group diet diversity score. We assessed the association of dietary diversity at admission with nutritional recovery, hospitalization, and death at program discharge and 12 weeks, and weight and height gain.

Results

Food groups most commonly consumed by children in seven days preceding SAM treatment were cereals, roots and tubers (N = 2364, 99.5%) and vitamin A rich fruits and vegetables (N = 2253, 94.8%). Egg (N = 472, 19.9%) and dairy (N = 659, 27.7%) consumption was low. Mean (SD) diet diversity score was significantly lower in the lean vs. non-lean season [2.7 (1.1) vs. 2.9 (1.0)]. There was no evidence that dietary diversity increased nutritional recovery at discharge (RR: 1.02, 95% CI: 1.00, 1.04) or 12 weeks (RR: 0.98, 95%CI: 0.94, 1.02). No significant association was found with risk of hospitalization or death, or weight and height gain. Egg consumption was protective against death at discharge (RR: 0.53, 95% CI: 0.39, 0.70) and 12 weeks (RR: 0.66, 95% CI: 0.45, 0.96). Vitamin A rich fruits and vegetable consumption was associated with greater risk of mortality in children at discharge (RR: 1.30, 95% CI: 1.08, 1.56) and 12 weeks (RR: 1.19, 95% CI: 1.03, 1.36).

Conclusions

We did not find evidence that dietary diversity influenced nutrition recovery or response to treatment for children with uncomplicated SAM in Niger. It is feasible consumption of nutrient-dense foods like eggs may be important for recovery from SAM. There is need for continued research to further elucidate drivers of nutritional recovery from acute malnutrition in different settings.

Trial registration

Trial registration number: ClinicalTrials.gov NCT01613547. Registered May 26, 2012.

Time spent being malnourished during the first five years of life! An unseen aspect of child malnutrition

The burden of malnutrition is often estimated in terms of 'prevalence' without considering two important contributing factors: incidence and duration. To illustrate this, we conducted a community-based retrospective cohort study involving 24,278 children enrolled in an integrated child development scheme in India. Anthropometric data of study participants from birth to five years of age were collected from the growth charts maintained by Anganwadi workers. Of all the growth charts reviewed, 1460 (6.0%) children died before their fifth birthday and 4013 (16.5%) were excluded after initial screening because either the growth chart was incomplete (4.8%) or had missing entries (11.7%). Of the remaining 20,265 children included in the study, in the first five years of their life, 35.6% suffered from exclusive moderate malnourishment and 9.4% from severe malnourishment. The most common age groups for the onset of moderate and severe malnutrition were 9-11 months and 12-15 months, respectively. The mode, median and mean duration of time spent by children being severely underweight was 3, 7 and 8.4 months respectively, and being moderately underweight was 8, 11 and 15.1 months, respectively. Thus, a comprehensive strategy for preventing the onset of malnutrition (both moderate and severe) among children is urgently needed.

[Development of a predictive score of severe acute malnutrition among children under 5 years of age]

Introduction

L’objectif de cette étude est de développer un score prédictif de la malnutrition aiguë sévère (MAS) chez les enfants de 6 à 59 mois.

Méthodes

Etude cas-témoins: les cas (n = 263) étaient les enfants de 6 à 59 mois admis à l’hôpital Sendwe de Lubumbashi pour une MAS; les témoins (n = 263) étaient les enfants de même âge admis dans le même hôpital pour une pathologie autre que la MAS. Nous avons procédé par une analyse univariée puis multivariée. La discrimination du score était évaluée à l’aide de la courbe ROC et du C-index.

Résultats

Après modélisation logistique, neuf critères ressortent comme facteurs prédictifs de MAS: le faible poids à la naissance, la diarrhée à répétition/chronique, le nombre de repas journaliers < 3, l’âge d’arrêt d’allaitement maternel < 6 mois, l’âge d’introduction d’alimentation de complément < 6 mois, l’âge maternel < 25 ans, la parité < 5, l’antécédent familial de malnutrition et le nombre d’enfants âgés de moins de 5 ans dans la fratrie ≥ 3. L’aire sous la courbe ROC est de 0,9685, la sensibilité de 93,54%, la spécificité de 93,16%, la valeur prédictive positive de 93,18% et le rapport de vraisemblance positif de 6,84%.

Conclusion

Nous proposons un score prédictif du risque de survenue de MAS dans une population de moins de 5 ans. Ce score prédictif de MAS serait un outil clinique utile et simple pour cibler la population à risque, limiter les taux élevés de malnutrition et réduire la morbidité et la mortalité infanto-juvénile enregistrés dans les pays en développement.

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.

Gut Bacteria Missing in Severe Acute Malnutrition, Can We Identify Potential Probiotics by Culturomics?

Severe acute malnutrition is the world-leading cause of children under-five's death. Recent metagenomics studies have established a link between gut microbiota and severe acute malnutrition, describing an immaturity with a striking depletion in oxygen-sensitive prokaryotes. Amoxicillin and therapeutic diet cure most of the children with severe acute malnutrition but an irreversible disruption of the gut microbiota is suspected in the refractory and most severe cases. In these cases, therapeutic diet may be unable to reverse the microbiota alteration leading to persistent impaired development or death. In addition, as enteric sepsis is a major cause of death in this context, identification of missing gut microbes to be tested as probiotics (live bacteria that confer a benefit to the host) to restore rapidly the healthy gut microbiota and prevent the gut pathogenic invasion is of foremost importance. In this study, stool samples of malnourished patients with kwashiorkor and healthy children were collected from Niger and Senegal and analyzed by culturomics and metagenomics. We found a globally decreased diversity, a decrease in the hitherto unknown diversity (new species isolation), a depletion in oxygen-sensitive prokaryotes including Methanobrevibacter smithii and an enrichment in potentially pathogenic Proteobacteria, Fusobacteria and Streptococcus gallolyticus. A complex of 12 species identified only in healthy children using culturomics and metagenomics were identified as probiotics candidates, providing a possible, defined, reproducible, safe, and convenient alternative to fecal transplantation to restore a healthy gut microbiota in malnourished children. Microbiotherapy based on selected strains has the potential to improve the current treatment of severe acute malnutrition and prevent relapse and death by reestablishing a healthy gut microbiota.

Correlates of thymus size and changes during treatment of children with severe acute malnutrition: a cohort study

Background

The impairment of immune functions associated with malnutrition may be one reason for the high mortality in children with severe acute malnutrition (SAM), and thymus atrophy has been proposed as a marker of this immunodeficiency. The aim of this study was to identify nutritional and clinical correlates of thymus size in children with SAM, and predictors of change in thymus size with nutritional rehabilitation.

Methods

In an observational study among children aged 6–59 months admitted with SAM in Uganda, we measured thymus area by ultrasound on hospital admission to treatment with F75 and F100, on hospital discharge and after 8 weeks of nutritional rehabilitation with ready-to-use therapeutic food, as well as in well-nourished healthy children. We investigated anthropometric, clinical, biochemical and treatment-related correlates of area and growth of the thymus.

Results

Eighty-five children with SAM with a median age of 16.5 months were included. On admission 27% of the children had a thymus undetectable by ultrasound. Median thymus area was 1.3 cm² in malnourished children, and 3.5 cm² in healthy children (p < 0.001). Most anthropometric z-scores, hemoglobin and plasma phosphate correlated positively with thymus area. Thymus area correlated negatively with caretaker-reported severity of illness, plasma α-1 acid glycoprotein, and C-reactive protein >5 mg/L. At follow-up after 8 weeks, median thymus area had increased to 2.5 cm² (p < 0.001). Increase in thymus area during treatment was associated with simultaneous increase in mid-upper-arm circumference, with 0.29 cm² higher increase in thymus area per cm larger increment in MUAC (p = 0.03). Children whose F-75 had partially been replaced by rice porridge during their hospital admission had less increase in thymus area after 8 weeks.

Conclusion

Malnutrition and inflammation are associated with thymus atrophy, and thymus area seems positively associated with plasma phosphate. Substituting therapeutic formula with unfortified rice porridge with the aim of alleviating diarrhea may impair regain of thymus size with nutritional rehabilitation. This calls for research into possible effects of phosphate status on thymus size and other immunological markers.

Trial registration

The study is based on data from the FeedSAM study, ISRCTN55092738.

Risk factors for death in children during inpatient treatment of severe acute malnutrition: a prospective cohort study

BACKGROUND

Children who receive in-hospital treatment of severe acute malnutrition often have high mortality rates, and the reasons are not well understood.

OBJECTIVE

We assessed risk factors for death in children who were treated for malnutrition in a hospital.

DESIGN

In a prospective observational study of 120 children who were receiving in-hospital treatment of severe acute malnutrition in Uganda with therapeutic formulas F-75 and F-100, we collected data on symptoms, clinical findings, plasma markers of refeeding syndrome (electrolytes and phosphate), and acute phase reactants, and recorded the nutritional therapy given in hospital.

RESULTS

Seventeen children (14%) died. Clinical risk factors for death were the presence of oral thrush (HR: 5.0; 95% CI: 1.6, 15.2), a caretaker-reported severity of illness on a visual analog scale (HR: 1.7; 95% CI: 1.1, 2.6), impaired consciousness (HR: 16.7; 95% CI: 3.1, 90.4), and a capillary refill time >2 s (HR: 3.9; 95% CI: 1.4, 11.3). HIV infection was not associated with mortality (HR: 3.0; 95% CI: 0.7, 12.4), which was most likely due to low power. Biochemical risk factors were a plasma C-reactive protein concentration >15 mg/L on admission and low plasma phosphate that was measured on day 2 (HR: 8.7; 95% CI: 2.5, 30.1), particularly in edematous children. The replacement of F-75 with unfortified rice porridge to ameliorate diarrhea was associated with a higher risk of death, particularly if given during the first 2 d (HR: 5.0; 95% CI: 1.9, 13.3), which was an association that remained after adjustment for potential confounders (HR: 69.5; 95% CI: 7.0, 694.6).

CONCLUSIONS

Refeeding syndrome may occur in children who are treated for malnutrition, even with moderately low plasma phosphate, and, in particular, in children with edematous malnutrition. The replacement of F-75 with unfortified rice porridge is associated with increased risk of death, which is possibly mediated by lowering plasma phosphate. The identified clinical risk factors may potentially improve the triage of children with malnutrition. This trial was registered at www.isrctn.com as ISRCTN55092738.

[Clinical signs of malnutrition in children living around a mining area: a case study in the city of Lubumbashi and its surrounding]

INTRODUCTION

Malnutrition remains to this day a major public health problem, particularly in developing countries. This study aimed to determine the clinical signs observed in malnourished children admitted to a care unit.

METHODS

This is a descriptive cross-sectional study, conducted from July 2013 to December 2014. Our study included 311 cases (182 malnourished children and 129 well-nourished children), based on exhaustive sampling, with an active screening of malnourished and well-nourished children. The diagnosis was made clinically and was associated with anthropometry.

RESULTS

The main collected symptoms in malnourished children were: cough or pneumonia in 42.50%, gastroenteritis in 38.55%, skin lesions in 22.91% of cases, fever in 22.35% of cases, edema in 19.0% of children, pallor in 8.38% of children; finally splenomegaly and hepatomegaly were the less common symptoms (1.68% and 2.89% respectively). Well-nourished children, instead, showed splenomegaly and fever associated with malaria.

CONCLUSION

Malnourished children living around a mining area don't differ in symptomatology from the other malnourished children, except for hepatomegaly and splenomegaly which are very rare in our malnourished children.

Paediatric HIV testing beyond the context of prevention of mother-to-child transmission: a systematic review and meta-analysis

BACKGROUND

Many HIV-positive children in low-income and middle-income countries remain undiagnosed. Although HIV testing in children at health facilities is recommended by WHO, it is not well implemented. This systematic review and meta-analysis examines the case-finding benefit of HIV screening in children aged 0-5 years in low-income and middle-income countries.

METHODS

We did this systematic review and meta-analysis in accordance with an a-priori protocol. We searched PubMed, MEDLINE, WHO Global Index Medicus, Web of Science, Médecins Sans Frontières, Cochrane, Embase, CABS Abstracts, and LILACS databases for articles published between Jan 1, 2004, and April 30, 2016, that reported the quantitative prevalence of HIV detected through screening in four key contexts (paediatric inpatient settings, paediatric outpatient settings, nutrition centres, and expanded programme on immunisation centres) in paediatric populations in low-income and middle-income countries. Articles were identified and data were extracted in duplicate. The primary outcome was HIV prevalence, for which we used a DerSimonian-Laird random-effects meta-analysis to pool prevalence data and 95% CIs. We did stratified analyses according to geographical context and testing strategy. This study is registered with PROSPERO, number CRD42014014372.

FINDINGS

Our search found 2996 studies, of which 26 met the inclusion criteria. Paediatric HIV prevalence across all settings was 15·6% (95% CI 11·8-19·5). HIV prevalence by setting was highest in paediatric inpatient settings (21·1%, 95% CI 14·9-27·3), followed by nutrition centres (13·1%, 95% CI 3·4-22·7), expanded programme on immunisation centres (3·3%, 95% CI 0-6·9), and paediatric outpatient settings (2·7%, 95% CI 0·3-5·2). Universal testing and testing triggered by symptoms had similar diagnostic yield in the inpatient setting (21·3%, 95% CI 11·6-31·0 in triggered testing vs 20·9%, 95% CI 13·5-28·3 in universal testing).

INTERPRETATION

HIV testing in paediatric populations in low-income and middle-income countries outside the context of prevention of mother-to-child transmission programmes provides an important opportunity to identify HIV-positive children. For countries wishing to prioritise interventions, the highest diagnostic yields were obtained from inpatient wards and nutrition centres. Universal testing might be the preferred approach since it did not have a substantially lower diagnostic yield than triggered testing

FUNDING

None.

Changes in whole-blood PUFA and their predictors during recovery from severe acute malnutrition

Children with severe acute malnutrition (SAM) with complications require in-patient management including therapeutic feeding. Little attention has been given to the effects of these feeds on the essential fatty acid status of children with SAM. The objective of this study was to describe changes in the PUFA composition in whole blood in children with SAM during treatment and to determine predictors of change. This prospective study took place in a paediatric nutrition rehabilitation unit in Kampala, Uganda, and assessed whole-blood fatty acid composition of children with SAM at admission, transition, discharge and follow-up (8 and 16 weeks). ANCOVA was used to identify predictors of change in whole-blood PUFA. The study included 120 children with SAM and twenty-nine healthy control children of similar age and sex. Among the SAM children, 38 % were female and 64 % had oedema. Whole-blood n-6 PUFA proportions increased from admission to follow-up, except for arachidonic acid, which decreased by 0·79 (95 % CI 0·46, 1·12) fatty acid percentage (FA%) from admission to transition and 0·10 (95 % CI 0·23, 0·44) FA% at discharge. n-3 Long-chain (LC) PUFA decreased by 0·21 (95 % CI 0·03, 0·40) FA% at discharge and 0·22 (95 % CI 0·01, 0·42) FA% at 8 weeks of follow-up. This decrease was greater in children from families with recent fish intake and those with nasogastric tube feeding. Current therapeutic feeds do not correct whole-blood levels of LCPUFA, particularly n-3 LCPUFA, in children with SAM. Increased attention is needed to the contents of n-3 LCPUFA in therapeutic feeds.

Changes in plasma phosphate during in-patient treatment of children with severe acute malnutrition: an observational study in Uganda

BACKGROUND

Children treated for severe acute malnutrition (SAM) are at risk of refeeding hypophosphatemia. Therapeutic diets have only recently become fortified with phosphorus to meet United Nations (UN) specifications, but to our knowledge no studies have investigated the effect.

OBJECTIVE

The aim was to assess concentrations and correlates of plasma phosphate (P-phosphate) at admission and during treatment and to identify correlates of changes in P-phosphate.

DESIGN

This was a prospective observational study in 6- to 59-mo-old children admitted for treatment of SAM to Mulago Hospital, Uganda. P-phosphate was measured at admission, on the second day of treatment with a therapeutic formula containing 75 kcal/100 mL and 560 mg phosphorus/L (F-75, Nutriset), at the start of the transition to a therapeutic formula containing 100 kcal/100 mL and 579 mg phosphorus/L (F-100; Nutriset), at day 2 of transition, and at discharge.

RESULTS

Among 120 children, mean ± SD P-phosphate at admission was 1.04 ± 0.31 mmol/L and increased by 0.43 (95% CI: 0.35, 0.52) mmol/L during the first 2 d and more slowly toward discharge. Most (79%) children experienced their lowest P-phosphate concentration at admission, and none developed severe hypophosphatemia. P-phosphate was lowest in children with edema and with elevated C-reactive protein, and a lower increase was seen with increasing caretaker-reported severity of illness. Partially or fully replacing F-75 with rice porridge (i.e., a local practice to reduce diarrhea) during the first 2 d of stabilization was associated with a 0.34-mmol/L (95% CI: 0.18, 0.50 mmol/L) lower increase in P-phosphate during the same first 2 d.

CONCLUSIONS

F-75, which complies with UN specifications and provides 73 mg phosphorus · kg(-1) · d(-1) (130 mL · kg(-1) · d(-1)), seems to prevent refeeding hypophosphatemia in children with SAM. Replacing this formula with rice porridge during the first days of treatment to manage diarrhea may have an adverse effect on P-phosphate concentrations. This study was registered at http://www.isrctn.com as ISRCTN55092738.

Gut Microbiota in Children Hospitalized with Oedematous and Non-Oedematous Severe Acute Malnutrition in Uganda

Background

Severe acute malnutrition (SAM) among children remains a major health problem in many developing countries. SAM manifests in both an oedematous and a non-oedematous form, with oedematous malnutrition in its most severe form also known as kwashiorkor. The pathogenesis of both types of malnutrition in children remains largely unknown, but gut microbiota (GM) dysbiosis has recently been linked to oedematous malnutrition. In the present study we aimed to assess whether GM composition differed between Ugandan children suffering from either oedematous or non-oedematous malnutrition.

Methodology/Principal Findings

As part of an observational study among children hospitalized with SAM aged 6–24 months in Uganda, fecal samples were collected at admission. Total genomic DNA was extracted from fecal samples, and PCR amplification was performed followed by Denaturing Gradient Gel Electrophoresis (DGGE) and tag-encoded 16S rRNA gene-targeted high throughput amplicon sequencing. Alpha and beta diversity measures were determined along with ANOVA mean relative abundance and G-test of independence followed by comparisons between groups. Of the 87 SAM children included, 62% suffered from oedematous malnutrition, 66% were boys and the mean age was 16.1 months. GM composition was found to differ between the two groups of children as determined by DGGE (p = 0.0317) and by high-throughput sequencing, with non-oedematous children having lower GM alpha diversity (p = 0.036). However, beta diversity analysis did not reveal larger differences between the GM of children with oedematous and non-oedematous SAM (ANOSIM analysis, weighted UniFrac, R = -0.0085, p = 0.584; unweighted UniFrac, R = 0.0719, p = 0.011).

Conclusions/Significance

Our results indicate that non-oedematous SAM children have lower GM diversity compared to oedematous SAM children, however no clear compositional differences were identified.

Severe acute malnutrition (SAM) is a major health problem, responsible for many deaths among young children in low-income countries. SAM manifests as oedematous or non-oedematous malnutrition. Oedematous malnutrition, also known as kwashiorkor, is a life-threatening condition, and even today we do not understand why some children develop oedema with malnutrition. Recently, an association between gut microbiota dysbiosis and oedematous malnutrition has been suggested. However, it remains unknown whether the gut microbiota differs between children with oedematous and non-oedematous malnutrition. In the present study, we collected fecal samples from children with SAM with and without oedema and analyzed the gut microbiota composition. We found that the pattern of bacteria was different in the two types of malnutrition, and that fewer different types of bacteria, on average, were present in the guts of non-oedematous children. However, we could not identify any specific type of bacteria that explained this difference. These results may contribute to the understanding of oedematous SAM, and inspire to further research into better ways of treatment of these very ill children.

Essential fatty acid composition and correlates in children with severe acute malnutrition

BACKGROUND

Severe acute malnutrition (SAM) is a common condition in children living in low-income countries and may be associated with reduced polyunsaturated fatty acids (PUFA) blood levels. The purpose of this study was to describe whole blood fatty acid composition and correlates of PUFA in children admitted with SAM.

METHODS

We conducted a cross-sectional study among children admitted with SAM at Mulago National Referral Hospital and healthy controls. Whole blood fatty acid composition was measured and correlated with clinical data such as oedema, levels of haemoglobin, C-reactive protein and HIV-infection status. Multiple linear regression analyses were used to identify correlates of PUFA.

RESULTS

The relative contribution of saturated fatty acid to the fatty acids in whole blood (FA%) were lower in 108 children with SAM compared to 24 well-nourished controls whereas most monounsaturated fatty acids were higher in children with SAM. Total and all n-6 PUFA including linoleic (18:2n-6, LA) and arachidonic acid (20:4n-6, AA), as well as total n-3 PUFA and docosahexaenoic acid (22:6n-3, DHA) were lower in children with SAM. The n-6:n-3 PUFA ratio was also lower in the children with SAM. Haemoglobin was a positive correlate of AA, n-3 docosapentaenoic acid (22:5n-3, n-3 DPA), DHA, total n-6 long chain (LC) PUFA and total n-3 LCPUFA. HIV infected children had 0.87 (0.47; 1.58) %-points less n-6 LCPUFA and 0.61 (0.03; 1.19) %-points less AA than the un-infected children.

CONCLUSION

Children with SAM presented with lower FA% of LCPUFA. HIV infection and low haemoglobin were also associated with lower FA% of LCPUFA, which may be related to lower numbers of blood cells. Nutrition rehabilitation interventions need to pay more attention to the intake of PUFA.

Characterization and scoring of skin changes in severe acute malnutrition in children between 6 months and 5 years of age

BACKGROUND

Severe acute malnutrition is a life-threatening condition. It can be associated with severe skin changes, first properly described by Williams in 1933. The aetiology of these skin changes is still unknown and their character has never been systematically described in dermatological terms. The skin changes have been shown to be a predictor of mortality in hospital care. Systematic investigations on the character of the skin changes that have effect on prognosis, are needed to investigate which of the skin changes that are relevant to improve treatment.

OBJECTIVES

Our main objective was to identify the skin changes characteristic of children with severe acute malnutrition and to develop a clinical score that describes the morphology and severity in dermatological terms. We also investigated if any of the different skin changes were connected to prognosis.

MATERIALS AND METHODS

At Mulago Hospital, Mwanamugimu (Department of Paediatrics and Child Health), Uganda, 120 children were included over a period of six months and observed when treated for severe acute malnutrition. Skin changes were registered through clinical examination and photo documentation and associated to prognosis using Cox and logistic regression analysis.

RESULTS

Skin manifestations were characterized by five objective skin signs: telogenic effluvium, pigmentary changes (hyper- and hypo-pigmentation), ichthyosiform skin changes, lichenoid skin changes and bullae-erosion-desquamation. The skin changes could be registered in a systematic manner using our simple clinical score. Lichenoid skin changes were a significant predictor of death and allowed improved accuracy of prediction of mortality.

CONCLUSIONS

The clinical score is simple and practical. A standardized way to register and score the skin changes, will allow a more unified way of reporting results in future studies. The standardization of observations, obtained through the proposed scoring system, will enable comparison of study results in the future.