Mortality and recovery following moderate and severe acute malnutrition in children aged 6-18 months in rural Jharkhand and Odisha, eastern India: A cohort study

Time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda, East Hararghe Zone, Eastern Ethiopia

Background

Acute malnutrition is a major global public health problem, particularly in low-and middle-income countries. A targeted supplementary feeding program is an approach recommended to address moderate acute malnutrition in food-insecure settings. Preventing and treating moderate acute malnutrition requires identifying factors shown to affect the treatment outcome and duration of stay on treatment. This study aimed to determine the time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda East Hararghe Zone, Eastern Ethiopia, from January 1 to December 31, 2022.

Methods

A facility-based retrospective cohort study was conducted on 567 children with moderate acute malnutrition in Fedis Woreda, East Hararghe Zone, eastern Ethiopia. A multi-stage sampling technique was employed, and data was collected using a structured checklist. Data were extracted from randomly selected records after obtaining ethical clearance. Data were cleaned, coded, entered into EpiData 4.6, and analyzed using STATA/SE version 14. Descriptive statistics and analytic analysis schemes, including bivariable and multivariable Cox proportional hazards models, were conducted, and finally, statistical significance was considered at p < 0.05.

Results

The overall median time to recovery was 16 weeks. The major predicting factors for time to recovery among children aged 6-59 months were admission with a mid-upper arm circumference of 12.1-12.4 centimeters (AHR = 1.02, 95% CI: 1.01-1.19), access to transportation to facilities (AHR = 0.62, 95% CI: 0.36-0.81), children using specialized nutritious foods (RUSF; AHR = 1.96, 95% CI: 1.36-3.11), and children who had diarrhea (AHR = 0.4, 95% CI: 0.31-0.71).

Conclusion

The study found a median recovery time of 16 weeks for children with targeted supplementary feeding. Significant predictors included admission with a MUAC of 12.1-12.4 centimeters, transportation access, RUSF use, and the presence of diarrhea. These findings highlighted the importance of these factors in determining and improving recovery from moderate-acute malnutrition.

The recent WHO guideline on acute malnutrition overestimates therapeutic energy requirement

The World Health Organization has recently updated the guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. Apart from differences with regard to the nutritional framework that defines the quantity of energy required as Ready-to-Use Therapeutic Food (RUTF) for the outpatient treatment of severe wasting and/or nutritional oedema, there are also important gaps in the practical guidance. Instead of the recommended energy intake of 150-185 kcal/kg/day, our alternative calculations indicate the requirement to be only 105-120 kcal/kg/day. If true, the implementation of such caloric overfeeding can have adverse consequences. Gaps in practical guidance also need to be addressed, including the timing of transition to home-based diets, maximal duration of therapeutic feeding, especially in non-responders (∼50% in South Asia), and the role of augmented home foods as the primary therapeutic food option.

Integrated child development service (ICDS) coverage among severe acute malnourished (SAM) children in India: A multilevel analysis based on national family health survey-5

Severe acute malnutrition (SAM) can be fatal for children, and potentially limit their cognitive and physical growth. The last three National Family Health Survey (NFHS) in India shows an increase in the prevalence of SAM among under-five children. Given the specific mandates under ICDS (Integrated Child Development Service) for SAM children, it is important to validate the coverage efficiency of ICDS on SAM children. This paper examines a possible association between the coverage efficiency of ICDS on SAM children. The study further aims to identify the determinants of ICDS service utilization among SAM children. We used data from the fifth round of the National Family Health Survey. Descriptive statistics was used to estimate the SAM coverage under ICDS. Multilevel Logistic Regression was used to identify the determinants of ICDS service utilization among SAM children. The burden of SAM is higher among older children (3+ age). Coverage of ICDS was more among younger children and the poorest households in the rural areas. Results from multilevel logistic regression showed that age had a significant relationship with the outcome variable. SAM children living in the rural areas had a significantly higher odds of being covered under ICDS service (OR 1.57; CI: (1.35, 1.82)) than their urban counterparts. Pregnant and lactating mothers who received ICDS services were significant determinants of SAM coverage under ICDS. There is no evidence that ICDS is more efficient in identifying and covering SAM children than non-SAM children. Despite special provisioning in place for SAM children, coverage of different ICDS services was similar to that of non-SAM children, and were in fact lower than non-SAM children for some categories. The study suggests that improving coverage of ICDS services among pregnant and lactating mothers would increase the coverage of ICDS services among SAM children.

Risk factors for moderate acute malnutrition among children with acute diarrhoea in India and Tanzania: a secondary analysis of data from a randomized trial

BACKGROUND

Moderate acute malnutrition (MAM) affects over 30 million children aged < 5 years worldwide. MAM may confer a greater risk of developing severe malnutrition and even mortality in children. Assessing risk factors for MAM may allow for earlier recognition of children at risk of deleterious health outcomes.

OBJECTIVE

To determine risk factors associated with the prevalence and development of MAM among children aged 6 to 59 months with acute diarrhoea who received treatment with oral rehydration solution and zinc supplementation.

METHODS

We conducted a secondary analysis of data from a randomized, dose-finding trial of zinc among children with acute diarrhoea in India and Tanzania. We used regression models to assess risk factors for prevalent MAM at the start of diarrhoea treatment and to identify risk factors associated with the development of MAM at 60 days. MAM was defined as weight for length (or height) Z score ≤-2 and > -3 or mid-upper arm circumference < 12.5 and ≥ 11.5 cm.

RESULTS

A total of 4,500 children were enrolled; 593 (13.2%) had MAM at the baseline. MAM at baseline was significantly less common among children in Tanzania than in India (adjusted risk ratio [aRR] 0.37, 95% confidence interval [CI]: 0.30, 0.44, P < 0.001), in children aged 24- < 60 months versus 6- < 12 months (aRR 0.46, 95% CI: 0.38, 0.56, P < 0.001), and in families with household wealth index higher than the median (aRR 0.79, 95% CI: 0.68, 0.92, P = 0.002). Sixty days after outpatient treatment and follow-up, 87 (2.5%) children developed MAM. When compared to children aged 6- < 12 months, children aged 24- < 60 months had a 52% lower risk of developing MAM. Every one unit increase in weight for length (or height) Z score at enrolment was associated with a 93% lower risk of developing MAM during follow-up.

CONCLUSIONS

Among children with diarrhoea, younger children and those from households with lower wealth were at greater risk of MAM. These children may benefit from targeted interventions focusing on feeding (targeted nutrition support for at-risk households) and follow up in order to reduce the occurrence of MAM and its consequences.

Evaluation of the Health and Nutritional Status of Discharged Children From Malnutrition Treatment Centres Using Mobile Phone Calls During the COVID-19 Lockdown in Jharkhand, India

Background The Indian state of Jharkhand has the highest rate of wasting (29%) among young children. Mobile audio call follow-up can be used to assess such children with severe acute malnutrition (SAM). Aim This study evaluated SAM children during the COVID-19 outbreak and learn more about the status of their home/community care, and caregivers' awareness of integrated child development services (ICDS) and COVID-19 prevention. Methods Contact numbers of caregivers for discharged children were obtained from 54 malnutrition treatment centers (MTCs). In April and June 2020, mentors conducted follow-up interviews using mobile phone calls. Results Seven children (1.72%) were reported dead and 400 were alive, mostly girls (59.5%). Only a few caregivers observed post-discharge ailments (15.4%) and weight loss (7.7%) in their children. Children aged six to 24 months were characterized by continued breastfeeding (88.0%) at most five to six times a day (45.8%). Most of the children were not fed as per maternal infant and young child feeding protocols. Age in months with an adjusted odds ratio (OR) of 0.55 (1.00-1.11) as a 95% confidence interval (CI), age category, with an adjusted OR of 4.32 (1.71- 10.94) as 95% CI, and breastfeeding with adjusted OR 1.85 (1.07- 3.21) as 95% CI were three major predictors for a well-fed child. Conclusion Community involvement is crucial in the follow-up of children with SAM for effective rehabilitation. Mobile phone audio call follow-up is a relatively cost-effective approach to tackle geographic barriers and COVID-19 lockdown-induced situations. There are major gaps mainly in informing caregivers on how to manage COVID-19 with breastfeeding.

Relapse of acute malnutrition and associated factors after discharge from nutrition stabilization centers among children in Eastern Ethiopia

Background

Acute malnutrition is a major global health problem primarily affecting under-five children. In sub-Saharan Africa, children treated for severe acute malnutrition (SAM) at an inpatient have high case fatality rate and is associated with relapse of acute malnutrition after discharge from inpatient treatment programs. However, there is limited data on the rate of relapse of acute malnutrition in children after discharge from stabilization centers in Ethiopia. Hence, this study aimed to assess the magnitude and predictors of relapse of acute malnutrition among children aged 6-59 months discharged from stabilization centers in Habro Woreda, Eastern Ethiopia.

Methods

A cross-sectional study was conducted among under-five children to determine the rate and predictors of relapse of acute malnutrition. A simple random sampling method was used to select participants. All randomly selected children aged 6-59 months discharged from stabilization centers between June 2019 and May 2020 were included. Data were collected using pretested semi-structured questionnaires and standard anthropometric measurements. The anthropometric measurements were used to determine relapse of acute malnutrition. Binary logistic regression analysis was used to identify factors associated with relapse of acute malnutrition. An odds ratio with 95% CI was used to estimate the strength of the association and a p-value less than 0.05 was considered statistically significant.

Results

A total of 213 children with mothers/caregivers were included in the study. The mean age in months of children was 33.9 ± 11.4. More than half (50.7%) of the children were male. The mean duration of children after discharge was 10.9 (± 3.0 SD) months. The magnitude of relapse of acute malnutrition after discharge from stabilization centers was 36.2% (95% CI: 29.6,42.6). Several determinant factors were identified for relapse of acute malnutrition. Mid-upper arm circumference less than 110 mm at admission (AOR = 2.80; 95% CI: 1.05,7.92), absence of latrine (AOR = 2.50, 95% CI: 1.09,5.65), absence of follow-up visits after discharge (AOR = 2.81, 95% CI: 1.15,7.22), not received vitamin A supplementation in the past 6 months (AOR = 3.40, 95% CI: 1.40,8.09), household food insecurity (AOR = 4.51, 95% CI: 1.40,15.06), poor dietary diversity (AOR = 3.10, 95% CI: 1.31,7.33), and poor wealth index (AOR = 3.90, 95% CI: 1.23,12.43) were significant predictors of relapse of acute malnutrition.

Conclusion

The study revealed very high magnitude of relapse of acute malnutrition after discharge from nutrition stabilization centers. One in three children developed relapse after discharge in Habro Woreda. Programmers working on nutrition should design interventions that focus on improving household food insecurity through strengthened public Safety Net programs and emphasis should be given to nutrition counseling and education, as well as to continuous follow-up and periodic monitoring, especially during the first 6 months of discharge, to reduce relapse of acute malnutrition.

Rate, risk factors and estimated time to develop attrition after under-five children started moderate acute malnutrition treatment in Gubalafto, North East Ethiopia

Lost from follow-up, after starting moderate acute malnutrition (MAM) is an ongoing challenge of public health until the admitted children reached the standard weight of a reference child. Thus, the present study aimed to assess the rate and estimated time to attrition after under-five children started treatment for MAM in the Gubalafto district. A facility-based retrospective cohort study was employed among 487 participant children who had been managed targeted therapeutic feeding from 1 June 2018 to 1 May 2021. The overall mean (±sd) age of the participants' children was 22⋅1 (±12⋅6) months. At the end of the study period, 55 (11⋅46 %) under-five children developed attrition from the treatment after starting ready use of therapeutic feeding. After checking all assumptions, a multivariable Cox regression model was used to claim independent predictors for time to attritions. The median time of attrition after starting treatment of MAM was 13 (IQR ±9) weeks, with the overall incidence of attrition rate reported at 6⋅75 children Per Week (95 % CI 5⋅56, 9⋅6). In the final model of multivariable Cox regression, the hazard of attrition was significantly higher for children from rural residence (AHR 1⋅61; 95 % CI 1⋅18, 2⋅18; P = 0⋅001), and caregivers with their dyads did not get nutritional counselling at baseline (AHR 2⋅78; 95 % CI 1⋅34, 5⋅78; P = 0⋅001). The findings of the present study showed that nearly one in every eleven under-five children was attrition (lost to follow-up) in a median time of 13 (IQR ±9) weeks. We strongly recommended for caregivers provisions of diversification of daily nutrition supplementation of their dyads.

Inflammatory stimuli alter bone marrow composition and compromise bone health in the malnourished host

Inflammation has a role in the pathogenesis of childhood malnutrition. We investigated the effect of malnutrition and inflammatory challenge on bone marrow composition and bone health. We studied an established murine model of moderate acute malnutrition at baseline and after acute inflammatory challenge with bacterial lipopolysaccharide (LPS), a surrogate of Gram-negative bacterial sepsis, or Leishmania donovani, the cause of visceral leishmaniasis. Both of these infections cause significant morbidity and mortality in malnourished children. Of the 2 stimuli, LPS caused more pronounced bone marrow changes that were amplified in malnourished mice. LPS challenge led to increased inflammatory cytokine expression (Il1b, Il6, and Tnf), inflammasome activation, and inflammatory monocyte accumulation in the bone marrow of malnourished mice. Depletion of inflammatory monocytes in Csfr1-LysMcre-DT malnourished mice significantly reduced the inflammasome activation and IL1-ß production after LPS challenge. The inflammatory challenge also led to increased expansion of mesenchymal stem cells (MSCs), bone marrow adiposity, and expression of genes (Pparg, Adipoq, and Srbp1) associated with adipogenesis in malnourished mice. This suggests that inflammatory challenge promotes differentiation of BM MSCs toward the adipocyte lineage rather than toward bone-forming osteoblasts in the malnourished host. Concurrent with this reduced osteoblastic potential there was an increase in bone-resorbing osteoclasts, enhanced osteoclast activity, upregulation of inflammatory genes, and IL-1B involved in osteoclast differentiation and activation. The resulting weakened bone formation and increased bone resorption would contribute to the bone fragility associated with malnutrition. Lastly, we evaluated the effect of replacing lipid rich in omega-6 fatty acids (corn oil) with lipid-rich in omega-3 fatty acids (fish oil) in the nutrient-deficient diet. LPS-challenged malnourished mice that received dietary fish oil showed decreased expression of inflammatory cytokines and Rankl and reduced osteoclast differentiation and activation in the bone marrow. This work demonstrates that the negative effect of inflammatory challenge on bone marrow is amplified in the malnourished host. Increasing dietary intake of omega-3 fatty acids may be a means to reduce inflammation and improve bone health in malnourished children.

Time to Recovery From Moderate Acute Malnutrition and Its Predictors Among Children 6–59 Months of Age Enrolled in Targeted Supplementary Feeding Program in Darolebu District, Eastern Ethiopia: A Retrospective Cohort Study

Background

Acute malnutrition is a major global public health problem, particularly in low and middle-income countries. A targeted supplementary feeding program is an approach recommended to address moderate acute malnutrition in food insecure settings. Preventing and treating moderate acute malnutrition requires identifying factors shown to affect the treatment outcome and duration of stay on treatment. This study aimed to determine the treatment outcome and predictors of recovery time from moderate acute malnutrition among children 6–59 months of age in Darolebu district, Eastern Ethiopia.

Methods

A retrospective cohort study design was conducted on 540 children with moderate acute malnutrition. A Kaplan–Meier survival analysis was used to estimate the recovery time. Cox proportional hazard regression model was used to determine the association between the independent and the outcome variables. The proportional hazard assumption of the model was checked graphically and statistically. Any violation of the proportional hazard assumption of the model was also considered and adjusted in the analysis. Finally, a variable with a P-value <0.05 in the multivariate cox regression model was considered statistically significant.

Results

The overall recovery rate was 73% (95% CI 69.4–76.4%) with the median time to recovery of 16 weeks. Being between the ages of 24 and 59 months (AHR = 1.24, 95% CI: 1.01–1.54), having a mid-upper arm circumference (MUAC) at admission between 11.5 and 11.9 cm (AHR = 1.27, 95% CI: 1.34–2.61), walking for an hour or less to receive services (AHR = 1.2, 95% CI: 1.02–1.89), using ready-to-use supplementary food (AHR= 1.8, 95%CI: 1.38–2.39) were significant predictors of recovery time.

Conclusion

The recovery rate was slightly below the accepted minimum international standard, suggesting that further work is needed to improve the treatment outcomes and mortality and morbidity associated with moderate acute malnutrition.

Effectiveness of a monthly schedule of follow-up for the treatment of uncomplicated severe acute malnutrition in Sokoto, Nigeria: A cluster randomized crossover trial

BACKGROUND

Community-based management of severe acute malnutrition (SAM) involves weekly or biweekly outpatient clinic visits for clinical surveillance and distribution of therapeutic foods. Distance to outpatient clinics and high opportunity costs for caregivers can represent major barriers to access. Reducing the frequency of outpatient visits while providing training to caregivers to recognize clinical danger signs at home between outpatient visits may increase acceptability, coverage, and public health impact of SAM treatment. We investigated the effectiveness of monthly clinic visits compared to the standard weekly follow-up in the outpatient treatment of uncomplicated SAM in northwestern Nigeria.

METHODS AND FINDINGS

We conducted a cluster randomized crossover trial to test the noninferiority of nutritional recovery in children with uncomplicated SAM receiving monthly follow-up compared to the standard weekly schedule. From January 2018 to November 2019, 3,945 children aged 6 to 59 months were enrolled at 10 health centers (5 assigned to monthly follow-up and 5 assigned to weekly follow-up) in Sokoto, Nigeria. In total, 96% of children (n = 1,976 in the monthly follow-up group and 1,802 in the weekly follow-up group) were followed until program discharge, and 91% (n = 1,873 in the monthly follow-up group and 1,721 in the weekly follow-up group) were followed to 3 months postdischarge. The mean age at admission was 15.8 months (standard deviation [SD] 7.1), 2,097/3,945 (53.2%) were girls, and the mean midupper arm circumference (MUAC) at admission was 105.8 mm (SD 6.0). In a modified intention-to-treat analysis, the primary outcome of nutritional recovery, defined as having MUAC ≥125 mm on 2 consecutive visits, was analyzed using generalized linear models, with generalized estimating equations to account for clustering. Nutritional recovery was lower in the monthly follow-up group compared to the weekly group (1,036/1,976, 52.4% versus 1,059/1,802, 58.8%; risk difference: -6.8%), and noninferiority was not demonstrated (lower bound of the confidence interval [CI] was -11.5%, lower than the noninferiority margin of 10%). The proportion of children defaulting was lower in the monthly group than in the weekly group (109/1,976, 5.5% versus 151/1,802, 8.4%, p = 0.03). Three months postdischarge, children in the monthly group were less likely to relapse compared to those in the weekly group (58/976, 5.9% versus 78/1,005, 7.8%, p = 0.03), but cumulative mortality at 3 months postdischarge was higher in the monthly group (159/1,873, 8.5% versus 106/1,721, 6.2%, p < 0.001). Study results may depend on context-specific factors including baseline level of care and the clinical status of children presenting to health centers, and, thus, generalizability of these results may be limited.

CONCLUSIONS

Where feasible, a weekly schedule of clinic visits should be preferred to maintain effectiveness of SAM treatment. Where geographic coverage of programs is low or frequent travel to outpatient clinics is difficult or impossible, a monthly schedule of visits may provide an alternative model to deliver treatment to those in need. Modifications to the outpatient follow-up schedule, for example, weekly clinic visits until initial weight gain has been achieved followed by monthly visits, could increase the effectiveness of the model and add flexibility for program delivery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03140904.

Risk and Adverse Outcome Factors of Severe Acute Malnutrition in Children: A Hospital-Based Study in Odisha

Background

 Malnutrition is prevalent in 41% of children less than five years old in developing countries.

Objective

To determine the clinical spectrum, identify the risk factors, and find out the factors responsible for the adverse outcomes of severe acute malnutrition (SAM) in children.

Methods

In this prospective cohort, children aged one month to five years with SAM from October 2016 to September 2018 were enrolled. Clinical profile, contributing factors, treatment, and outcome of cases (n=198) were noted.

Results

SAM was diagnosed in 323 (1.6%) of admitted cases. The unimmunized children were 123 (62.1%). Common co-morbidities were acute gastroenteritis (n=89, 44.9%), respiratory tract infection (n=88, 44.4%), and septicemia (n=54, 26.7%). Children not on exclusive breastfeeding (n=157, 79.1%), early complementary feeding (<6 months) (n=157, 88.2%), bottle-feeding (n=138, 77.55%), low birth weight (157, 79.1%), living in kutcha houses (115, 58.2%), and unavailability of safe drinking water (131, 66.4%) were the significant risk factors. Pneumonia, diarrhea, nutritional edema, hypothermia, and circulatory shock at the time of admission were responsible for adverse outcomes. One hundred and eighty-three (92.4%) children were cured and discharged and 15 (7.6%) children died.

Conclusions

Wrong feeding practices and unavailability of safe drinking water have an important bearing on the development of SAM children. Pneumonia, diarrhea, nutritional edema, hypothermia, and circulatory shock at the time of admission were responsible for adverse outcomes.

Capturing diversity and cultural drivers of food choice in eastern India

The EAT-Lancet Commission urgently called for "planetary health diets". The success of encouraging dietary shifts, however, crucially hinges on people, and more specifically on consumers' culture, context, socioeconomic status, food environment, attitudes, perceptions, beliefs, and behavior towards food choice. In India, enhanced food availability and accessibility do not readily lead to improved nutritional status. Thus, developing planetary health diets in India requires an understanding of systemic drivers of food choice. Food is an essential part of Indian culture and deeply rooted to the country's history, traditions, lifestyles, and customs. Yet, the diversity and cultural drivers of food choice are still insufficiently understood. To address this knowledge gap, we use expert elicitation to contextualize the "gastronomic systems research" framework to a target population of low-to middle-income households to capture the diversity and cultural drivers of food choice and its nutritional implications in rice-based diets in two states in eastern India. The experts catalogued 131 unique dishes associated with five differentiated daily dining occasions. The majority of dishes belong to the starch food group. Morning snacks exhibit the lowest nutritional diversity while dinners feature the highest diversity in both states. In West Bengal, dish options tend to be carbohydrate-rich and energy-dense, and a significant number of dishes are fried and oily. The gastronomic system mapped by the experts provides a useful baseline for nutritionists, policymakers, and food system actors as a first step in the design of nutrition intervention strategies to develop planetary health diets in eastern India.

Acute malnutrition recovery energy requirements based on mid-upper arm circumference: Secondary analysis of feeding program data from 5 countries, Combined Protocol for Acute Malnutrition Study (ComPAS) Stage 1

Background

Severe and moderate acute malnutrition (SAM and MAM) are currently treated with different food products in separate treatment programs. The development of a unified and simplified treatment protocol using a single food product aims to increase treatment program efficiency and effectiveness. This study, the first stage of the ComPAS trial, sought to assess rate of growth and energy requirements among children recovering from acute malnutrition in order to design a simplified, MUAC-based dosage protocol.

Methods

We obtained secondary data from patient cards of children aged 6–59 months recovering from SAM in outpatient therapeutic feeding programs (TFPs) and from MAM in supplementary feeding programs (SFPs) in five countries in Africa and Asia. We used local polynomial smoothing to assess changes in MUAC and proportional weight gain between clinic visits and assessed their normalized differences for a non-zero linear trend. We estimated energy needs to meet or exceed the growth observed in 95% of visits.

Results

This analysis used data from 5518 patients representing 33942 visits. Growth trends in MUAC and proportional weight gain were not significantly different, each lower at higher MUAC values: MUAC growth averaged 2mm/week at lower MUACs (100 to <110mm) and 1mm/week at higher MUACs (120mm to <125mm); and proportional weight gain declined from 3.9g/kg/day to 2.4g/kg/day across the same MUAC values. In 95% of visits by children with a MUAC 100mm to <125mm who were successfully treated, energy needs could be met or exceeded with 1,000 kilocalories a day.

Conclusion

Two 92g sachets of Ready-to-Use Therapeutic Food (RUTF) (1,000kcal total) is proposed to meet the estimated total energy requirements of children with a MUAC 100mm to <115mm, and one 92g sachet of RUTF (500kcal) is proposed to meet half the energy requirements of children with a MUAC of 115 to <125mm. A simplified, combined protocol may enable a more holistic continuum of care, potentially contributing to increased coverage for children suffering from acute malnutrition.