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Tiwari R, Tickell KD, Yoshioka E, Otieno J, Shah A, Richardson BA, Keter L, Okello M, Nyabinda C, Trehan I, McGrath CJ, Means AR, Houpt ER, Liu J, Platts-Mills JA, Njunge JM, Rwigi D, Diakhate MM, Nyaoke J, Ochola E, John-Stewart G, Walson JL, Pavlinac PB, Singa BO. Lactoferrin and lysozyme to promote nutritional, clinical and enteric recovery: a protocol for a factorial, blinded, placebo-controlled randomised trial among children with diarrhoea and malnutrition (the Boresha Afya trial). BMJ Open 2024; 14:e079448. [PMID: 39122384 PMCID: PMC11331881 DOI: 10.1136/bmjopen-2023-079448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 06/21/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION Children with moderate or severe wasting are at particularly high risk of recurrent or persistent diarrhoea, nutritional deterioration and death following a diarrhoeal episode. Lactoferrin and lysozyme are nutritional supplements that may reduce the risk of recurrent diarrhoeal episodes and accelerate nutritional recovery by treating or preventing underlying enteric infections and/or improving enteric function. METHODS AND ANALYSIS In this factorial, blinded, placebo-controlled randomised trial, we aim to determine the efficacy of lactoferrin and lysozyme supplementation in decreasing diarrhoea incidence and improving nutritional recovery in Kenyan children convalescing from comorbid diarrhoea and wasting. Six hundred children aged 6-24 months with mid-upper arm circumference <12.5 cm who are returning home after an outpatient visit or inpatient hospital stay for diarrhoea will be enrolled. Children will be randomised to 16 weeks of lactoferrin, lysozyme, a combination of the two, or placebo and followed for 24 weeks, with biweekly home visits by community health workers and clinic visits at 4, 10, 16 and 24 weeks. The primary analysis will compare the incidence of moderate-to-severe diarrhoea and time to nutritional recovery between each intervention arm and placebo. The trial will also test whether these interventions reduce enteric pathogen carriage, decrease enteric permeability and/or increase haemoglobin concentration in enrolled children. Finally, we will evaluate the acceptability, adherence and cost-effectiveness of lactoferrin and/or lysozyme. ETHICS AND DISSEMINATION The trial has been approved by the institutional review boards of the Kenya Medical Research Institute, the University of Washington, the Kenyan Pharmacy and Poisons Board, and the Kenyan National Commission on Science, Technology and Innovation. The results of this trial will be shared with local and international stakeholders and published in peer-reviewed journals, and the key findings will be presented at relevant conferences. TRIAL REGISTRATION NUMBER NCT05519254, PACTR202108480098476.
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Affiliation(s)
- Ruchi Tiwari
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Emily Yoshioka
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Joyce Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Lucia Keter
- Kenya Medical Research Institute, Nairobi, Nairobi County, Kenya
| | - Maureen Okello
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Indi Trehan
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Christine J McGrath
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Arianna Rubin Means
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, North Carolina, USA
| | - Jie Liu
- School of Public Health, Qingdao University, Qingdao, China
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, North Carolina, USA
| | - James M Njunge
- Centre for Geographic Medicine Research Coast, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Doreen Rwigi
- Kenya Medical Research Institute, Nairobi, Nairobi County, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Mareme M Diakhate
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Julius Nyaoke
- Kenya Medical Research Institute, Nairobi, Nairobi County, Kenya
| | - Eric Ochola
- Kenya Medical Research Institute, Nairobi, Nairobi County, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Judd L Walson
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Benson O Singa
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Ogwel B, Mzazi V, Nyawanda BO, Otieno G, Omore R. Predictive modeling for infectious diarrheal disease in pediatric populations: A systematic review. Learn Health Syst 2024; 8:e10382. [PMID: 38249852 PMCID: PMC10797570 DOI: 10.1002/lrh2.10382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 07/09/2023] [Accepted: 07/17/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Diarrhea is still a significant global public health problem. There are currently no systematic evaluation of the modeling areas and approaches to predict diarrheal illness outcomes. This paper reviews existing research efforts in predictive modeling of infectious diarrheal illness in pediatric populations. Methods We conducted a systematic review via a PubMed search for the period 1990-2021. A comprehensive search query was developed through an iterative process and literature on predictive modeling of diarrhea was retrieved. The following filters were applied to the search results: human subjects, English language, and children (birth to 18 years). We carried out a narrative synthesis of the included publications. Results Our literature search returned 2671 articles. After manual evaluation, 38 of these articles were included in this review. The most common research topic among the studies were disease forecasts 14 (36.8%), vaccine-related predictions 9 (23.7%), and disease/pathogen detection 5 (13.2%). Majority of these studies were published between 2011 and 2020, 28 (73.7%). The most common technique used in the modeling was machine learning 12 (31.6%) with various algorithms used for the prediction tasks. With change in the landscape of diarrheal etiology after rotavirus vaccine introduction, many open areas (disease forecasts, disease detection, and strain dynamics) remain for pathogen-specific predictive models among etiological agents that have emerged as important. Additionally, the outcomes of diarrheal illness remain under researched. We also observed lack of consistency in the reporting of results of prediction models despite the available guidelines highlighting the need for common data standards and adherence to guidelines on reporting of predictive models for biomedical research. Conclusions Our review identified knowledge gaps and opportunities in predictive modeling for diarrheal illness, and limitations in existing attempts whilst advancing some precursory thoughts on how to address them, aiming to invigorate future research efforts in this sphere.
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Affiliation(s)
- Billy Ogwel
- Kenya Medical Research Institute, Center for Global Health Research (KEMRI‐CGHR)KisumuKenya
- Department of Information SystemsUniversity of South AfricaPretoriaSouth Africa
| | - Vincent Mzazi
- Department of Information SystemsUniversity of South AfricaPretoriaSouth Africa
| | - Bryan O. Nyawanda
- Kenya Medical Research Institute, Center for Global Health Research (KEMRI‐CGHR)KisumuKenya
| | - Gabriel Otieno
- Department of ComputingUnited States International UniversityNairobiKenya
| | - Richard Omore
- Kenya Medical Research Institute, Center for Global Health Research (KEMRI‐CGHR)KisumuKenya
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Ahmed SM, Brintz BJ, Talbert A, Ngari M, Pavlinac PB, Platts-Mills JA, Levine AC, Nelson EJ, Walson JL, Kotloff KL, Berkley JA, Leung DT. Derivation and external validation of a clinical prognostic model identifying children at risk of death following presentation for diarrheal care. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001937. [PMID: 37368867 DOI: 10.1371/journal.pgph.0001937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Diarrhea continues to be a leading cause of death for children under-five. Amongst children treated for acute diarrhea, mortality risk remains elevated during and after acute medical management. Identification of those at highest risk would enable better targeting of interventions, but available prognostic tools lack validation. We used clinical and demographic data from the Global Enteric Multicenter Study (GEMS) to build clinical prognostic models (CPMs) to predict death (in-treatment, after discharge, or either) in children aged ≤59 months presenting with moderate-to-severe diarrhea (MSD), in Africa and Asia. We screened variables using random forests, and assessed predictive performance with random forest regression and logistic regression using repeated cross-validation. We used data from the Kilifi Health and Demographic Surveillance System (KHDSS) and Kilifi County Hospital (KCH) in Kenya to externally validate our GEMS-derived CPM. Of 8060 MSD cases, 43 (0.5%) children died in treatment and 122 (1.5% of remaining) died after discharge. MUAC at presentation, respiratory rate, age, temperature, number of days with diarrhea at presentation, number of people living in household, number of children <60 months old living in household, and how much the child had been offered to drink since diarrhea started were predictive of death both in treatment and after discharge. Using a parsimonious 2-variable prediction model, we achieved an area under the ROC curve (AUC) of 0.84 (95% CI: 0.82, 0.86) in the derivation dataset, and an AUC = 0.74 (95% CI 0.71, 0.77) in the external dataset. Our findings suggest it is possible to identify children most likely to die after presenting to care for acute diarrhea. This could represent a novel and cost-effective way to target resources for the prevention of childhood mortality.
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Affiliation(s)
- Sharia M Ahmed
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Ben J Brintz
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Alison Talbert
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya
| | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya
| | - Patricia B Pavlinac
- Department of Global Health, Global Center for Integrated Health of Women, Adolescents and Children (Global WACh), University of Washington, Seattle, WA, United States of America
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States of America
| | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Eric J Nelson
- Department of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States of America
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, United States of America
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Derivation and external validation of a clinical prognostic model identifying children at risk of death following presentation for diarrheal care. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.08.23285625. [PMID: 36798150 PMCID: PMC9934800 DOI: 10.1101/2023.02.08.23285625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Diarrhea continues to be a leading cause of death for children under-five. Amongst children treated for acute diarrhea, mortality risk remains elevated during and after acute medical management. Identification of those at highest risk would enable better targeting of interventions, but available prognostic tools lack validation. We used clinical and demographic data from the Global Enteric Multicenter Study (GEMS) to build predictive models for death (in-treatment, after discharge, or either) in children aged ≤59 months presenting with moderate-to-severe diarrhea (MSD), in Africa and Asia. We screened variables using random forests, and assessed predictive performance with random forest regression and logistic regression using repeated cross-validation. We used data from the Kilifi Health and Demographic Surveillance System (KHDSS) and Kilifi County Hospital (KCH) in Kenya to externally validate our GEMS-derived clinical prognostic model (CPM). Of 8060 MSD cases, 43 (0.5%) children died in treatment and 122 (1.5% of remaining) died after discharge. MUAC at presentation, respiratory rate, age, temperature, number of days with diarrhea at presentation, number of people living in household, number of children <60 months old living in household, and how much the child had been offered to drink since diarrhea started were predictive of death both in treatment and after discharge. Using a parsimonious 2-variable prediction model, we achieve an AUC=0.84 (95% CI: 0.82, 0.86) in the derivation dataset, and an AUC=0.74 (95% CI 0.71, 0.77) in the external dataset. Our findings suggest it is possible to identify children most likely to die after presenting to care for acute diarrhea. This could represent a novel and cost-effective way to target resources for the prevention of childhood mortality.
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Ahmed SM, Brintz BJ, Pavlinac PB, Shahrin L, Huq S, Levine AC, Nelson EJ, Platts-Mills JA, Kotloff KL, Leung DT. Derivation and external validation of clinical prediction rules identifying children at risk of linear growth faltering. eLife 2023; 12:78491. [PMID: 36607225 PMCID: PMC9833824 DOI: 10.7554/elife.78491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 12/29/2022] [Indexed: 01/07/2023] Open
Abstract
Background Nearly 150 million children under-5 years of age were stunted in 2020. We aimed to develop a clinical prediction rule (CPR) to identify children likely to experience additional stunting following acute diarrhea, to enable targeted approaches to prevent this irreversible outcome. Methods We used clinical and demographic data from the Global Enteric Multicenter Study (GEMS) to build predictive models of linear growth faltering (decrease of ≥0.5 or ≥1.0 in height-for-age z-score [HAZ] at 60-day follow-up) in children ≤59 months presenting with moderate-to-severe diarrhea, and community controls, in Africa and Asia. We screened variables using random forests, and assessed predictive performance with random forest regression and logistic regression using fivefold cross-validation. We used the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study to (1) re-derive, and (2) externally validate our GEMS-derived CPR. Results Of 7639 children in GEMS, 1744 (22.8%) experienced severe growth faltering (≥0.5 decrease in HAZ). In MAL-ED, we analyzed 5683 diarrhea episodes from 1322 children, of which 961 (16.9%) episodes experienced severe growth faltering. Top predictors of growth faltering in GEMS were: age, HAZ at enrollment, respiratory rate, temperature, and number of people living in the household. The maximum area under the curve (AUC) was 0.75 (95% confidence interval [CI]: 0.75, 0.75) with 20 predictors, while 2 predictors yielded an AUC of 0.71 (95% CI: 0.71, 0.72). Results were similar in the MAL-ED re-derivation. A 2-variable CPR derived from children 0-23 months in GEMS had an AUC = 0.63 (95% CI: 0.62, 0.65), and AUC = 0.68 (95% CI: 0.63, 0.74) when externally validated in MAL-ED. Conclusions Our findings indicate that use of prediction rules could help identify children at risk of poor outcomes after an episode of diarrheal illness. They may also be generalizable to all children, regardless of diarrhea status. Funding This work was supported by the National Institutes of Health under Ruth L. Kirschstein National Research Service Award NIH T32AI055434 and by the National Institute of Allergy and Infectious Diseases (R01AI135114).
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Affiliation(s)
- Sharia M Ahmed
- Division of Infectious Diseases, University of Utah School of MedicineSalt lake CityUnited States
| | - Ben J Brintz
- Division of Epidemiology, University of Utah School of MedicineSalt Lake CityUnited States
| | - Patricia B Pavlinac
- Department of Global Health, Global Center for Integrated Health of Women, Adolescents and Children (Global WACh), University of WashingtonSeattleUnited States
| | - Lubaba Shahrin
- International Centre for Diarrhoeal Disease ResearchDhakaBangladesh
| | - Sayeeda Huq
- International Centre for Diarrhoeal Disease ResearchDhakaBangladesh
| | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School of Brown UniversityProvidenceUnited States
| | - Eric J Nelson
- Department of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of FloridaGainesvilleUnited States
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of VirginiaCharlottesvilleUnited States
| | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development, University of Maryland School of MedicineBaltimoreUnited States
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of MedicineSalt lake CityUnited States,Division of Microbiology & Immunology, University of Utah School of MedicineSalt Lake CityUnited States
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David EE, Yameen MA, Igwenyi IO, David CN, Nwobodo V, Ismail AK. Zinc Deficiency Elevates Fecal Protein, But Not Electrolyte and Short-Chain Fatty Acid, Levels in Enterotoxigenic Escherichia coli-Induced Diarrhea in Rats. Pediatr Gastroenterol Hepatol Nutr 2022; 25:79-86. [PMID: 35087736 PMCID: PMC8762603 DOI: 10.5223/pghn.2022.25.1.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 10/09/2021] [Accepted: 12/17/2021] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To determine the effect of zinc deficiency on fecal protein, electrolyte, and short-chain fatty acid levels in both heat-stable (ST) and heat-labile (LT) enterotoxigenic Escherichia coli (ETEC)-induced diarrhea in rats. METHODS Albino rats, weighing 100 to 150 g, were divided into 2 groups, with 15 animals each: non-zinc and zinc-deficient. These two groups were sub-divided into three sub-groups with five rats each: control (saline); LT-ETEC; and ST-ETEC. Sodium phytate (30 mmol/L) was added to the animals' water to induce zinc deficiency, while diarrhea was induced using 5×109 ETEC cells/mL. Fecal protein levels were estimated using the Bradford method, while sodium and potassium levels were determined using atomic absorption spectrophotometry. Short-chain fatty acids were measured using gas chromatography-mass spectrometry. RESULTS Among the non-zinc and zinc-deficient groups, there were significant increases (p=0.04), (p=0.03) in fecal protein concentrations (mg/mL) in the LT-ETEC- (4.50±0.33), (6.50±0.26) and ST-ETEC- (3.85±0.19), (5.98±0.32) induced groups compared to the control groups (2.60±0.52), (3.50±0.11) respectively. Fecal sodium and potassium levels (mg/L) were significantly (p=0.029) increased in non-zinc-deficient rats induced with LT-ETEC (9.35±0.95, 1.05±0.48), and ST-ETEC (9.96±1.02, 1.21±0.45) compared with the control group (8.07±0.44, 0.47±0.17) but the increase were not statistically significant (p=0.059) in the zinc deficient rat groups. Fecal acetate and propionate levels (mg/g) significantly (p=0.032) increased when induced with LT-ETEC and ST-ETEC in non-zinc and zinc-deficient groups compared with the control groups. CONCLUSION Zinc deficiency among rats with ETEC-induced diarrhea elevated fecal protein loss but may not have an effect on fecal sodium, potassium and short-chain fatty acid levels.
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Affiliation(s)
- Ebuka E. David
- Department of Biochemistry, Alex Ekwueme Federal University Ndufu-Alike Ikwo, Ebonyi State, Nigeria
| | | | | | - Chidinma N. David
- Department of Microbiology, Ebonyi State University, Ebonyi State, Nigeria
| | - Valentine Nwobodo
- Department of Applied Biochemistry, Nnamdi Azikiwe University, Awka, Anambra State, Nigeria
| | - Akindele K. Ismail
- Department of Microbiology, Alex Ekwueme Federal University Ndufu-Alike Ikwo, Ebonyi State, Nigeria
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Li Z, Kim R, Vollmer S, Subramanian SV. Factors Associated With Child Stunting, Wasting, and Underweight in 35 Low- and Middle-Income Countries. JAMA Netw Open 2020; 3:e203386. [PMID: 32320037 PMCID: PMC7177203 DOI: 10.1001/jamanetworkopen.2020.3386] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Evidence on the relative importance of various factors associated with child anthropometric failures (ie, stunting, underweight, and wasting) and their heterogeneity across countries can inform global and national health agendas. OBJECTIVE To assess the relative significance of factors associated with child anthropometric failures in 35 low- and middle-income countries (LMICs). DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of 299 353 children who were born singleton and aged 12 to 59 months with nonpregnant mothers and valid anthropometric measures assessed the strengths of associations of 26 factors with child stunting, underweight, and wasting, using Demographic and Health Surveys (2007-2018) from 35 LMICs. Data analysis was conducted from July 2019 to February 2020. EXPOSURES A total of 9 direct factors (ie, dietary diversity score; breastfeeding initiation; vitamin A supplements; use of iodized salt; infectious disease in past 2 weeks; oral rehydration therapy for children with diarrhea; care seeking for suspected pneumonia; full vaccination; and indoor pollution) and 17 indirect factors (household wealth; maternal and paternal education; maternal and paternal height and body mass index; maternal autonomy for health care, movement, and money; water source; sanitation facility; stool disposal; antenatal care; skilled birth attendant at delivery; family planning needs; and maternal marriage age) were assessed. MAIN OUTCOMES AND MEASURES Three anthropometric failure outcomes were constructed based on the 2006 World Health Organization child growth standards: stunting (height-for-age z score less than -2 standard deviations [SDs]), underweight (weight-for-age z score less than -2 SDs), and wasting (weight-for-height z score less than -2 SDs). RESULTS Among the 299 353 children aged 12 to 59 months included in the analysis, 38.8% (95% CI, 38.6%-38.9%) had stunting, 27.5% (95% CI, 27.3%-27.6%) had underweight, and 12.9% (95% CI, 12.8%-13.0%) had wasting. In the pooled sample, short maternal height was the strongest factor associated with child stunting (odds ratio [OR], 4.7; 95% CI, 4.5-5.0; P < .001), followed by lack of maternal education (OR, 1.9; 95% CI, 1.8-2.0; P < .001), poorest household wealth (OR, 1.7; 95% CI,1.6-1.8; P < .001), and low maternal body mass index (OR, 1.6; 95% CI, 1.6-1.7; P < .001). Short paternal height was also significantly associated with higher odds of stunting (OR, 1.9; 95% CI, 1.7-2.2; P < .001). Consistent results were found for underweight (eg, short maternal height: OR, 3.5; 95% CI, 3.3-3.7; P < .001; lack of maternal education: OR, 1.8; 95% CI, 1.7-2.0; P < .001) and wasting (eg, low maternal body mass index: OR, 2.3; 95% CI, 2.1-2,4; P < .001; poorest household wealth: OR, 1.2; 95% CI, 1.1-1.3; P < .001). Parental nutritional status and household socioeconomic conditions ranked the strongest (1st to 4th) for most countries, with a few exceptions (eg, lack of maternal education ranked 18th-20th in 8 countries for child wasting). Other factors were not associated with anthropometric failures in pooled analysis and had large country-level heterogeneity; for example, unsafe water was not associated with child underweight in the pooled analysis (OR, 0.97; 95% CI, 0.95-1.00; P < .001), and it ranked from 4th to 20th across countries. CONCLUSIONS AND RELEVANCE In this study, socioeconomic conditions and parental nutritional status were the strongest factors associated with child anthropometric failures. Poverty reduction, women's education, and nutrition programs for households could be important strategies for reducing child undernutrition; however, country-specific contexts should be considered in national policy discussions.
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Affiliation(s)
- Zhihui Li
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Sciences, Korea University, Seoul, South Korea
- Department of Public Health Sciences, Graduate School, Korea University, Seoul, South Korea
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Germany
| | - S. V. Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
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Brander RL, Pavlinac PB, Walson JL, John-Stewart GC, Weaver MR, Faruque ASG, Zaidi AKM, Sur D, Sow SO, Hossain MJ, Alonso PL, Breiman RF, Nasrin D, Nataro JP, Levine MM, Kotloff KL. Determinants of linear growth faltering among children with moderate-to-severe diarrhea in the Global Enteric Multicenter Study. BMC Med 2019; 17:214. [PMID: 31767012 PMCID: PMC6878715 DOI: 10.1186/s12916-019-1441-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/08/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Moderate-to-severe diarrhea (MSD) in the first 2 years of life can impair linear growth. We sought to determine risk factors for linear growth faltering and to build a clinical prediction tool to identify children most likely to experience growth faltering following an episode of MSD. METHODS Using data from the Global Enteric Multicenter Study of children 0-23 months old presenting with MSD in Africa and Asia, we performed log-binomial regression to determine clinical and sociodemographic factors associated with severe linear growth faltering (loss of ≥ 0.5 length-for-age z-score [LAZ]). Linear regression was used to estimate associations with ΔLAZ. A clinical prediction tool was developed using backward elimination of potential variables, and Akaike Information Criterion to select the best fit model. RESULTS Of the 5902 included children, mean age was 10 months and 43.2% were female. Over the 50-90-day follow-up period, 24.2% of children had severe linear growth faltering and the mean ΔLAZ over follow-up was - 0.17 (standard deviation [SD] 0.54). After adjustment for age, baseline LAZ, and site, several factors were associated with decline in LAZ: young age, acute malnutrition, hospitalization at presentation, non-dysenteric diarrhea, unimproved sanitation, lower wealth, fever, co-morbidity, or an IMCI danger sign. Compared to children 12-23 months old, those 0-6 months were more likely to experience severe linear growth faltering (adjusted prevalence ratio [aPR] 1.97 [95% CI 1.70, 2.28]), as were children 6-12 months of age (aPR 1.72 [95% CI 1.51, 1.95]). A prediction model that included age, wasting, stunting, presentation with fever, and presentation with an IMCI danger sign had an area under the ROC (AUC) of 0.67 (95% CI 0.64, 0.69). Risk scores ranged from 0 to 37, and a cut-off of 21 maximized sensitivity (60.7%) and specificity (63.5%). CONCLUSION Younger age, acute malnutrition, MSD severity, and sociodemographic factors were associated with short-term linear growth deterioration following MSD. Data routinely obtained at MSD may be useful to predict children at risk for growth deterioration who would benefit from interventions.
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Affiliation(s)
- Rebecca L Brander
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | | | - Judd L Walson
- Department of Epidemiology, Global Health, Pediatrics, Medicine, Childhood Acute Illness and Nutrition Network, University of Washington, Seattle, WA, USA
| | - Grace C John-Stewart
- Department of Epidemiology, Global Health, Pediatrics, Medicine, University of Washington, Seattle, WA, USA
| | - Marcia R Weaver
- Department of Global Health, Health Services, Health Metrics Sciences, University of Washington, Seattle, WA, USA
| | - Abu S G Faruque
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - Anita K M Zaidi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.,Present Address: Enteric and Diarrheal Diseases Program, Bill and Melinda Gates Foundation, Seattle, WA, USA
| | - Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India.,Present Address: Translational Health Science and Technology Institute, Faridabad, India
| | - Samba O Sow
- Centre pour le Développement des Vaccines, Bamako, Mali
| | - M Jahangir Hossain
- Medical Research Council Unit, The Gambia at London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Pedro L Alonso
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique.,Present Address: Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Robert F Breiman
- Global Disease Detection Division, Kenya Office of the US Centers for Disease Control and Prevention, Nairobi, Kenya.,Present Address: Global Health Institute Emory University, Atlanta, GA, USA
| | - Dilruba Nasrin
- Center for Vaccine Development, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James P Nataro
- Center for Vaccine Development, Department of Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA.,Present Address: Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Myron M Levine
- Center for Vaccine Development and Global Health, Department of Pediatrics and Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, Department of Pediatrics and Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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