Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries

Mass azithromycin for prevention of child mortality among children with acute malnutrition: A subgroup analysis of a cluster randomized controlled trial

Children with acute malnutrition are at high risk of morality. Mass azithromycin distribution reduces all-cause mortality among children aged 1-59 months, and effects may be greater in underweight infants. Here, we evaluate the efficacy of azithromycin for reducing all-cause mortality in children aged 6-59 months with acute malnutrition (mid-upper arm circumference, MUAC, < 12.5 cm). Communities in Nouna District, Burkina Faso were 1:1 randomized to biannual mass distribution of single dose azithromycin or placebo to all children aged 1-59 months. Mortality was assessed during each census and treatment round. MUAC measurements were collected for all children. We evaluated the effect of azithromycin on mortality in subgroups of children aged 6-59 months defined by acute malnutrition (MUAC < 12.5 cm versus MUAC ≥ 12.5 cm). In children with MUAC < 12.5 cm, mortality rates were 51% lower among those living in azithromycin communities compared to placebo (incidence rate ratio 0.49, 95% confidence interval, CI, 0.25 to 0.99; incidence rate difference -18.1 deaths per 1,000 person-years, 95% CI -37.0 to -0.01), which was greater than the reduction in mortality among children with MUAC ≥ 12.5 cm (P-value for interaction on the relative scale = 0.09; P-value for interaction of the additive scale = 0.03). Children with acute malnutrition may benefit from single dose azithromycin above and beyond those without acute malnutrition. Trial registration: ClinicalTrials.gov NCT03676764; https://clinicaltrials.gov/study/NCT03676764.

Examining the burden and relationship between stunting and wasting among Timor-Leste under five rural children

Globally and in Timor-Leste, wasting and stunting remain major public health problems among 'under five years children, but the interrelationship between the two has been poorly investigated. A better understanding of this interrelationship is a prerequisite to improving wasting and stunting programming. In our study, we assessed the influence of age on the prevalence of wasting and stunting, the overlap between the two conditions, and the effect of wasting parameters on linear growth catch-up using the data of 401 children recruited at 0 to 54 months of age [median (IQR) of 17 (7-32) months] with repeated anthropometric assessments [median (IQR) follow-up time was 25 (16-39) months]. At recruitment, prevalences of stunting, wasting and concurrence of the two conditions were 54.6%, 9.5% and 4.6%, respectively. These prevalences were already high and above the thresholds for public health importance among children below months of age and remained high throughouttheir childhood. Over the follow-up period, the change (95%CI) in Height-for-Age Z-score (HAZ) was -0.01 (-0.13; 0.11) (p = 0.850), and that of the Height-for-Age Difference (HAD) was -3.74 (-4.28; -3.21) cm (p<0.001). Stunting reversal was observed in 25.6% of those stunted at recruitment, while a positive change in HAD was observed in only 19.6% of assessed children. Path analysis by structural equation modelling showed no significant direct effect of WHZ at recruitment on the likelihood of positive change in HAD, with its influence being fully mediated by its change over the follow-up period. This change had an inverse relationship with the occurrence of a positive change in HAD. On the contrary, Mid-Upper Arm Circumference at recruitment had a significant positive direct effect on the likelihood of a positive HAD change. These results show that interventions to combat wasting and stunting need to be integrated.

Wasting coexisting with underweight and stunting among children aged 6‒59 months hospitalised in Garissa County Referral Hospital, Kenya

Management of undernourished children depends only on wasting yet it can coexist with underweight and/or stunting. Among children admitted to hospital with acute illness, we determined the proportion with wasting coexisting with underweight and/or stunting and their risk factors. A retrospective review of hospital records of children 6‒59 months old admitted at Garissa County referral hospital, Kenya, from January 2017 to December 2019 was conducted. Using World Health Organization 2006 growth standards, undernutrition were defined: wasting as Weight-for-height Z-score < -2, stunting Height-for-age Z-score < -2 and underweight Weight-for-age Z-score < -2. We studied wasting coexisting with underweight and/or stunting. Among 624 children recruited, 347 (56%) were males and 511 (82%) <24 months old. Diarrhoea 210 (34%) and pallor/anaemia 310 (50%) were the most frequent admission diagnosis. HIV infection was present among 8 (1.3%) children. Wasting, underweight and stunting were present among 595 (95%), 518 (83%) and 176 (28%) children respectively. 161 (26%), 506 (81%) and 161 (26%) children had wasting coexisting with stunting, underweight and both stunting and underweight respectively. In the multivariable regression, diarrhoea was positively associated with wasting coexisting with stunting (adjusted risk ratio [aRR = 2.96] [95% CI = 2.06‒4.23]) and anaemia with wasting coexisting with underweight (aRR = 1.23) (95% CI = 1.03‒1.47). Overall, 343 (55%) children were discharged alive, 67 (11%) absconded from the wards, 164 (26%) were transferred to another hospital and 50 (8.0%) died before discharge. The risk of inpatient death was 10.3%, 7.9%, 8.4% and 6.8% among children not wasted, wasted only, wasted & underweight, and wasted and underweight and stunted respectively (Chi-square p = 0.60). The study reports an unacceptably high levels of undernourishment, including coexisting forms of undernutrition among hospitalised children. This highlights a public health priority for current nutrition therapeutic care and need of continuity of care among those children discharged alive in the community-based management of acute malnutrition programmes.

Improving case-detection of severe wasting among under-five-year-old children in Timor Leste: A secondary analysis of data from the 2020 national cross-sectional food and nutrition survey

The World Health Organization recommends using weight-for-height Z-score (WHZ) <-3 or Mid-Upper Arm Circumference (MUAC) <115 mm as independent criteria for diagnosing severe wasting. However, there are several challenges in using the WHZ criterion. As a result, the MUAC (and edema)-only approach for identifying children needing treatment for severe wasting has been developed and is being rapidly scaled-up globally, including in Timor-Leste. But previous studies reported that MUAC<115 mm has poor diagnostic accuracy for detecting children with WHZ<-3. The two options being explored globally for improving the identification of these children in MUAC (and edema)-only programming contexts include expanding MUAC cut-off and the combination of the indicators MUAC and Weight-for-Age Z-score (WAZ). This study explored the accuracy for diagnosing severe wasting (WHZ<-3) of these two options in Timor-Leste. We conducted a secondary analysis of data from the 2020 national Timor-Leste Food and Nutrition Survey. We tested the accuracy of various MUAC cut-offs, and predefined case definitions in five age groups (0-5 months, 6-23 months, 24-59 months, 6-59 months, and 0-59 months). We calculated the standard diagnostic test parameters (sensitivity, specificity, Youden Index, and others) and used the Youden Index as the principal criterion for rating the overall level of accuracy. The sample analyzed comprised 11,056 children with complete information on our key variables (anthropometric data, age, and sex), of whom 52.2% were boys. The age groups 0 to 5 months, 6 to 23 months, and 24 to 59 months represented 9.0%, 33.7%, and 57.3% of the sample, respectively. We found that the optimal diagnostic MUAC cut-off varied across the age groups between 117 mm and 142 mm, with the Youden Index remaining < 55% in all the age groups considered. The use of case definitions combing MUAC and WAZ optimized the identification of children with WHZ<-3. The case definition MUAC<130 mm or WAZ<-3 Z-score had the best diagnostic accuracy in all the age groups except for the 0 to 5 months age group for which the case definition MUAC<110 mm or WAZ<-2 Z-score had the highest Youden Index. Our findings show that it is challenging to significantly improve diagnostic accuracy for identifying children with WHZ<-3 by only expanding the MUAC cut-off in under five Timorese children. However, In settings facing challenges in using WHZ, the combination of MUAC and WAZ indicators offers a promising approach. Further research is needed to confirm the effectiveness of the proposed combination of MUAC and WAZ indicators case definitions in a programmatic context in Timor-Leste, and other similar contexts.

Locally Prepared Therapeutic Food for Treatment of Severely Underweight Children in Rural India: An Interventional Prospective Controlled Community-Based Study with Long Follow-Up:-'SAMMAN' Trial

BACKGROUND

Severely underweight (SUW) children contribute significantly to under-five mortality and morbidity. There are WHO guidelines for the management of severe acute malnutrition but no specific guidelines for SUW management.

OBJECTIVE

The objectives were to achieve a recovery rate of 30% at 90 days of treatment for severe underweight (SUW) children aged 6-60 months, compare changes in weight-for-age Z (WAZ) scores, growth patterns, and case fatality rates between intervention and reference arms (RA), and reduce the prevalence of SUW in the intervention arm (IA). The target of a 30% recovery rate was achievable and significant based on our past research conducted in similar settings.

METHODS

Design: A prospective controlled community-based, longitudinal, two arms (IA, RA), intervention study with long follow-up was conducted between January 2011 and October 2023.

SETTING

Primary care for participants from 14 villages in rural Melghat, India.

PARTICIPANTS

The study participants included SUW children aged 6-60 months and age-matched (±2 weeks) normal controls. The SAMMAN (Acronym for SAM-Management) intervention was comprised of local therapeutic food-micronutrient (LTF-MN) therapy for 90 days, intensive behavior change communication, infection treatment, and quarterly anthropometric records. SUW recovery, growth patterns, case fatality rate, prevalence at 90 days of therapy and at 60 months of age, and survival until early adolescence were assessed. ANCOVA analysis was used to obtain changes in Z-scores.

RESULTS

In the IA, the recovery rate was 36.8% at 90 days and 78.2% at 60 months of age. The mean difference in change in WAZ scores between the intervention arm and the reference arm was statistically significant (p < 0.0001). Growth patterns were similar between the two arms up to early adolescence. The SUW case fatality rate was significantly lower in the IA (0.9%) as compared to 4.62% in the RA at 60 months (p = 0.022). The reduction in SUW prevalence in intervention villages was higher than in the control villages (p < 0.001). The cost of management per SUW child was 3888 INR (47 USD) less than RUTF.

CONCLUSION

The SAMMAN intervention is safe and cost-effective for significantly improving WAZ scores, sustainable, and hence replicable in resource-limited areas.

Understanding the socio-demographic and programmatic factors associated with adolescent motherhood and its association with child undernutrition in Bangladesh

BACKGROUND

Worldwide, a significant number of girls become mothers during adolescence. In Bangladesh, adolescent childbirth is highly prevalent and has adverse effects on children's health and undernutrition. We aimed to identify the relationship between the undernutrition of children and adolescent motherhood, the factors associated with adolescent mothers' age at first birth, and to examine the programmatic factors and gaps influencing children's undernutrition in Bangladesh.

METHODS

We analysed the 'Bangladesh Demographic and Health Survey' BDHS-17-18 data and desk review. To examine the factors associated with adolescent motherhood and its impact on child undernutrition, data from 7,643 mother-child pairs were selected. Child stunting, wasting, and underweight were measured according to the World Health Organisation (WHO) median growth guidelines based on z-scores - 2. Univariate, bivariate, simple, and multiple logistic regressions were used for analyse. We followed the systematic procedures for the literature review.

RESULTS

Approximately, 89% of adolescents aged ≤ 19 years were married and 71% of them gave their first childbirth. Children of adolescent mothers (≤ 19 years) were significantly 1.68 times more wasted (aOR: 1.68; 95% CI: 1.08 to 2.64), 1.37 times more underweight (aOR: 1.37; 95% CI: 1.01 to 1.86) and either form 1.32 times more stunting, wasting or underweight (aOR:1.32; 95% Cl: 1.05 to 1.66) compared to the children of adult mothers (> 19 years) after adjusting potential confounders. The factors associated with mothers' first childbirth during adolescence were the age gap between husband and wife 5-10 years (aOR: 1.81; 95% Cl: 1.57-2.10) and age gap > 10 years (aOR: 2.41; 95% Cl: 1.96-2.97) compared with the age group < 5 years, and husbands' education (aOR: 1.29; 95% Cl: 1.04-1.61) compared with the uneducated husbands. In the literature review, we found potential gaps in focusing on the Adolescent Sexual and Reproductive Health (ASRH) program in Bangladesh, from thirty-two programmes only half of them focused on adolescents aged 10-19 years, and eleven programmes focused only on girls.

CONCLUSION

Children of adolescent mothers are at risk of wasting, underweight, and any form of undernutrition. For effective policies and interventions in Bangladesh, it is important to emphasise delaying adolescent pregnancy and prioritising child undernutrition.

Effectiveness of acute malnutrition treatment with a simplified, combined protocol in Central African Republic: An observational cohort study

A simplified, combined protocol admitting children with a mid-upper-arm circumference (MUAC) of <125 mm or oedema to malnutrition treatment with ready-to-use therapeutic food (RUTF) uses two sachets of RUTF per day of those with MUAC < 115 mm and/or oedema and one sachet of RUTF per day for those with MUAC 115-<125 mm. This treatment previously demonstrated noninferior programmatic outcomes compared with standard treatment and high recovery in a routine setting. We aimed to observe the protocol's effectiveness in a routine setting at scale, in two health districts of the Central African Republic through an observational cohort study. The pilot enrolled children for 1 year in consortium by the Ministry of Health and nongovernmental partners. A total of 7909 children were admitted to the simplified, combined treatment. Treatment resulted in an 81.2% overall recovery, with a mean length of stay (LOS) of 38.7 days and a mean RUTF consumption of 43.4 sachets per child treated. Among children admitted with MUAC < 115 mm or oedema, 67.9% recovered with a mean LOS of 48.1 days and consumed an average of 70.9 RUTF sachets. Programme performance differed between the two districts, with an overall defaulting rate of 31.1% in the Kouango-Grimari health district, compared to 8.2% in Kemo. Response to treatment by children admitted with severe acute malnutrition (SAM) by MUAC and SAM by oedema was similar. The simplified, combined protocol resulted in a satisfactory overall recovery and low RUTF consumption per child treated, with further need to understand defaulting in the context.

Machine Learning Approach for Predicting the Impact of Food Insecurity on Nutrient Consumption and Malnutrition in Children Aged 6 Months to 5 Years

BACKGROUND

Food insecurity significantly impacts children's health, affecting their development across cognitive, physical, and socio-emotional dimensions. This study explores the impact of food insecurity among children aged 6 months to 5 years, focusing on nutrient intake and its relationship with various forms of malnutrition.

METHODS

Utilizing machine learning algorithms, this study analyzed data from 819 children in the West Bank to investigate sociodemographic and health factors associated with food insecurity and its effects on nutritional status. The average age of the children was 33 months, with 52% boys and 48% girls.

RESULTS

The analysis revealed that 18.1% of children faced food insecurity, with household education, family income, locality, district, and age emerging as significant determinants. Children from food-insecure environments exhibited lower average weight, height, and mid-upper arm circumference compared to their food-secure counterparts, indicating a direct correlation between food insecurity and reduced nutritional and growth metrics. Moreover, the machine learning models observed vitamin B1 as a key indicator of all forms of malnutrition, alongside vitamin K1, vitamin A, and zinc. Specific nutrients like choline in the "underweight" category and carbohydrates in the "wasting" category were identified as unique nutritional priorities.

CONCLUSION

This study provides insights into the differential risks for growth issues among children, offering valuable information for targeted interventions and policymaking.

How age and sex affect treatment outcomes for children with severe malnutrition: A multi-country secondary data analysis

Age and sex influence the risk of childhood wasting. We aimed to determine if wasting treatment outcomes differ by age and sex in children under 5 years, enroled in therapeutic and supplementary feeding programmes. Utilising data from stage 1 of the ComPAS trial, we used logistic regression to assess the association between age, sex and wasting treatment outcomes (recovery, death, default, non-response, and transfer), modelling the likelihood of recovery versus all other outcomes. We used linear regression to calculate differences in mean length of stay (LOS) and mean daily weight gain by age and sex. Data from 6929 children from Kenya, Chad, Yemen and South Sudan was analysed. Girls in therapeutic feeding programmes were less likely to recover than boys (pooled odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.72-0.97, p = 0.018). This association was statistically significant in Chad (OR: 0.61, 95% CI: 0.39-0.95, p = 0.030) and Yemen (OR: 0.47, 95% CI: 0.27-0.81, p = 0.006), but not in Kenya and South Sudan. Multinomial analysis, however, showed no difference in recovery between sexes. There was no difference between sexes for LOS, but older children (24-59 months) had a shorter mean LOS than younger children (6-23 months). Mean daily weight gain was consistently lower in boys compared with girls. We found few differences in wasting treatment outcomes by sex and age. The results do not indicate a need to change current programme inclusion requirements or treatment protocols on the basis of sex or age, but future research in other settings should continue to investigate the aetiology of differences in recovery and implications for treatment protocols.

Mortality risk in infants receiving therapeutic care for malnutrition: A secondary analysis

Small and nutritionally at-risk infants aged under 6 months (<6 months) are at high risk of death, but important evidence gaps exist on how to best identify them. We aimed to determine associations between anthropometric deficits and mortality among infants <6 months admitted to inpatient therapeutic care. A secondary analysis of 2002-2008 data included 5034 infants aged <6 months from 12 countries. We estimated the prevalence, concurrence, and severity of wasted, stunted, and underweight, as stand-alone indicators, and using the Composite Index of Anthropometric Failure (CIAF), which combines these indicators into six subgroups of single and multiple anthropometric deficits and into one combined indicator called CIAF. We used logistic regression to examine the association of different anthropometric deficits with in-programme mortality. Among 3692 infants aged <6 months with complete data, 3539 (95.8%) were underweight, 3058 (82.8%) were wasted, 2875 (77.8%) were stunted and 3575 (96.8%) had CIAF. Infants with multiple anthropometric deficits were presented with significantly lower anthropometric indices, that is, they were more severely wasted, stunted and underweight. A total of 141 infants died during inpatient therapeutic care. Among these, severely wasted (116) and severely underweight (138) infants had higher odds of mortality than normal infants (odds ratio [OR] = 2.1, 95% confidence interval [CI]: 1.2-2.7, p = 0.009, and OR = 3.3, 95% CI: 0.8-13.6, p = 0.09, respectively). Boys had higher odds of inpatient mortality than girls (OR = 1.40, 95% CI: 1.02-1.92, p = 0.03). Mortality was only observed in infants <6 months presenting multiple anthropometric deficits, although their odds of mortality were not significant, for example, OR = 2.4, 95% CI: 0.5-10.0, p = 0.21 for stunted, wasted and underweight infants <6 months. In conclusion, multiple anthropometric deficits (CIAF) is common among infants <6 months and may be reported in nutrition care programmes and surveys. Both weight-for-length/height z-score and weight-for-age z-score were found to be useful indicators for programme admission and in-programme prognosis. Future work needs to explore which better accounts for admission bias. Boys appear to be most at-risk of dying while receiving malnutrition therapeutic care. Programmes should ensure that all infants receive timely, evidence-based, effective care.

Growth Patterns Between Ages 0 and 36 Months Among US Children With Orofacial Cleft: A Retrospective Cohort Study

BACKGROUND

Little is known about how young children with orofacial cleft grow over time.

OBJECTIVE

To characterize longitudinal growth patterns from ages 0 to 36 months in US children with an orofacial cleft.

DESIGN

A retrospective cohort study.

PARTICIPANTS/SETTING

Children with cleft lip, cleft lip and palate, or cleft palate who were younger than age 36 months at a hospital encounter between 2010 and 2019 (N = 1334) were included. The setting was a US tertiary care children's hospital with a cleft center that serves a 5-state region.

MAIN OUTCOME MEASURE

Weight-for-age z scores (WAZ) and length-for-age z scores (LAZ).

STATISTICAL ANALYSES PERFORMED

Longitudinal growth patterns were characterized using generalized linear mixed models to estimate mean WAZ and LAZ from age 0 to 36 months.

RESULTS

Growth in infants with cleft slowed dramatically during the first 3 to 4 months of life, rebounded with catch-up growth until age 12 months for cleft lip and cleft palate and until age 36 months for cleft lip and palate. When comparing populations, children with any type of cleft demonstrated subpar growth compared with World Health Organization standards. Growth deficits were more common in those with cleft lip and palate and cleft palate compared with those with cleft lip. The intraclass coefficient showed that most of the variability in the WAZ (65%) was between individuals, whereas 35% was within an individual. The intraclass coefficient for LAZ showed that most of the variability in the LAZ (74%) was between individuals, whereas 26% was within an individual. The proportion of variance attributable to cleft type and/or comorbidities accounted for <5% of the variance for WAZ and LAZ. WAZ and LAZ were lower in children with comorbidities than those without comorbidities with cleft and World Health Organization standards.

CONCLUSIONS

Infants with cleft lip and palate, cleft palate, and a cleft with comorbidities have higher rates of poor growth than peers with cleft lip and a cleft with no comorbidities, respectively.

Comparing time to recovery in wasting treatment: simplified approach vs. standard protocol among children aged 6-59 months in Ethiopia-a cluster-randomized, controlled, non-inferiority trial

Introduction

Wasting occurs when the body's nutritional needs are unmet due to insufficient intake or illness. It represents a significant global challenge, with approximately 45 million infants and children under 5 years of age suffering from wasting in 2022.

Methods

A cluster-randomized, controlled, non-inferiority trial was conducted in three regions of Ethiopia. A non-inferiority margin of 15%, along with a recovery rate of 90% and a minimum acceptable recovery rate of 75%, were considered alongside an intra-cluster correlation coefficient of 0.05 and an anticipated loss to follow-up of 10% in determining the total sample size of 1,052 children. Children with severe acute malnutrition (SAM) in the simplified group received two sachets of ready-to-use therapeutic food (RUTF) daily, while the standard group received RUTF based on their body weight. For moderate acute malnutrition (MAM) cases, the simplified group received one sachet of RUTF, whereas the standard group received one sachet of ready-to-use supplementary food daily. A non-parametric Kaplan-Meir curve was utilized to compare the survival time to recovery.

Results

A total of 1,032 data points were gathered. For SAM cases, the average length of stay was 8.86 (±3.91) weeks for the simplified protocol and 8.26 (±4.18) weeks for the standard protocol (P = 0.13). For MAM cases, the average length of stay was 8.18 (±2.96) weeks for the simplified approach and 8.32 (±3.55) weeks for the standard protocol (P = 0.61). There was no significant difference (P = 0.502) observed between the simplified protocol [8 weeks, interquartile range (IQR): 7.06-8.94] and the standard protocol [9 weeks (IQR: 8.17-9.83)] among children with SAM on the median time to cure. There was no significant difference (P = 0.502) in the time to cure between the simplified approach [8 weeks (IQR: 7.53-8.47)] and the standard protocol [8 weeks (IQR: 7.66-8.34)] among children with MAM. The survival curves displayed similarity, with the log-rank test not showing significance (P > 0.5), indicating the non-inferiority of the simplified approach for cure time.

Conclusion

The findings showed that the simplified and standard protocols demonstrated no significant differences in terms of the average duration of stay and time required for recovery.

Clinical Trial Registration

https://pactr.samrc.ac.za/, Identifier (PACTR202202496481398).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm randomized controlled trial

BACKGROUND

Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol.

METHODS

This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ.

DISCUSSION

This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.

Adolescent pregnancy is associated with child undernutrition: Systematic review and meta-analysis

Adolescent pregnancy is associated with poor fetal growth and development which, in turn, increases the risk of childhood wasting and underweight. However, evidence on how young maternal age affects childhood anthropometry beyond the neonatal period is limited. This systematic review and meta-analysis examined associations between adolescent pregnancy and child wasting and underweight and explored potential underlying social and biological factors. Peer-reviewed literature published in English since 1990 was systematically searched. Eligible studies presented data on wasting and/or underweight in children (≤59 months) born to adolescent mothers (10-19, or ≤24 years where applicable) from low- and middle-income countries. Data extraction used a predefined extraction sheet. Both meta-analysis and qualitative synthesis were performed. Of 92 identified studies, 57 were included in the meta-analysis. The meta-analysis showed that children born to adolescent versus adult mothers were at a higher risk of moderate (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.00-1.26 p = 0.04) and severe underweight (OR: 1.21, 95% CI: 1.08-1.35 p < 0.01). Associated risk of wasting was not statistically significant: (OR: 1.05, 95% CI: 0.98-1.12 p = 0.17); severe wasting (OR: 1.16, 95% CI: 0.68-1.96 p = 0.59). These findings were supported by the qualitative synthesis. Evidence on the potential role of biological/social factors was limited, but suggested an intermediary role of maternal nutritional status which warrants further exploration. Particularly in contexts where adolescent pregnancy remains common, interventions to both delay adolescent pregnancy and improve adolescent nutritional status could help reduce the risk of undernutrition in children and contribute to breaking the intergenerational cycle of malnutrition.

Seasonality of Acute Malnutrition in African Drylands: Evidence From 15 Years of SMART Surveys

Reduction of wasting, or low weight-for-height, is a critical target for the Zero Hunger Sustainable Development Goal, yet robust evidence establishing continuous seasonal patterns of wasting is presently lacking. The current consensus of greatest hunger during the preharvest period is based on survey designs and analytical methods, which discretize time frame into preharvest/postharvest, dry/wet, or lean/plenty seasons. We present a spatiotemporally nuanced study of acute malnutrition seasonality in African drylands using a 15-year data set of Standardized Monitoring and Assessment of Relief and Transition surveys (n = 412,370). Climatological similarity was ensured by selecting subnational survey regions with 1 rainy season and by spatially matching each survey to aridity and livelihood zones. Harmonic logit regression models indicate 2 peaks of wasting during the calendar year. Greatest wasting prevalence is estimated in April to May, coincident with the primary peak of temperature. A secondary peak of wasting is observed in August to October, coinciding with the primary peak of rainfall and secondary peak of temperature. This pattern is retained across aridity and livelihood zones and is sensitive to temperature, precipitation, and vegetation. Improved subnational estimation of acute malnutrition seasonality can thus assist decision makers and practitioners in data-sparse settings and facilitate global progress toward Zero Hunger.

Severe Acute Malnutrition: The Potential of Non-Peanut, Non-Milk Ready-to-Use Therapeutic Foods

PURPOSE OF REVIEW

This review provides information on the prospect and effectiveness of ready-to-use therapeutic foods (RUTFs) produced locally without the addition of milk and peanut.

RECENT FINDINGS

The foods used in fighting malnutrition in the past decades contributed little to the success of the alleviation program due to their non-effectiveness. Hence, RUTFs are introduced to fight malnutrition. The peanut allergies, the high cost of milk, and the high production cost of peanut RUTF have made its distribution, treatment spread, and accessibility very slow, especially in areas where it is highly needed. There is a need, therefore, for a low-cost RUTF that is acceptable and effective in treating severe acute malnutrition among under-5 children. This review shows both the success and failure of reported studies on the use of non-peanut and non-milk RUTF, including their cost of production as compared to the standard milk and peanut-based RUTF. It was hypothesised that replacing the milk ingredient component with legumes like soybeans can reduce the cost of production of RUTFs while also delivering an effective product in managing and treating severe acute malnutrition (SAM). Consumers generally accept them better because of their familiarity with the raw materials.

Risk factors in underweight older children with sickle cell anemia: a comparison of low- to high-income countries

Previously, we demonstrated that older children with sickle cell anemia (SCA) living in Nigeria are at increased risk of death if they are underweight (weight-for-age z score < -1). We now conducted a cross-sectional study in low- and high-income settings to determine the risk factors for being underweight a in children aged 5 to 12 years with SCA. The children from low- and high-income settings were eligible participants for the Primary Prevention of Stroke in Children with Sickle Cell Disease in Nigeria (SPRING; N = 928) and the Silent Cerebral Infarct (SIT, North America/Europe; N = 1093) trials, respectively. The median age in the SPRING and SIT cohorts was 8.1 and 8.5 years, respectively (P < .001). A total of 87.9% (n = 816) of participants in the SPRING trial (low-income) met the study criteria for being underweight (weight-for-age z score < -1), and 22.7% (n = 211) for severely underweight (weight-for-age z score < -3), significantly higher than the SIT (high-income) cohort at 25.7% underweight (n = 281) and 0.7% severely underweight (n = 8; P < .001 for both comparisons). In the combined cohort, older age (odds ratio [OR], 1.24; P < .001) and lower hemoglobin level (OR, 0.67; P < .001) were associated with being underweight. Age and hemoglobin level remained statistically significant in separate models for the SPRING and SIT cohorts. Older age and lower hemoglobin levels in children aged 5 to 12 years with SCA are associated with being underweight in low- and high-income settings.

Undernutrition in children aged 0-59 months by region and over time: secondary analysis of the Burkina Faso 2012-2018 National Nutrition Surveys

The global burden of undernutrition remains high, responsible for significant under-five mortality in resource-limited settings. Numerous sustainable development goals (SDGs) are linked to nutrition, and nationally representative nutrition surveillance is a key activity to track progress towards SDGs and guide efficient programmes.

OBJECTIVES

The aim of this study is to look at spatial and temporal trends in undernutrition in children under 5 years age in Burkina Faso.

SETTING

We used data from annual National Nutrition Surveys using Standardised Monitoring and Assessment of Relief and Transitions methodology (anthropometry, morbidity) over 7 years (2012-2018) in Burkina Faso.

PARTICIPANTS

Children of under 5 years from households selected through systemic sampling at countrywide level.

MAIN OUTCOME MEASURES

Prevalence of stunting (height-for-age z-score, <-2), underweight (weight-for-age z-score, <-2) and wasting (weight-for-height z-score, <-2) at regional and national. We used general linear mixed models, adjusted by age, survey year, sex, presence of fever and/or diarrhoea, and poverty index to quantify the risk of undernutrition over time and by region of residence.

RESULTS

Between 2012 and 2018, decreases were observed overall in the prevalence of growth retardation (stunting) decreased from 33.0% (95% CI 32.3 to 33.8) in 2012 to 26.7% (95% CI 26.2 to 27.3) in 2018. Underweight reduced from 24.4% (95% CI 23.7 to 25.1) to 18.7% (95% CI 18.2 to 19.2) for the same period and wasting decreased from 10.8% (95% CI 10.3 to 11.3) in 2012 to 8.4% (95% CI 8.1 to 8.8) in 2018. However, there was substantial variation across the country, with increased risk of undernutrition in the regions of Sahel, East and Cascades primarily. High-risk regions were characterised by a lower poverty index and limited access to healthcare services.

CONCLUSIONS

Our findings could inform national policymakers in refining and optimising resource allocation based on the identification of high-risk areas.

Causes and consequences of child growth faltering in low-resource settings

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

Child wasting and concurrent stunting in low- and middle-income countries

Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.

Identifying underweight in infants and children using growth charts, lookup tables and a novel "MAMI" slide chart: A cross-over diagnostic and acceptability study

Malnutrition is a leading cause of preventable deaths in infants and children. To benefit from treatment and prevention programmes, malnourished children must first be identified. Low weight-for-age is an anthropometric indicator of malnutrition which is gaining much recent attention because it is particularly effective at identifying children at highest risk of death. However, assessing weight-for-age can be challenging. We aimed to evaluate a novel, low-cost weight-for-age slide chart and compare its performance against two traditional methods. We conducted a cross-over diagnostic study comparing a new "MAMI" slide-chart against traditional growth charts and look-up tables. Participants were health and public health professionals working or studying in the UK. Each acted as their own control, using all three methods but in random order. Under timed conditions, they evaluated hypothetical scenarios, arranged in a random sequence. Each tool's diagnostic accuracy and response rate were compared. User preferences were also recorded. Sixty-two participants took part. Diagnostic accuracy was highest for the MAMI chart: 79%(351/445) correct assessments. Accuracy using look-up tables was 70%(308/438). Growth charts performed worst: 61%(217/353) correct (p-value<0.01). The mean number of scenarios (±SD) correctly identified by each participant in 4-minutes was 3.5(±2.19) using growth charts; 4.97(±2.50) using look-up tables; 5.66(±2.69) using MAMI charts (ANOVA, p-value<0.01). This translates to approximately 53, 75 and 85 correct assessments per participant in an hour for the respective tools. No statistically significant differences were found with participants' years of experience or profession type. Most participants, 43/62(69%), preferred the MAMI chart and reported it to be easier and faster to use than traditional tools. We conclude that weight-for-age assessment is quicker and more accurate using the newly-developed MAMI slide chart as opposed to traditional methods. It should be further field tested in other settings since the potential to improve the efficiency and effectiveness of treatment programmes is great.

Concurrent wasting and stunting among marginalised children in Sana'a city, Yemen: a cross-sectional study

Concurrent wasting and stunting (WaSt) is a serious form of malnutrition among young children, particularly vulnerable groups affected by the conflict. Understanding the prevalence and risk factors of WaSt among vulnerable children is important to develop effective intervention measures to reduce the burden of WaSt. The present study aimed to identify the prevalence of and risk factors for WaSt among marginalised children aged 6-59 months in Sana'a city, Yemen. A community-based cross-sectional design was conducted on a total sample size of 450 marginalised children aged 6-59 months who lived at home with their mothers. Multivariable logistic regression analysis was performed and the prevalence of WaSt was found to be 10⋅7 %. Children aged 24-59 months were protected from WaSt (adjusted odds ratio (AOR) 0⋅40, 95 % confidence interval (CI) 0⋅21, 0⋅75). A higher prevalence of WaSt was associated with male sex (AOR 2⋅31, 95 % CI 1⋅13, 4⋅71), no history of being breastfed (AOR 3⋅57, 95 % CI 1⋅23, 10⋅39), acute diarrhoea (AOR 2⋅12, 95 % CI 1⋅12, 4⋅02) and family income sources of assistance from others (AOR 2⋅74, 95 % CI 1⋅08, 6⋅93) or salary work (AOR 2⋅22, 95 % CI 1⋅10, 4⋅47). Continued breast- and bottle-feeding were not associated with WaSt in children aged 6-23 months. Mothers' age, education and work status, family size and drinking water source were not associated with WaSt. Overall, we found that the prevalence of WaSt among marginalised children remained high. Interventions to improve household income, hygienic conditions and child feeding practices are necessary to promote child growth.

Altered methionine-sulfone levels are associated with impaired growth in HIV-exposed-uninfected children

OBJECTIVE

To determine immune-metabolic dysregulation in children born to women living with HIV.

METHODS

Longitudinal immune-metabolomic analyses of plasma of 32 pregnant women with HIV (WHIV) and 12 uninfected women and their children up to 1.5 years of age were performed.

RESULTS

Using liquid chromatography-mass spectrometry and a multiplex bead assay, 280 metabolites (57 amino acids, 116 positive lipids, 107 signalling lipids) and 24 immune mediators (e.g. cytokines) were quantified. combinational antiretroviral therapy (cART) exposure was categorized as cART initiation preconception (long), cART initiation postconception up to 4 weeks before birth (medium) and cART initiation within 3 weeks of birth (short). Plasma metabolite profiles differed between HIV-exposed-uninfected (HEU)-children with long cART exposure compared to HIV-unexposed-children (HUU). Specifically, higher levels of methionine-sulfone, which is associated with oxidative stress, were detected in HEU-children with long cART exposure compared to HUU-children. High infant methionine-sulfone levels were reflected by high prenatal plasma levels in the mother. Increased methionine-sulfone levels in the children were associated with decreased growth, including both weight and length.

CONCLUSION

These findings based on longitudinal data demonstrate that dysregulation of metabolite networks associated with oxidative stress in children born to WHIV is associated with restricted infant growth.

Association between maternal decision-making and mental health and the nutritional status of children under 6 years of age in sub-urban Nigeria

BACKGROUND

We assessed the association between decision-making power and mental health status of mothers and the nutritional status of their children less than 6 years old in Ile-Ife, Nigeria.

METHODS

This was a secondary data analysis of 1549 mother-child dyads collected through a household survey conducted between December 2019 and January 2020. The independent variables were maternal decision-making and mental health status (general anxiety, depressive symptoms, parental stress). The dependent variable was the child's nutritional status (thinness, stunting, underweight and overweight). Confounders were maternal income, age, and education status, and the child's age and sex. The associations between the dependent and independent variables were determined using multivariable binary logistic regression analysis after adjusting for confounders. The adjusted odds ratios (AORs) were determined.

RESULTS

Children of mothers with mild general anxiety had lower odds of stunting than children of mothers with normal anxiety (AOR: 0.72; p = 0.034). Mothers who did not make decisions on children's access to health care (AOR: 0.65; p < 0.001) had children with lower odds of being thin than those whose mothers made decisions on their access to health care. Children of mothers with clinically significant parenting stress levels (AOR: 0.75; p = 0.033), severe depressive symptoms (AOR: 0.70; p = 0.041) and who were not decision makers on the access of their children to health care (AOR: 0.79; p = 0.035) had lower odds of underweight.

CONCLUSIONS

Maternal decision-making status and mental health status were associated with the nutritional status of children less than 6 years in a sub-urban community in Nigeria. Further studies are needed to understand how maternal mental health is associated with the nutritional status of Nigerian preschool children.

Post-Recovery Relapse of Children Treated with a Simplified, Combined Nutrition Treatment Protocol in Mali: A Prospective Cohort Study

The present study aimed to determine the 6-month incidence of relapse and associated factors among children who recovered from acute malnutrition (AM) following mid-upper arm circumference (MUAC)-based simplified combined treatment using the ComPAS protocol. A prospective cohort of 420 children who had reached a MUAC ≥ 125 mm for two consecutive measures was monitored between December 2020 and October 2021. Children were seen at home fortnightly for 6 months. The overall 6-month cumulative incidence of relapse [95%CI] into MUAC < 125 mm and/or edema was 26.1% [21.7; 30.8] and 1.7% [0.6; 3.6] to MUAC < 115 mm and/or edema. Relapse was similar among children initially admitted to treatment with a MUAC < 115 mm and/or oedema and among those with a MUAC ≥ 115 mm but <125 mm. Relapse was predicted by lower anthropometry both at admission to and discharge from treatment, and a higher number of illness episodes per month of follow-up. Having a vaccination card, using an improved water source, having agriculture as the main source of income, and increases in caregiver workload during follow-up all protected from relapse. Children discharged as recovered from AM remain at risk of relapsing into AM. To achieve reduction in relapse, recovery criteria may need to be revised and post-discharge strategies tested.

Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children

OBJECTIVE

To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children.

DESIGN

Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations.

SETTING

Community-based, prospective studies from twelve countries in Africa and Asia.

PARTICIPANTS

Children aged 6-59 months living in the study areas.

RESULTS

For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone.

CONCLUSIONS

Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.

A hybrid ensemble approach to accelerate the classification accuracy for predicting malnutrition among under-five children in sub-Saharan African countries

BACKGROUND

The proper intake of nutrients is essential to the growth and maturation of youngsters. In sub-Saharan Africa, 1 in 7 children dies before age 5 y, and more than a third of these deaths are attributed to malnutrition. The main purpose of this study was to develop a majority voting-based hybrid ensemble (MVBHE) learning model to accelerate the prediction accuracy of malnutrition data of under-five children in sub-Saharan Africa.

METHODS

This study used available under-five nutritional secondary data from the Demographic and Health Surveys performed in sub-Saharan African countries. The research used bagging, boosting, and voting algorithms, such as random forest, decision tree, eXtreme Gradient Boosting, and k-nearest neighbors machine learning methods, to generate the MVBHE model.

RESULTS

We evaluated the model performances in contrast to each other using different measures, including accuracy, precision, recall, and the F1 score. The results of the experiment showed that the MVBHE model (96%) was better at predicting malnutrition than the random forest (81%), decision tree (60%), eXtreme Gradient Boosting (79%), and k-nearest neighbors (74%).

CONCLUSIONS

The random forest algorithm demonstrated the highest prediction accuracy (81%) compared with the decision tree, eXtreme Gradient Boosting, and k-nearest neighbors algorithms. The accuracy was then enhanced to 96% using the MVBHE model. The MVBHE model is recommended by the present study as the best way to predict malnutrition in under-five children.

Concurrent wasting and stunting among under-five children in the context of Ethiopia: A generalised mixed-effects modelling

Concurrent wasting and stunting (WaSt) is a condition where both wasting and stunting exist in a child at the same time. This study aimed to assess the prevalence of WaSt and to identify potential associated factors in Ethiopia.  A total of 33,650 children aged between 0 and 59 months were included in the analysis from the four waves of the Ethiopian Demographic and Health Survey. A mixed-effects logistic regression model was used to identify the determinants of WaSt. The prevalence of WaSt was found to be 4.7% (95% confidence interval [CI]: (4.5-4.9)), with respectively 2.5% (95% CI: 2.1-3.1) and 4.9% (95% CI: 4.7-5.2) among children in urban and rural settings. Children: (i) in the age group 12-23 months (adjusted odds ratio [AOR]: 4.16, 95% CI: (3.20-5.42)) and 24-59 months (AOR: 3.08, 95% CI: (2.28-4.17)); (ii) who were perceived by their mothers to be smaller than normal at birth (AOR: 1.98, 95% CI: (1.57-2.50)); (iii) had diarrhoea (AOR: 1.38, 95% CI: (1.11-1.71)); and (iv) fever in the past 2 weeks (AOR: 1.38, 95% CI: (1.10-1.71)) reported higher odds of WaSt. Being a female child (AOR: 0.57, 95% CI: (0.48-0.69)), having received measles vaccination (AOR: 0.71, 95% CI: (0.55-0.89)), having a mother with a normal body mass index (18.5-24.9 kg/m² ) (AOR: 0.57, 95% CI: (0.48-0.68)), having a wealthier household (AOR: 0.67, 95% CI: (0.50-0.90)), and living in rural setting (AOR: 0.49, 95% CI: (0.32-0.74)) were associated with reduced odds of WaSt. The prevalence of WaSt was high, with approximately 1 in 20 Ethiopian children suffering from the condition and needing a prompt response to minimize the poor health and developmental outcomes. Children perceived by their mother to be smaller than normal at birth, older children, and babies with diarrhoea and fever had higher odds of WaSt.

Anthropometric criteria for best-identifying children at high risk of mortality: a pooled analysis of twelve cohorts

OBJECTIVE

To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme implications.

DESIGN

A multiple cohort individual data meta-analysis of mortality risk (within 6 months of measurement) by anthropometric case definitions. Sensitivity, specificity, informedness and inclusivity in predicting mortality, face validity and compatibility with current standards and practice were assessed and operational consequences were modelled.

SETTING

Community-based cohort studies in twelve low-income countries between 1977 and 2013 in settings where treatment of wasting was not widespread.

PARTICIPANTS

Children aged 6 to 59 months.

RESULTS

Of the twelve anthropometric case definitions examined, four (weight-for-age Z-score (WAZ) <-2), (mid-upper arm circumference (MUAC) <125 mm), (MUAC < 115 mm or WAZ < -3) and (WAZ < -3) had the highest informedness in predicting mortality. A combined case definition (MUAC < 115 mm or WAZ < -3) was better at predicting deaths associated with weight-for-height Z-score <-3 and concurrent wasting and stunting (WaSt) than the single WAZ < -3 case definition. After the assessment of all criteria, the combined case definition performed best. The simulated workload for programmes admitting based on MUAC < 115 mm or WAZ < -3, when adjusted with a proxy for required intensity and/or duration of treatment, was 1·87 times larger than programmes admitting on MUAC < 115 mm alone.

CONCLUSIONS

A combined case definition detects nearly all deaths associated with severe anthropometric deficits suggesting that therapeutic feeding programmes may achieve higher impact (prevent mortality and improve coverage) by using it. There remain operational questions to examine further before wide-scale adoption can be recommended.

Nutritional status and eating behavior of children with autism spectrum disorders in Vietnam: A case-control study

Background: Atypical eating behaviors and feeding issues are common in children with autism spectrum disorder (ASD). Aim: This study aims to evaluate the nutritional status and eating behavior of the ASD and typically developing groups. Methods: A case-control study was conducted from January to April 2019 in Nghe An, Vietnam. A total of 93 children in each group participated in the study with their main caregivers. We applied the Children's Eating Behavior Inventory (CEBI) to evaluate the eating behaviors of children. Results: Overweight and obesity in ASD children accounted for 41.9%. The CEBI score and %CEBI of the ASD group was higher than that of the control group (104.0 ± 14.2 and 91.3 ± 8.3; 24.1 ± 21.4 and 5.0 ± 11.8, respectively). Most of the adverse mealtime behaviors of ASD children focused on excessive duration (52.7%), distraction (40.9%), and food refusal (39.8%). In total 88.2% of caregivers had to comfort their ASD children at every meal, followed by threatening, scolding, or punishing children if they refused to eat (57.0%). Conclusion: Being overweight/obese and having eating behavior difficulties were prevalent among ASD children in Vietnam. Safer alternatives, such as lifestyle measures and seeking help from a nutritional therapist, can help ASD children reduce weight and modify their erroneous feeding habits.

How Can Nutrition Research Better Reflect the Relationship Between Wasting and Stunting in Children? Learnings from the Wasting and Stunting Project

Childhood wasting and stunting affect large numbers of children globally. Both are important risk factors for illness and death yet, despite the fact that these conditions can share common risk factors and are often seen in the same child, they are commonly portrayed as relatively distinct manifestations of undernutrition. In 2014, the Wasting and Stunting project was launched by the Emergency Nutrition Network. Its aim was to better understand the complex relationship and associations between wasting and stunting and examine whether current separations that were apparent in approaches to policy, financing, and programs were justified or useful. Based on the project's work, this article aims to bring a wasting and stunting lens to how research is designed and financed in order for the nutrition community to better understand, prevent, and treat child undernutrition. Discussion of lessons learnt focuses on the synergy and temporal relationships between children's weight loss and linear growth faltering, the proximal and distal factors that drive diverse forms of undernutrition, and identifying and targeting people most at risk. Supporting progress in all these areas requires research collaborations across interest groups that highlight the value of research that moves beyond a focus on single forms of undernutrition, and ensures that there is equal attention given to wasting as to other forms of malnutrition, wherever it is present.

How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies

Children with weight-for-age z-score (WAZ) <-3 have a high risk of death, yet this indicator is not widely used in nutrition treatment programming. This pooled secondary data analysis of children aged 6-59 months aimed to examine the prevalence, treatment outcomes, and growth trajectories of children with WAZ <-3 versus children with WAZ ≥-3 receiving outpatient treatment for wasting and/or nutritional oedema, to inform future protocols. Binary treatment outcomes between WAZ <-3 and WAZ ≥-3 admissions were compared using logistic regression. Recovery was defined as attaining mid-upper-arm circumference ≥12.5 cm and weight-for-height z-score ≥-2, without oedema, within a period of 17 weeks of admission. Data from 24,829 children from 9 countries drawn from 13 datasets were included. 55% of wasted children had WAZ <-3. Children admitted with WAZ <-3 compared to those with WAZ ≥-3 had lower recovery rates (28.3% vs. 48.7%), higher risk of death (1.8% vs. 0.7%), and higher risk of transfer to inpatient care (6.2% vs. 3.8%). Growth trajectories showed that children with WAZ <-3 had markedly lower anthropometry at the start and end of care, however, their patterns of anthropometric gains were very similar to those with WAZ ≥-3. If moderately wasted children with WAZ <-3 were treated in therapeutic programmes alongside severely wasted children, we estimate caseloads would increase by 32%. Our findings suggest that wasted children with WAZ <-3 are an especially vulnerable group and those with moderate wasting and WAZ <-3 likely require a higher intensity of nutritional support than is currently recommended. Longer or improved treatment may be necessary, and the timeline and definition of recovery likely need review.

Anthropometric deficits and the associated risk of death by age and sex in children aged 6-59 months: A meta-analysis

Risk of death from undernutrition is thought to be higher in younger than in older children, but evidence is mixed. Research also demonstrates sex differences whereby boys have a higher prevalence of undernutrition than girls. This analysis described mortality risk associated with anthropometric deficits (wasting, underweight and stunting) in children 6-59 months by age and sex. We categorised children into younger (6-23 months) and older (24-59 months) age groups. Age and sex variations in near-term (within 6 months) mortality risk, associated with individual anthropometric deficits were assessed in a secondary analysis of multi-country cohort data. A random effects meta-analysis was performed. Data from seven low-or-middle-income-countries collected between 1977 and 2013 were analysed. One thousand twenty deaths were recorded for children with anthropometric deficits. Pooled meta-analysis estimates showed no differences by age in absolute mortality risk for wasting (RR 1.08, p = 0.826 for MUAC < 125 mm; RR 1.35, p = 0.272 for WHZ < -2). For underweight and stunting, absolute risk of death was higher in younger (RR 2.57, p < 0.001) compared with older children (RR 2.83, p < 0.001). For all deficits, there were no differences in mortality risk for girls compared with boys. There were no differences in the risk of mortality between younger and older wasted children, supporting continued inclusion of all children under-five in wasting treatment programmes. The risk of mortality associated with underweight and stunting was higher among younger children, suggesting that prevention programmes might be justified in focusing on younger children where resources are limited. There were no sex differences by age in mortality risk for all deficits.

Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe

Introduction

Stunting or linear growth faltering, measured by length-for-age Z-score (LAZ), remains a significant public health challenge, particularly in rural low-income and middle-income countries. It is a marker of inadequate environments in which infants are born and raised. However, the contributions of household resource insecurities, such as food and water, to growth and growth trajectory are understudied.

Methods

We used the cluster-randomised Sanitation Hygiene and Infant Nutrition Efficacy trial to determine the association of household-level food insecurity (FI) and water insecurity (WI) on LAZ and LAZ trajectory among infants during early life. Dimensions of FI (poor access, household shocks, low availability and quality) and WI (poor access, poor quality, low reliability) were assessed with the multidimensional household food insecurity and the multidimensional household water insecurity measures. Infant length was converted to LAZ based on the 2006 WHO Child Growth Standards. We report the FI and WI fixed effects from multivariable growth curve models with repeated measures of LAZ at 1, 3, 6, 12 and 18 months (M1-M18).

Results

A total of 714 and 710 infants were included in our analyses of LAZ from M1 to M18 and M6 to M18, respectively. Mean LAZ values at each time indicated worsening linear growth. From M1 to M18, low food availability and quality was associated with lower LAZ (β=-0.09; 95% -0.19 to -0.13). From M6 to M18, poor food access was associated with lower LAZ (β=-0.11; 95% -0.20 to -0.03). None of the WI dimensions were associated with LAZ, nor with LAZ trajectory over time.

Conclusion

FI, but not WI, was associated with poor linear growth among rural Zimbabwean infants. Specifically, low food availability and quality and poor food access was associated with lower LAZ. There is no evidence of an effect of FI or WI on LAZ trajectory.

Effectiveness of Acute Malnutrition Treatment at Health Center and Community Levels with a Simplified, Combined Protocol in Mali: An Observational Cohort Study

A simplified, combined protocol was created that admits children with a mid-upper-arm circumference (MUAC) of <125 mm or edema to malnutrition treatment with ready-to-use therapeutic food (RUTF) that involves prescribing two daily RUTF sachets to children with MUAC < 115 mm or edema and one daily sachet to those with 115 mm ≤ MUAC < 125 mm. This treatment was previously shown to result in non-inferior programmatic outcomes compared with standard treatment. We aimed at observing its effectiveness in a routine setting at scale, including via delivery by community health workers (CHWs). A total of 27,800 children were admitted to the simplified, combined treatment. Treatment resulted in a 92% overall recovery, with a mean length of stay of 40 days and a mean RUTF consumption of 62 sachets per child treated. Among children admitted with MUAC < 115 mm or edema, 87% recovered with a mean length of stay of 55 days and consuming an average of 96 RUTF sachets. The recovery in all sub-groups studied exceeded 85%. Treatment by CHWs resulted in a similar (94%) recovery to treatment by formal healthcare workers (92%). The simplified, combined protocol resulted in high recovery and low RUTF consumption per child treated and can safely be adopted by CHWs to provide treatment at the community level.

Neurodevelopment and Recovery From Wasting

BACKGROUND AND OBJECTIVES

Acute illness with malnutrition is a common indication for hospitalization among children in low- and middle-income countries. We investigated the association between wasting recovery trajectories and neurodevelopmental outcomes in young children 6 months after hospitalization for an acute illness.

METHODS

Children aged 2 to 23 months were enrolled in a prospective observational cohort of the Childhood Acute Illness &amp; Nutrition Network, in Uganda, Malawi, and Pakistan between January 2017 and January 2019. We grouped children on the basis of their wasting recovery trajectories using change in mid-upper arm circumference for age z-score. Neurodevelopment was assessed with the Malawi Developmental Assessment Tool (MDAT development-for-age z-score [DAZ]) at hospital discharge and after 6 months.

RESULTS

We included 645 children at hospital discharge (mean age 12.3 months ± 5.5; 55% male); 262 (41%) with severe wasting, 134 (21%) with moderate wasting, and 249 (39%) without wasting. Four recovery trajectories were identified: high-stable, n = 112; wasted-improved, n = 404; severely wasted-greatly improved, n = 48; and severely wasted-not improved, n = 28. The children in the severely wasted-greatly improved group demonstrated a steep positive MDAT-DAZ recovery slope. This effect was most evident in children with both wasting and stunting (interaction wasted-improved × time × stunting: P &lt; .001). After 6 months, the MDAT DAZ in children with wasting recovery did not differ from community children. In children who never recovered from wasting, there remained a significant delay in MDAT DAZ scores.

CONCLUSIONS

Neurodevelopment recovery occurred in parallel with wasting recovery in children convalescing from acute illness and was influenced by stunting.

Pooled prevalence of stunting and associated factors among children aged 6-59 months in Sub-Saharan Africa countries: A Bayesian multilevel approach

Background

Over 155 million children under five suffer from stunting, and it is responsible for over one million deaths and 54.9 million Disability Adjusted Life Years (DALYS) of under-five children worldwide. These predominantly occurred in low-and middle-income countries like sub-Saharan Africa. Stunted children begin their lives at a marked disadvantage. Some of these are; poor cognition and educational performance, low adult wages, lost productivity and, when accompanied by excessive weight gain later in childhood, an increased risk of nutrition-related chronic diseases in adult life and the devastating effects of stunting can last a lifetime and even affect the next generation. Despite this, its magnitude rises in the past 25 years in sub-Saharan Africa. Studies that capture the pooled prevalence and associated factors of stunting among children aged 6–59 months in sub-Saharan Africa are limited. Therefore, this study was carried out on the basis of the Bayesian approach to determine the pooled prevalence and predictors of stunting among children aged 6–59 months in Sub-Saharan Africa.

Objective

To assess the pooled prevalence of stunting and associated factors among children aged 6–59 months in Sub-Saharan Africa

Methods

For this study a total of 173,483 weighted samples from the demography and health survey data set of 35 sub-Saharan African countries from 2008 to 2020 were used. After checking Variation between cluster by computing Intraclass Correlation Coefficient, binary logistic regression model was conducted based on hierarchical Bayesian statistical approach to account the hierarchical nature of demography and health survey data and to get reliable estimates by using additional information from the prior distribution. Adjusted odds ratio with 95% credible interval of the best fitted model was used to ascertain the predictors.

Results

The pooled prevalence of stunting in Sub-Saharan Africa was about 35% (95%CI: 34.87, 35.31). Of the sub-regions, the highest prevalence of stunting was in East Africa, 37% (95%, CI: 36.96, 37.63) followed by Central Africa, 35% (95%CI: (34.93, 35.94). Being male (AOR = 1.27, 95% CrI 1.25, 1.30), small birth size (AOR = 1.29, CrI 1.25, 1.32), home delivery (AOR = 1.17, CrI 1.14, 1.20), and no education of mothers (AOR = 3.07, CrI 2.79, 3.39) were some of the significant predictors of stunting of children.

Conclusion and recommendation

The prevalence of stunting of children in sub-Saharan Africa is among the highest in the world. Predictors such as being male, being small at birth, a child delivered at home, and, low level of maternal education were some of the predictors of childhood stunting. Stakeholders and non-governmental organizations should consider those contributing factors of stunting when they plan and design nutritional improvement programs.

Clinical practice guidelines for the prevention of childhood obesity: A systematic review of quality and content

Obesity in childhood is a significant global issue, and prevention is key to reducing prevalence. Healthcare providers can play an important role in the prevention of obesity. The aim of this systematic review was to identify and evaluate clinical practice guidelines (CPGs) for preventing childhood obesity with a focus on the role of medical doctors. Peer-reviewed literature and gray literature sources were searched for CPGs published from 2010 to 2021. Eleven CPGs were identified. Quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Collaboration (AGREE II) instrument; seven CPGs were higher quality and four lower quality. Recommendations within the CPGs covered three main areas: growth monitoring, maintaining a healthy weight, and managing overweight. The importance of involving the whole family and healthy lifestyle behaviors was emphasized. The majority of the CPGs rated poorly in guideline applicability highlighting the need for practical implementation tools. Although our review identified a number of CPGs relevant to the prevention of obesity for doctors working with children and their families, more research is needed to produce high-quality meaningful and applicable CPGs to maximize uptake, implementation, and ultimately, benefit to children and their families.

Towards standardised and valid anthropometric indicators of nutritional status in middle childhood and adolescence

Recognition of the importance of nutrition during middle childhood (age 5-9 years) and adolescence (age 10-19 years) is increasing, particularly in the context of global food insecurity and rising overweight and obesity rates. Until now, policy makers have been slow to respond to rapidly changing patterns of malnutrition across these age groups. One barrier has been a scarcity of consistent and regular nutrition surveillance systems for these age groups. What should be measured, and how best to operationalise anthropometric indicators that have been the cornerstone of nutrition surveillance in younger children and in adults, has been the topic of ongoing debate. Even with consensus on the importance of a given anthropometric indicator, difficulties arise in interpreting trends over time and between countries owing to the use of different terminologies, reference data, and cutoff points. In this Viewpoint we highlight the need to revisit anthropometric indicators across middle childhood and adolescence, a process that will require WHO and UNICEF coordination, the engagement of national implementors and policy makers, and partnership with research communities and donors.

Public Health Implications of Wasting and Stunting Relationship in Children under Five Years Highly Vulnerable to Undernutrition in Guatemala: The REDAC Study

(1) Background: Guatemala is the Latin American country with the highest prevalence of childhood stunting. Short height can bias the diagnosis of wasting when using the weight-for-height indicator. The aim of this study was to evaluate the diagnostic concordance of the anthropometric indicators of wasting and the relationship between wasting and stunting in children from highly vulnerable communities in Guatemala. (2) Methods: The sample consisted of 13,031 anthropometric records of children under five years of age (49.5% girls, average age of 27.9 months), including weight, height, and mid-upper arm circumference (MUAC), collected in March–August 2019. The proportions of stunting, underweight, and wasting, assessed by three different indicators, as well as their concurrence through the Composite Index of Anthropometric Failure were calculated. (3) Results: Stunting affected 73% of the sample, and 74.2% showed anthropometric failure. Wasting varied by indicator (weight-for-height: 2.8%; MUAC: 4.4%; MUAC-for-age: 10.6%). Concordance between MUAC and weight-for-height was very low (Kappa: 0.310; sensitivity: 40.9%). MUAC identified more wasted children in the stunted group (53.6% vs. 26.5%), while the opposite occurred in the non-stunted group (34.8% vs. 46.7%). (4) Conclusion: The presence of stunting affected the diagnosis of wasting, and both indicators should be included as diagnostic criteria for screening campaigns and in the treatment of moderate to acute wasting in vulnerable populations affected by multiple forms of undernutrition.

Lack of Associations between Environmental Exposures and Environmental Enteric Dysfunction among 18-Month-Old Children in Rural Malawi

Environmental enteric dysfunction (EED) is common and contributes to linear growth faltering (stunting) and mortality among children in low-resource settings. A few studies on the environmental causes of EED have been conducted but the exact exposures that cause or predispose children to EED are context-specific and not clear. This study aimed to assess associations between selected environmental exposures and EED markers among 620 18-month-old children. This was a secondary analysis of data from Malawian children who participated in a randomized controlled trial (iLiNS-DYAD, registered at clinicaltrials.gov as NCT01239693) from birth to 18 months of age. Data on environmental exposures, including drinking water source, sanitation, exposure to animals, housing materials, season, residential area, and food insecurity were collected at enrolment. Biomarkers of EED included concentrations of calprotectin, regenerating 1B protein (REG1B), and alpha-1-antitrypsin from stool samples to assess intestinal inflammation, repair, and permeability, respectively. We performed bivariate and multivariable analyses to assess associations between environmental exposures and EED biomarkers. Adjusting for possible confounders, we did not find associations between the selected environmental exposures and the three biomarkers. These results do not provide support for our hypothesis that the studied adverse environmental exposures are associated with increased concentrations of children's EED markers in rural Malawi.

The prevalence and socio-demographic risk factors of coexistence of stunting, wasting, and underweight among children under five years in Bangladesh: a cross-sectional study

Background

Childhood stunting, wasting and underweight are significant public health challenges. There is a gap in knowledge of the coexistence of stunting, wasting, and underweight among children under five years (under-5) in Bangladesh. This study aims to (i) describe the prevalence of the coexistence of stunting, wasting, and underweight and ii) examine the risk factors for the coexistence of stunting, wasting, and underweight among children under-5 in Bangladesh.

Methods

This study included 6,610 and 7,357 under-5 children from Bangladesh Demographic Health Surveys (BDHS) 2014 and 2017/18, respectively. The associations between the coexistence of stunting, wasting, and underweight and independent variables were assessed using the Chi-square test of independence. The effects of associated independent variables were examined using negative binomial regression.

Results

The prevalence of coexistence of stunting, wasting, and underweight gradually declined from 5.2% in 2014 to 2.7% in 2017/18. Children born with low birth weight ((adjusted incidence rate ratios, aIRR) 2.31, 95% CI 1.64, 3.24)); children of age group 36–47 months (aIRR 2.26, 95% CI 1.67, 3.08); children from socio-economically poorest families (aIRR 2.02, 95% CI 1.36, 2.98); children of mothers with no formal education (aIRR 1.98, 95% CI 1.25, 3.15); and children of underweight mothers (aIRR 1.73, 95% CI 1.44, 2.08) were the most important risk factors. Further, lower incidence among children with the coexistence of stunting, wasting, and underweight was observed in the 2017–18 survey (aIRR 0.59, 95% CI 0.49, 0.70) compared to children in the 2014 survey.

Conclusions

One out of thirty-five under-5 children was identified to have coexistence of stunting, wasting, and underweight in Bangladesh. The burden of coexistence of stunting, wasting, and underweight was disproportionate among children born with low birth weight, socio-economically poorest, a mother with no formal education, and underweight mothers, indicating the need for individual, household, and societal-level interventions to reduce the consequences of coexistence of stunting, wasting, and underweight.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00584-x.

Linear Growth Spurts are Preceded by Higher Weight Gain Velocity and Followed by Weight Slowdowns Among Rural Children in Burkina Faso: A Longitudinal Study

BACKGROUND

The temporal relationship between length (linear) and weight (ponderal) growth in early life is important to support optimal nutrition program design. Studies based on measures of attained size have established that wasting often precedes stunting, but such studies do not capture responsiveness of growth to previous compared with current conditions. As a result, the temporality of linear and ponderal growth relationships remain unclear.

OBJECTIVES

We used growth velocity indicators to assess the temporal bidirectional relationships between linear and ponderal growth in children.

METHODS

Using monthly anthropometric measurements from 5039 Burkinabè children enrolled at 6 months of age and followed until 28 months from August 2014 to December 2016, we employed multilevel mixed-effects models to investigate concurrent and lagged associations between linear and ponderal growth velocity, controlling for time trends, seasonality, and morbidity.

RESULTS

Faster ponderal growth is associated with faster concurrent and subsequent linear growth (0.21-0.72 increase in length velocity z-score per unit increase in weight velocity z-score), while faster linear growth is associated with slower future weight gain (0.009-0.02 decrease in weight velocity z-score per unit increase in length velocity z-score), especially among children 9-14 months. Ponderal growth slows around the same time as peaks in morbidity, followed roughly a month later by slower linear growth.

CONCLUSIONS

Use of velocity measures to assess temporal dependencies between linear and ponderal growth demonstrate that the same growth-limiting conditions likely affect both length and weight velocity, that slow ponderal growth likely limits subsequent linear growth, and that linear growth spurts may not be accompanied by sufficient increases in dietary intake to avoid slowdowns in weight gain.

Performance of Machine Learning Classifiers in Classifying Stunting among Under-Five Children in Zambia

Stunting is a global public health issue. We sought to train and evaluate machine learning (ML) classification algorithms on the Zambia Demographic Health Survey (ZDHS) dataset to predict stunting among children under the age of five in Zambia. We applied Logistic regression (LR), Random Forest (RF), SV classification (SVC), XG Boost (XgB) and Naïve Bayes (NB) algorithms to predict the probability of stunting among children under five years of age, on the 2018 ZDHS dataset. We calibrated predicted probabilities and plotted the calibration curves to compare model performance. We computed accuracy, recall, precision and F1 for each machine learning algorithm. About 2327 (34.2%) children were stunted. Thirteen of fifty-eight features were selected for inclusion in the model using random forest. Calibrating the predicted probabilities improved the performance of machine learning algorithms when evaluated using calibration curves. RF was the most accurate algorithm, with an accuracy score of 79% in the testing and 61.6% in the training data while Naïve Bayesian was the worst performing algorithm for predicting stunting among children under five in Zambia using the 2018 ZDHS dataset. ML models aids quick diagnosis of stunting and the timely development of interventions aimed at preventing stunting.

Anthropometric Indicators as Predictors of Mortality in Early Life Among Low Birthweight Indian Infants

Background

Low birthweight (LBW) babies (<2.5 kg) are at higher risk of mortality and weight for height z score is currently recommended for identifying infants at risk of mortality.

Objective

To compare different anthropometric measures at 28-day of age in a cohort of LBW Indian infants for predicting mortality between 28-day and 180-day of age.

Methods

We used data from an individually randomized controlled trial of LBW infants weighing between 1,500 and 2,250 g. Sensitivity, specificity, positive, and negative likelihood ratios, positive and negative predictive values, and area under receiver operating characteristics curves (AUC) were used to estimate the discrimination of mortality risk. The Cox regression was used to estimate hazard ratios and population attributable fraction for each anthropometric indicator. These estimates were calculated for individual as well as combinations of anthropometric indicators at the cut-off of –2 and –3 SD of the WHO 2006 growth standards.

Results

Severe underweight (weight-for-age z-scores [WAZ] < –3) had a sensitivity of 75.0%, specificity of 68.0% with an AUC of 0.72. The risk of death was higher (HR 6.18; 95% CI 4.29–8.90) with a population attributable fraction of 0.63 (95% CI 0.52–0.72) for infants severely underweight at 28-day of age. Combination of different anthropometric measures did not perform better than individual measures.

Conclusion

Severe underweight (WAZ < –3) better discriminated deaths among LBW infants < 6 months of age. It can be considered for diagnosis of nutritionally at-risk infants in this age group.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT02653534].

Child stunting starts in utero: Growth trajectories and determinants in Ugandan infants

Childhood stunting remains a public health burden worldwide. Although many studies have examined early life and in-utero risk factors; most have been observational and have used analytic techniques that make inferences limited to population means, thereby obscuring important within-group variations. This study addressed that important gap. Using data from a birth cohort of Ugandan infants (n = 4528), we applied group-based trajectory modelling to assess diverse patterns of growth among children from birth to 1-year old. A multinomial regression model was conducted to understand the relationship between risk factors and observed patterns across groups. We found that the onset of stunting occurred before birth and followed four distinct growth patterns: chronically stunted (Group 1), recovery (Group 2), borderline stunted (Group 3) and normal (Group 4). The average length-for-age z-score (LAZ) at birth was -2.6, -3.9, -0.6 and 0.5 for Groups 1-4, respectively. Although both Groups 1 and 2 were stunted at birth, stunting persisted in Group 1 while children in Group 2 recovered by the fourth month. Group 3 exhibited mild stunting while Group 4 was normal. Wasting and underweight were observed in all groups, with the highest prevalence of underweight in Group 1. Wasting gradually increased among children born already stunted (Groups 1 and 2). This showed the importance of distinguishing children by their growth patterns rather than aggregating them and only comparing population averages against global growth standards. The design of nutrition interventions should consider the differential factors and potential for growth gains relative to different risks within each group.

Feeding practices of children within institution‐based care: A retrospective analysis of surveillance data

There is limited information on the feeding practices of 9.42 million children living within institution‐based care (IBC) worldwide. Poor feeding practices can predispose or exacerbate malnutrition, illness and disability. Here we describe the feeding practices of children living within IBC based on a retrospective analysis of records from 3335 children, 0–18 years old, participating in Holt International's Child Nutrition Program (CNP), from 36 sites in six countries. Data analysed included demographic information on age, sex, feeding practices, disabilities and feeding difficulties. Descriptive statistics were produced. A generalised linear model explored associations between feeding difficulties and disability and 2 × 2 tables examined feeding difficulties over time. An additional set of feeding observations with qualitative and quantitative data was analysed. At baseline, the median age of children was 16 months (0.66–68 months) with 1650/3335 (49.5%) females. There were 757/3335 (22.7%) children with disabilities; 550/984 (55.9%) were low birth weight; 311/784 (39.7%) were premature; 447/3113 (14.4%) had low body mass index and 378/3335 (11.3%) had feeding difficulties. The adjusted risk of having a feeding difficulty was 5.08 ([95% confidence interval: 2.65–9.7], p ≤ 0.001) times greater in children with disabilities than those without. Many children saw their feeding difficulties resolve after 1‐year in CNP, 54/163 (33.1%) for children with disabilities and 57/106 (53.8%) for those without disabilities. Suboptimal hygiene, dietary and feeding practices were reported. In conclusion, feeding difficulties were common in IBC, especially among children with disabilities. Supporting safe interactive mealtimes for children living within IBC should be prioritised, to ensure overall health and development.

Feeding difficulties are common among children living in institution‐based care (IBC), particularly but not exclusively among those children with disabilities.

Suboptimal feeding practices were common in IBC and encompassed inadequate hygiene, limited support for self‐feeding, reading children's feeding cues (especially around pacing and satiety), addressing feeding difficulties, such as difficulty chewing or swallowing. These should be prioritised in training and supervision for caregivers.

Addressing the needs of this vulnerable group should include support for safe feeding techniques. These should be prioritised to help ease the transition into eventual family‐based care if we are to move towards deinstitutionalizing children and strengthening families.