Inpatient and outpatient treatment for acute malnutrition in infants under 6 months; a qualitative study from Senegal

Characteristics and treatment outcomes of malnutrition among infants aged less than 6 months in North-East Nigeria (2019-2022)

Recommendations for the management of malnutrition among infants aged less than 6 months (<6 m) are based on limited evidence. This study aimed to describe the characteristics, treatment outcomes and outcome-associated factors among malnourished infants <6 m admitted at Médecins Sans Frontières (MSF) inpatient and ambulatory therapeutic feeding centres (ITFC and ATFC) in North-East Nigeria, 2019-2022. We conducted a descriptive analysis of the cohorts and logistic regression to measure the association between two selected outcomes-inpatient mortality and defaulting from the ambulatory programme-and possible factors associated. In total, 940 infants <6 m were admitted at ITFC. Most of them presented severe acute malnutrition and comorbidities, with diarrhoea being the most frequent. On discharge, 13.3% (n = 125) of infants were cured, 72.9% (n = 684) stabilized (referred to ATFC), 6.5% (n = 61) left against medical advice and 4.2% (n = 39) died. The median length of hospital stay was 10 days [IQR 7-14]. A hospital stay shorter than 10 days was significantly associated with inpatient mortality (aOR = 12.51, 95% confidence interval [CI] = 3.72-42.11, p ≤ 0.01). Among 561 infants followed up at the ATFC, only 2.8% reported comorbidities. On discharge, 80.9% (n = 429) were cured, 16.2% (n = 86) defaulted and 1.1% (n = 6) died. Male sex (aOR = 1.94, 95% CI = 1.15-3.27, p = 0.01), internally displaced status (aOR = 1.70, 95% CI = 1.05-2.79, p = 0.03) and <-3 WLZ (aOR = 1.95, 95% CI = 1.05-3.63, p = 0.03) were significantly associated with programme defaulting. Stabilization and recovery rates among malnourished infants <6 m in the studied project align with acceptable standards in this humanitarian setting. Notable defaulting rates from outpatient care should be further explored.

Community-based management of acute malnutrition for infants under 6 months of age is safe and effective: analysis of operational data

OBJECTIVE

To assess the effectiveness of outpatient management with ready-to-use and supplementary foods for infants under 6 months (u6m) of age who were unable to be treated as inpatients due to social and economic barriers.

DESIGN

Review of operational acute malnutrition treatment records.

SETTING

Twenty-one outpatient therapeutic feeding clinics in rural Malawi.

PARTICIPANTS

Infants u6m with acute malnutrition treated as outpatients because of barriers to inpatient treatment. The comparison group consisted of acutely malnourished children 6-9 months of age who were being treated at the same time in the same location in the context of two different randomised clinical trials.

RESULTS

A total of 323 infants u6m were treated for acute malnutrition (130 severe and 193 moderate). A total of 357 infants 6-9 months old with acute malnutrition (seventy-four severe and 283 moderate) were included as contemporaneous controls. Among infants u6m with severe acute malnutrition, 98 (75·4 %) achieved nutritional recovery; in comparison, 56 (75·7 %) of those with severe acute malnutrition 6-9 months old recovered. Among infants u6m with moderate acute malnutrition, 157 (81·3 %) recovered; in comparison, 241 (85·2 %) of those aged 6-9 months recovered.

CONCLUSIONS

In a rural Malawian population of infants u6m who had generally already stopped exclusive breast-feeding and were now acutely malnourished, treatment with therapeutic or supplementary foods under the community management of acute malnutrition model was safe and effective. In settings where social and financial factors make hospital admission challenging, consideration should be given to lowering the recommended age of ready-to-use therapeutic and supplementary foods to infants u6m.

Implementing a Care Pathway for small and nutritionally at-risk infants under six months of age: A multi-country stakeholder consultation

Nutritional vulnerability under the age of 6 months is prevalent in low- and middle-income countries with 20.1% infants underweight, 21.3% wasted and 17.6% stunted in a recent review. A novel Care Pathway for improved management of small and nutritionally at-risk infants under 6 months and their mothers (MAMI) has recently been developed to provide outpatient care at large coverage. We aimed to investigate stakeholders' views on the feasibility of its implementation and to identify barriers and enablers. This was an early stage formative mixed-methods study: an online survey plus in-depth interviews with country-level stakeholders in nutrition and child health from different geographical regions and stakeholder groups. 189 stakeholders from 42 countries responded to the online survey and 14 remote interviews were conducted. Participants expressed an urgent need for improved detection and care for small and nutritionally at-risk infants under 6 months. Whilst they considered the MAMI Care Pathway feasible and relevant, they noted it was largely unknown in their country. The most mentioned implementation barriers were: community-specific needs and health care seeking barriers, health workers' lack of competence in breastfeeding counselling and the absence of a validated anthropometric screening method. Possible enablers for its implementation were: patients' preference for outpatient care, integrating the MAMI care pathway into existing maternal and child health programmes and the possibility of a local pilot project. Adaptation to the local context was considered crucial in further scale-up.

Interventions to support the re-establishment of breastfeeding and their application in humanitarian settings: A systematic review

In 1998, the World Health Organisation (WHO) published general guidelines proposing essential measures to achieve relactation. Yet, increased knowledge about the practical set-up of relactation support interventions in different contexts is needed, especially in humanitarian settings, where nonbreastfed infants are particularly at risk. This study aimed to compile and assess the characteristics, outcomes and factors influencing the implementation of relactation support interventions reported since the latest WHO recommendations. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, undertaking a search from Medline, Embase, PubMed Central, Web of Science, Global Health and CINAHL electronic databases. Studies published in English and Spanish, reporting characteristics and outcomes of relactation support provided to non-(breastfeeding) BF mothers with infants aged less than 6 months were included. Data were analysed by narrative synthesis and the Johanna Briggs Institute Critical Appraisal Tools were used for quality assessment. Overall, 16 studies met the inclusion criteria. Most were observational and conducted in middle-income countries, only one focused on humanitarian settings. Studies reported inpatient and community-based interventions, which generally followed WHO recommendations for relactation. In 13 out of 16 studies, over 80% of mothers restarted BF after receiving relactation support. Enabling factors included younger infant age, shorter lactation gap, mother's strong motivation, family support, and continuous skilled support. Although current literature suggests that intensive relactation support can contribute to re-establish BF, its application and effectiveness in humanitarian settings remain uncertain. Further research is needed to explore the effectiveness, feasibility and acceptability of different approaches to relactation support, especially in humanitarian settings.

The Role of Outpatient Care Accreditation in Enhancing Foreign Patients' Perception of Colombian Medical Tourism: A Quasi-experimental Design

This study analyzes whether hospitals accredited by the Joint Commission International in outpatient medical care protocols located in Colombia achieve a higher quality perception from foreign patients compared to others treated in a non-accredited one. A t-test with Welch correction, chi-square test, correlation coefficient of Tau Kendall, pre-test, post-test, complementary questionnaire and a 2 focus groups were used in 178 foreign patients. It was observed that patients treated in accredited hospitals had a higher quality perception than the non-accredited group. However, it was found that an unbalanced application of the 3 variables negatively alters quality judgment. Findings contributes to understanding the Colombian medical tourism in depth using non-conventional instruments.