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Teshome MS, Verbecque E, Mingels S, Granitzer M, Abessa TG, Bruckers L, Belachew T, Rameckers E. Investigating the Effects of Dietary Supplementation and High-Intensity Motor Learning on Nutritional Status, Body Composition, and Muscle Strength in Children with Moderate Thinness in Southwest Ethiopia: A Cluster-Randomized Controlled Trial. Nutrients 2024; 16:3118. [PMID: 39339716 PMCID: PMC11435431 DOI: 10.3390/nu16183118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 09/12/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND In Ethiopia, moderate thinness (MT) is a persistent issue among children. Yet, evidence on the effects of dietary supplementation and motor skills training in these children is limited. OBJECTIVE This study aimed to assess the effect of Ready-to-Use Supplementary Food (RUSF), whether or not combined with high-intensity motor learning (HiML), on weight, height, body composition, and muscle strength in children 5-7 years old with MT living in Jimma Town, Ethiopia. METHODS A cluster-randomized controlled trial was carried out among 69 children (aged 5-7) with MT assigned to receive RUSF (n = 23), RUSF + HiML (n = 25), or no intervention (control group, n = 21). A multivariable Generalized Estimating Equations model was used and the level of significance was set at alpha < 0.05. RESULTS At baseline, there were no significant differences in the outcome measurements between the RUSF, RUSF + HiML, and control groups. However, after 12 weeks of intervention, there were significant mean differences in differences (DIDs) between the RUSF group and the control arm, with DIDs of 1.50 kg for weight (p < 0.001), 20.63 newton (N) for elbow flexor (p < 0.001), 11.00 N for quadriceps (p = 0.023), 18.95 N for gastrocnemius sup flexor of the leg (p < 0.001), and 1.03 kg for fat-free mass (p = 0.022). Similarly, the mean difference in differences was higher in the RUSF + HiML group by 1.62 kg for weight (p < 0.001), 2.80 kg for grip strength (p < 0.001), 15.93 for elbow flexor (p < 0.001), 16.73 for quadriceps (p < 0.001), 9.75 for gastrocnemius sup flexor of the leg (p = 0.005), and 2.20 kg for fat-free mass (p < 0.001) compared the control arm. CONCLUSION RUSF alone was effective, but combining it with HiML had a synergistic effect. Compared to the control group, the RUSF and RUSF + HiML interventions improved the body composition, height, weight, and muscle strength of the studied moderately thin children. The findings of this study suggest the potential that treating moderately thin children with RUSF and combining it with HiML has for reducing the negative effects of malnutrition in Ethiopia. Future research should explore these interventions in a larger community-based study. This trial has been registered at the Pan African Clinical Trials Registry (PACTR) under trial number PACTR202305718679999.
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Affiliation(s)
- Melese Sinaga Teshome
- Department of Nutrition and Dietetics, Faculty of Public Health, Health Institute, Jimma University, Jimma 378, Ethiopia;
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and Physiotherapy, Hasselt University, Wetenschapspark 7, 3590 Diepenbeek, Belgium; (E.V.); (S.M.); (M.G.); (T.G.A.); (E.R.)
| | - Evi Verbecque
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and Physiotherapy, Hasselt University, Wetenschapspark 7, 3590 Diepenbeek, Belgium; (E.V.); (S.M.); (M.G.); (T.G.A.); (E.R.)
| | - Sarah Mingels
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and Physiotherapy, Hasselt University, Wetenschapspark 7, 3590 Diepenbeek, Belgium; (E.V.); (S.M.); (M.G.); (T.G.A.); (E.R.)
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Leuven University, 3000 Leuven, Belgium
| | - Marita Granitzer
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and Physiotherapy, Hasselt University, Wetenschapspark 7, 3590 Diepenbeek, Belgium; (E.V.); (S.M.); (M.G.); (T.G.A.); (E.R.)
| | - Teklu Gemechu Abessa
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and Physiotherapy, Hasselt University, Wetenschapspark 7, 3590 Diepenbeek, Belgium; (E.V.); (S.M.); (M.G.); (T.G.A.); (E.R.)
- Department of Special Needs and Inclusive Education, Jimma University, Jimma 378, Ethiopia
| | - Liesbeth Bruckers
- I-BioStat, Data Science Institute, Hasselt University, 3590 Hasselt, Belgium;
| | - Tefera Belachew
- Department of Nutrition and Dietetics, Faculty of Public Health, Health Institute, Jimma University, Jimma 378, Ethiopia;
| | - Eugene Rameckers
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and Physiotherapy, Hasselt University, Wetenschapspark 7, 3590 Diepenbeek, Belgium; (E.V.); (S.M.); (M.G.); (T.G.A.); (E.R.)
- Research School CAPHRI, Department of Rehabilitation Medicine, Maastricht University, 6200 Maastricht, The Netherlands
- Centre of Expertise in Rehabilitation and Audiology, 6281 Hoensbroek, The Netherlands
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Melaku B, Gebremichael B, Negash B, Kitessa M, Kassa O, Dereje J, Kefelegn R, Firdisa D. Time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda, East Hararghe Zone, Eastern Ethiopia. Front Nutr 2024; 11:1369419. [PMID: 39171105 PMCID: PMC11335514 DOI: 10.3389/fnut.2024.1369419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 07/29/2024] [Indexed: 08/23/2024] Open
Abstract
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.
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Affiliation(s)
- Berhanu Melaku
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Berhe Gebremichael
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Belay Negash
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Monas Kitessa
- School of pharmacy, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Obsan Kassa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Jerman Dereje
- Department of psychiatry, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Reta Kefelegn
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Dawit Firdisa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Teshome MS, Bekele T, Verbecque E, Mingels S, Granitzer M, Abessa TG, Lema TB, Rameckers E. Body composition and associated factors among 5-7-year-old children with moderate acute malnutrition in Jimma town in southwest Ethiopia: A comparative cross-sectional study. MATERNAL & CHILD NUTRITION 2024; 20:e13655. [PMID: 38661055 PMCID: PMC11168370 DOI: 10.1111/mcn.13655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024]
Abstract
Acute malnutrition affects not only the growth and development but also the body composition of children. However, its specific effects have not yet been characterized. This study aims to compare the body composition of 5-7-year-old children with moderate acute malnutrition (MAM) to that of their well-nourished (WN) peers and identify associated factors. A school-based comparative cross-sectional study was conducted from June to July 2022 in Jimma town, southwest Ethiopia. The study participants were selected from eight kindergartens and eight primary schools using a simple random sampling technique based on the proportional allocation of the sample to the size of the population in the respective school. Descriptive statistics and multivariable linear regression analyses were used to assess the mean differences and associations between variables and isolate independent predictors of body composition, respectively. The statistical significance was determined using ß-coefficients with 95% confidence intervals and a p value of ≤ 0.05. Data were captured from 388 (194 MAM and 194 WN) children with a response rate of 97.9%. The mean fat-free mass of WN children was significantly higher compared with those with MAM (p < 0.001). The mean (SD) of fat mass of MAM children was 4.23 ± 0.72 kg, 4.36 ± 0.88 kg and 4.08 ± 0.89 kg for 5, 6 and 7-year-olds, respectively. For WN children, the mean (SD) of fat mass was 4.92 ± 0.88 kg for 5 years old, 5.64 ± 1.01 kg for 6 years old and 5.75 ± 1.26 kg for 7 years old (p < 0.001). On the multivariable linear regression analysis after controlling for background variables, WN children exhibited 1.51 times higher fat-free mass compared with MAM children (β = 1.51, p = 0.003). A unit increase in age of the study participants was associated with a 1.37 increment in fat-free mass (β = 1.37, p < 0.001). WN children had 1.07 times higher fat mass compared with children with MAM (β = 1.07, p < 0.001). A unit increase in the age of the child resulted in 0.15 times increment in fat mass (β = 0.15, p = 0.020), and being female was associated with a 0.37 increase in fat mass (β = 0.37, p < 0.001). The results showed that the mean fat mass and fat-free mass were significantly lower among moderately acute malnourished children than in WN children showing the loss of both body compartments due to malnutrition. The body mass index for age, age of the child and sex of the child were significantly linked to both fat-free mass and fat mass.
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Affiliation(s)
- Melese Sinaga Teshome
- Department of Nutrition and Dietetics, Faculty of Public Health, Health InstituteJimma UniversityJimmaEthiopia
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and PhysiotherapyHasselt UniversityDiepenbeekBelgium
| | - Tamirat Bekele
- Department of Nutrition and Dietetics, Faculty of Public HealthJimma UniversityJimmaEthiopia
| | - Evi Verbecque
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and PhysiotherapyHasselt UniversityDiepenbeekBelgium
| | - Sarah Mingels
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and PhysiotherapyHasselt UniversityDiepenbeekBelgium
- Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation SciencesLeuven UniversityLeuvenBelgium
| | - Marita Granitzer
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and PhysiotherapyHasselt UniversityDiepenbeekBelgium
| | - Teklu Gemechu Abessa
- Department of Special Needs and Inclusive EducationJimma UniversityJimmaEthiopia
| | - Tefera Belachew Lema
- Department of Nutrition and Dietetics, Faculty of Public Health, Health InstituteJimma UniversityJimmaEthiopia
| | - Eugene Rameckers
- Rehabilitation Research Centre (REVAL), Rehabilitation Sciences and PhysiotherapyHasselt UniversityDiepenbeekBelgium
- Research School CAPHRI, Department of Rehabilitation MedicineMaastricht UniversityMaastrichtThe Netherlands
- Centre of Expertise in Rehabilitation and AudiologyHoensbroekThe Netherlands
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Makori N, Masanja H, Masumo R, Rashid S, Jumbe T, Tegeye M, Esau D, Muiruri J, Mchau G, Mafung'a SH, Moshi C, Shosho N, Kwara V, Mshida H, Leyna G. Efficacy of ready-to-use food supplement for treatment of moderate acute malnutrition among children aged 6 to 59 months. MATERNAL & CHILD NUTRITION 2024; 20:e13602. [PMID: 38192064 PMCID: PMC10981477 DOI: 10.1111/mcn.13602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/08/2023] [Accepted: 11/22/2023] [Indexed: 01/10/2024]
Abstract
Moderate acute malnutrition (MAM) is a persistent public health problem in Tanzania. The current approach for its management is nutrition counselling. However, there has been no commercial production of ready-to-use supplementary foods for the management of MAM in the country but rather imported from companies outside the country. The objective of the study was to determine the ability of a ready-to-use food supplementation versus corn soya blend (CSB+) to manage MAM. The randomised controlled trial employed three parallel arm approach. The first arm received CSB+ and infant and young child feeding (IYCF) counselling, the second arm received ready-to-use food (RUF) and IYCF counselling and the third arm, a control group, received IYCF as standard care for three consecutive months. Results indicated that the overall proportion of children who recovered from MAM was 65.6%. There was a significant difference (p < 0.001) in the proportion of children who recovered from MAM between the three arms (CSB+, RUF and standard care). Results revealed further a high recovery rate of 83.7% in the RUF arm, followed by 71.9% in the CSB+ arm and 41% in the standard care arm. The risk differences for RUF compared with CSB+ and standard care were 11.8% and 42.7%, respectively. RUFs can be used as an alternative supplement to conventional CSB+ for the management of MAM in children and, thus, has the potential to scale up its use to address the problem of MAM among 6 to 59 months' children.
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Affiliation(s)
- Nyabasi Makori
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
| | - Hope Masanja
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
| | - Ray Masumo
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
| | - Suleman Rashid
- Department of Food Science and AgroprocessingSokoine University of AgricultureMorogoroTanzania
| | - Theresia Jumbe
- Department of Food Science and AgroprocessingSokoine University of AgricultureMorogoroTanzania
| | | | | | | | - Geofrey Mchau
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
| | - Stanslaus H. Mafung'a
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
| | - Cypriana Moshi
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
| | | | - Vera Kwara
- World Food ProgrammeDar Es SalaamTanzania
| | - Hoyce Mshida
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
| | - Germana Leyna
- Department of Nutrition Education and Training (NET)Tanzania Food and Nutrition CentreDar es salaamTanzania
- Department of Epidemiology and BiostatisticsMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
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López-Ejeda N, Charle-Cuéllar P, Samake S, Dougnon AO, Sánchez-Martínez LJ, Samake MN, Bagayoko A, Bunkembo M, Touré F, Vargas A, Guerrero S. Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali. Front Public Health 2024; 12:1283148. [PMID: 38450139 PMCID: PMC10915236 DOI: 10.3389/fpubh.2024.1283148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 01/12/2024] [Indexed: 03/08/2024] Open
Abstract
Background Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs). Methods A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units. Results The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%). Implications Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.
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Affiliation(s)
- Noemí López-Ejeda
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | - Salimata Samake
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | | | - Luis Javier Sánchez-Martínez
- EPINUT Research Group (ref. 920325), Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Mahamadou N’tji Samake
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Aliou Bagayoko
- Nutrition Directorate of the General Directorate of Health and Public Hygiene, Ministry of Health, Bamako, Mali
| | - Magloire Bunkembo
- Nutrition and Health Department, Action Against Hunger, Bamako, Mali
| | - Fanta Touré
- West and Central Africa Regional Office, Action Against Hunger, Dakar, Senegal
| | - Antonio Vargas
- Nutrition and Health Department, Action Against Hunger, Madrid, Spain
| | - Saul Guerrero
- Child Nutrition and Development Office, UNICEF, New York, NY, United States
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Kisenge R, Dhingra U, Rees CA, Liu E, Dutta A, Saikat D, Dhingra P, Somji S, Sudfeld C, Simon J, Ashorn P, Sazawal S, Duggan CP, Manji K. Risk factors for moderate acute malnutrition among children with acute diarrhoea in India and Tanzania: a secondary analysis of data from a randomized trial. BMC Pediatr 2024; 24:56. [PMID: 38238656 PMCID: PMC10797730 DOI: 10.1186/s12887-024-04551-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 01/10/2024] [Indexed: 01/22/2024] Open
Abstract
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.
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Affiliation(s)
- Rodrick Kisenge
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania.
| | - Usha Dhingra
- Centre for Public Health Kinetics, New Delhi, India
| | - Chris A Rees
- Division of Paediatric Emergency Medicine, Emory University School of Medicine, Atlanta, USA
| | - Enju Liu
- Clinical Research Centre, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Arup Dutta
- Centre for Public Health Kinetics, New Delhi, India
| | - Deb Saikat
- Centre for Public Health Kinetics, New Delhi, India
| | | | - Sarah Somji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
| | - Chris Sudfeld
- Clinical Research Centre, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Jon Simon
- The World Health Organization, Geneva, Switzerland
| | - Per Ashorn
- The World Health Organization, Geneva, Switzerland
| | | | - Christopher P Duggan
- Clinical Research Centre, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, USA
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
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Sánchez-Martínez LJ, Charle-Cuéllar P, Gado AA, Dougnon AO, Sanoussi A, Ousmane N, Lazoumar RH, Toure F, Vargas A, Hernández CL, López-Ejeda N. Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger. Front Nutr 2023; 10:1253545. [PMID: 38099186 PMCID: PMC10719846 DOI: 10.3389/fnut.2023.1253545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023] Open
Abstract
Introduction Of the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers. Methods This study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers. Results The recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff. Conclusion The outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.
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Affiliation(s)
- Luis Javier Sánchez-Martínez
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | | | | | | | - Atté Sanoussi
- Nutrition Direction, Ministry of Health, Niamey, Niger
| | | | | | - Fanta Toure
- Action Against Hunger, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Candela Lucía Hernández
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
| | - Noemí López-Ejeda
- Unit of Physical Anthropology, Department of Biodiversity, Ecology and Evolution, Faculty of Biological Sciences, Complutense University of Madrid, Madrid, Spain
- EPINUT Research Group (Ref. 920325), Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Sturgeon JP, Njunge JM, Bourke CD, Gonzales GB, Robertson RC, Bwakura-Dangarembizi M, Berkley JA, Kelly P, Prendergast AJ. Inflammation: the driver of poor outcomes among children with severe acute malnutrition? Nutr Rev 2023; 81:1636-1652. [PMID: 36977352 PMCID: PMC10639108 DOI: 10.1093/nutrit/nuad030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - James M Njunge
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Ruairi C Robertson
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | | | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Paul Kelly
- is with the Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
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9
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Teshale EB, Nigatu YD, Delbiso TD. Relapse of severe acute malnutrition among children discharged from outpatient therapeutic program in western Ethiopia. BMC Pediatr 2023; 23:441. [PMID: 37659998 PMCID: PMC10474695 DOI: 10.1186/s12887-023-04269-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Children with severe acute malnutrition (SAM) without complication are treated in the outpatient therapeutic program (OTP) and the program has been reported to be effective. However, relapse post-discharge from the program is poorly defined, and scarcely evaluated across programs and research. The objective of this study is to assess the prevalence of SAM among children post-discharge from the OTP and to identify factors associated with SAM relapse in Gambella Region, Western Ethiopia. METHODS We conducted a facility-based cross-sectional study among 208 children aged 6-59 months who have been discharged from the OTP as cured. Baseline data were collected from caregivers using structured questionnaire. Child anthropometry and oedema was measured. The association between SAM relapse and the risk factors were assessed using bivariate and multivariable logistic regression models. RESULTS The prevalence of SAM relapse was 10.1% (95% CI: 5.8-14.0%). The odds of SAM relapse was significantly higher in children with mothers who had no exposure to education and promotion about infant and young child feeding (IYCF) practices (OR = 5.7; 95% CI: 1.3-12.6), children who were not fully immunized for their age (OR = 8.0; 95% CI: 3.8-23.4), and children with mid-upper arm circumference (MUAC) at discharge of < 12.5 cm (OR = 4.4; 95% CI: 2.1-12.8) than their counterparts. CONCLUSIONS To reduce SAM relapse, the OTP programs should avoid premature discharge and consider provision of supplementary food for children with low MUAC at discharge. Further, the OTP discharge criteria should consider both the anthropometric indicators - weight-for-height/length z-score (WHZ) and MUAC - and the absence of bilateral pitting oedema irrespective of the anthropometric indicator that is used during admission. Promotion of nutrition education and improving child immunization services and coverage would help reduce SAM relapse.
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Affiliation(s)
| | - Yakob Desalegn Nigatu
- Department of Public Health Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tefera Darge Delbiso
- Department of Public Health Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia.
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Papadopoulou E, Lim YC, Chin WY, Dwan K, Munabi-Babigumira S, Lewin S. Lay health workers in primary and community health care for maternal and child health: identification and treatment of wasting in children. Cochrane Database Syst Rev 2023; 8:CD015311. [PMID: 37646367 PMCID: PMC10467022 DOI: 10.1002/14651858.cd015311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Since the early 2010s, there has been a push to enhance the capacity to effectively treat wasting in children through community-based service delivery models and thus reduce morbidity and mortality. OBJECTIVES To assess the effectiveness of identification and treatment of moderate and severe wasting in children aged five years or under by lay health workers working in the community compared with health providers working in health facilities. SEARCH METHODS We searched MEDLINE, CENTRAL, two other databases, and two ongoing trials registers to 24 September 2021. We also screened the reference lists of related systematic reviews and all included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies in children aged five years or under with moderate wasting (defined as weight-for-height Z-score (WHZ) below -2 but no lower than ≥ -3, or mid-upper-arm circumference (MUAC) below 125 mm but no lower than 115 mm, and no nutritional oedema) or severe wasting (WHZ below -3 or MUAC below 115 mm or nutritional oedema). Eligible interventions were: • identification by lay health workers (LHWs) of children with wasting (intervention 1); • identification by LHWs of children with wasting and medical complications needing referral (intervention 2); and • identification by LHWs of children with wasting without medical complications needing referral (intervention 3). Eligible comparators were: • identification and treatment of wasting by health professionals such as nurses or doctors (at health facilities); and • identification and treatment of wasting by health facility-based teams, including health professionals and LHWs. DATA COLLECTION AND ANALYSIS Two review authors independently screened trials, extracted data and assessed risk of bias using the Cochrane risk of bias tool (RoB 2) and Cochrane Effective Practice and Organisation of Care (EPOC) guidelines. We used a random-effects model to meta-analyse data, producing risk ratios (RRs) for dichotomous outcomes in trials with individual allocation, adjusted RRs for dichotomous outcomes in trials with cluster allocation (using the generic inverse variance method in Review Manager 5), and mean differences (MDs) for continuous outcomes. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included two RCTs and five non-RCTs. Six studies were from African countries, and one was from Pakistan. Six studies included children with severe wasting, and one included children with moderate wasting. All studies offered home-based ready-to-use therapeutic food treatment and monitoring. Children received antibiotics in three studies, vitamins or micronutrients in three studies, and deworming treatment in two studies. In three studies, the comparison arm involved LHWs screening children for malnutrition and referring them to health facilities for diagnosis and treatment. All the non-randomised studies had a high overall risk of bias. Interventions 1 and 2 Identification and referral for treatment by LHWs, compared with treatment by health professionals following self-referral, may result in little or no difference in the percentage of children who recover from moderate or severe wasting (MD 1.00%, 95% confidence interval (CI) -2.53 to 4.53; 1 RCT, 29,475 households; low certainty). Intervention 3 Compared with treatment by health professionals following identification by LHWs, identification and treatment of severe wasting in children by LHWs: • may slightly reduce improvement from severe wasting (RR 0.93, 95% CI 0.86 to 0.99; 1 RCT, 789 participants; low certainty); • may slightly increase non-response to treatment (RR 1.44, 95% CI 1.04 to 2.01; 1 RCT, 789 participants; low certainty); • may result in little or no difference in the number of children with WHZ above -2 on discharge (RR 0.94, 95% CI 0.28 to 3.18; 1 RCT, 789 participants; low certainty); • probably results in little or no difference in the number of children with WHZ between -3 and -2 on discharge (RR 1.09, 95% CI 0.87 to 1.36; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with WHZ below -3 (severe wasting) on discharge (RR 1.23, 95% CI 0.75 to 2.04; 1 RCT, 789 participants; moderate certainty); • probably results in little or no difference in the number of children with MUAC equal to or greater than 115 mm on discharge (RR 0.99, 95% CI 0.93 to 1.06; 1 RCT, 789 participants; moderate certainty); • results in little or no difference in weight gain per day (mean weight gain 0.50 g/kg/day higher, 95% CI 1.74 lower to 2.74 higher; 1 RCT, 571 participants; high certainty); • probably has little or no effect on relapse of severe wasting (RR 1.03, 95% CI 0.69 to 1.54; 1 RCT, 649 participants; moderate certainty); • may have little or no effect on mortality among children with severe wasting (RR 0.46, 95% CI 0.04 to 5.98; 1 RCT, 829 participants; low certainty); • probably has little or no effect on the transfer of children with severe wasting to inpatient care (RR 3.71, 95% CI 0.36 to 38.23; 1 RCT, 829 participants; moderate certainty); and • probably has little or no effect on the default of children with severe wasting (RR 1.48, 95% CI 0.65 to 3.40; 1 RCT, 829 participants; moderate certainty). The evidence was very uncertain for total MUAC gain, MUAC gain per day, total weight gain, treatment coverage, and transfer to another LHW site or health facility. No studies examined sustained recovery, deterioration to severe wasting, appropriate identification of children with wasting or oedema, appropriate referral of children with moderate or severe wasting, adherence, or adverse effects and other harms. AUTHORS' CONCLUSIONS Identification and treatment of severe wasting in children who do not require inpatient care by LHWs, compared with treatment by health professionals, may lead to similar or slightly poorer outcomes. We found only two RCTs, and the evidence from non-randomised studies was of very low certainty for all outcomes due to serious risks of bias and imprecision. No studies included children aged under 6 months. Future studies must address these methodological issues.
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Affiliation(s)
| | | | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kerry Dwan
- The Liverpool School of Tropical Medicine, Liverpool, UK
| | - Susan Munabi-Babigumira
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health and Functioning, Western Norway University of Applied Sciences, Bergen, Norway
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Department of Health Sciences, Norwegian University of Science and Technology (NTNU), Ålesund, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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11
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Padhani ZA, Cichon B, Das JK, Salam RA, Stobaugh HC, Mughal M, Rutishauser-Perera A, Black RE, Bhutta ZA. Systematic Review of Management of Moderate Wasting in Children over 6 Months of Age. Nutrients 2023; 15:3781. [PMID: 37686813 PMCID: PMC10490450 DOI: 10.3390/nu15173781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
The effective management of the 33 million children with moderate acute malnutrition (MAM) is key to reducing childhood morbidity and mortality. In this review, we aim to evaluate the effectiveness of specially formulated foods (SFFs) compared to non-food-based approaches to manage MAM in children >6 months old. We conducted a search on ten databases until 23 August 2021 and included five studies, covering 3387 participants. Meta-analysis of four studies comparing SFFs to counselling or standard of care showed that SFFs likely increase recovery rate, reduce non-response, and may improve weight-for-height z-score, weight-for-age z-score and time to recovery, but have little or no effect on MUAC gain. One study on a multicomponent intervention (SFFs, antibiotics and counselling provided to high-risk MAM) compared to counselling only was reported narratively. The intervention may increase weight gain after 24 weeks but may have little or no effect on weight gain after 12 weeks and on non-response and mortality after 12 and 24 weeks of enrollment. The effect of this intervention on recovery was uncertain. In conclusion, SFFs may be beneficial for children with moderate wasting in humanitarian contexts. Programmatic recommendations should consider context and cost-effectiveness.
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Affiliation(s)
- Zahra A. Padhani
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, SA 5000, Australia
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan; (J.K.D.); or (Z.A.B.)
| | | | - Jai K. Das
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan; (J.K.D.); or (Z.A.B.)
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Rehana A. Salam
- Centre of Research Excellence, Melanoma Institute Australia, University of Sydney, Sydney, NSW 2006, Australia;
| | - Heather C. Stobaugh
- Action against Hunger USA, Technical Services and Innovation Department, Washington, DC 20463, USA;
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, USA
| | - Muzna Mughal
- Action against Hunger UK, London SE10 0ER, UK; (M.M.); (A.R.-P.)
| | | | - Robert E. Black
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA;
| | - Zulfiqar A. Bhutta
- Institute for Global Health and Development, Aga Khan University, Karachi 74800, Pakistan; (J.K.D.); or (Z.A.B.)
- Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
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12
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Sarfraz A, Ahmed S, Muhammad S, Rehman N, Soomro SI, Qureshi K, Jakhro S, Umrani F, Greene A, Syed S, Moore SR, Ali SA. Standard RUTF vs. locally-made RUSF for acutely malnourished children: A quasi-experimental comparison of the impact on growth and compliance in a rural community of Pakistan. PLoS One 2023; 18:e0287962. [PMID: 37437065 PMCID: PMC10337979 DOI: 10.1371/journal.pone.0287962] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/14/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND The reduction in severe and moderate acute malnutrition (SAM and MAM) rates in Pakistan has been sub-optimal compared to other low-and middle-income countries (LMICs). Specially-formulated products have been designed globally to manage SAM and MAM, such as ready-to-use therapeutic food (RUTF) and ready-to-use supplementary food (RUSF), with variable efficacies. RUTF is primarily produced and patented in industrialized countries, raising supply challenges in resource-constrained regions with a high burden of acute malnutrition. RUSF minimizes costs by using locally-available ingredients while providing similar nutritional value. In this study, we compared the efficacy, side effects, and compliance of two months of supplementation with either RUTF or RUSF. METHODS Children aged nine months in the rural district of Matiari, Pakistan, with a weight-for-height z-score (WHZ) <-2 received either RUTF (500 kcal sachet) for two months in 2015 or RUSF (520 kcal sachet) for two months in 2018. RESULTS The RUSF group had a higher height gain and mid-upper arm circumferences (MUAC) score. Higher compliance was noted with lower side effects in the RUSF group. A higher compliance rate did correlate with the growth parameters in respective groups. CONCLUSION Our study found that both RUTF and RUSF partially improve the anthropometric status of acutely malnourished children, with neither being superior to the other.
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Affiliation(s)
- Azza Sarfraz
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sheraz Ahmed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Muhammad
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeb Rehman
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sanam Iram Soomro
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Khaliq Qureshi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sadaf Jakhro
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fayaz Umrani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Adam Greene
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Sana Syed
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Sean R. Moore
- Department of Pediatrics, University of Virginia, Charlottesville, VA, United States of America
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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13
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Tsegaye AT, Pavlinac PB, Turyagyenda L, Diallo AH, Gnoumou BS, Bamouni RM, Voskuijl WP, van den Heuvel M, Mbale E, Lancioni CL, Mupere E, Mukisa J, Lwanga C, Atuhairwe M, Chisti MJ, Ahmed T, Shahid AS, Saleem AF, Kazi Z, Singa BO, Amam P, Masheti M, Berkley JA, Walson JL, Tickell KD. The Role of Food Insecurity and Dietary Diversity on Recovery from Wasting among Hospitalized Children Aged 6-23 Months in Sub-Saharan Africa and South Asia. Nutrients 2022; 14:3481. [PMID: 36079736 PMCID: PMC9460249 DOI: 10.3390/nu14173481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Current guidelines for the management of childhood wasting primarily focus on the provision of therapeutic foods and the treatment of medical complications. However, many children with wasting live in food-secure households, and multiple studies have demonstrated that the etiology of wasting is complex, including social, nutritional, and biological causes. We evaluated the contribution of household food insecurity, dietary diversity, and the consumption of specific food groups to the time to recovery from wasting after hospital discharge. Methods: We conducted a secondary analysis of the Childhood Acute Illness Network (CHAIN) cohort, a multicenter prospective study conducted in six low- or lower-middle-income countries. We included children aged 6−23 months with wasting (mid-upper arm circumference [MUAC] ≤ 12.5 cm) or kwashiorkor (bipedal edema) at the time of hospital discharge. The primary outcome was time to nutritional recovery, defined as a MUAC > 12.5 cm without edema. Using Cox proportional hazards models adjusted for age, sex, study site, HIV status, duration of hospitalization, enrollment MUAC, referral to a nutritional program, caregiver education, caregiver depression, the season of enrollment, residence, and household wealth status, we evaluated the role of reported food insecurity, dietary diversity, and specific food groups prior to hospitalization on time to recovery from wasting during the 6 months of posthospital discharge. Findings: Of 1286 included children, most participants (806, 63%) came from food-insecure households, including 170 (13%) with severe food insecurity, and 664 (52%) participants had insufficient dietary diversity. The median time to recovery was 96 days (18/100 child-months (95% CI: 17.0, 19.0)). Moderate (aHR 1.17 [0.96, 1.43]) and severe food insecurity (aHR 1.14 [0.88, 1.48]), and insufficient dietary diversity (aHR 1.07 [0.91, 1.25]) were not significantly associated with time to recovery. Children who had consumed legumes and nuts prior to diagnosis had a quicker recovery than those who did not (adjusted hazard ratio (aHR): 1.21 [1.01,1.44]). Consumption of dairy products (aHR 1.13 [0.96, 1.34], p = 0.14) and meat (aHR 1.11 [0.93, 1.33]), p = 0.23) were not statistically significantly associated with time to recovery. Consumption of fruits and vegetables (aHR 0.78 [0.65,0.94]) and breastfeeding (aHR 0.84 [0.71, 0.99]) before diagnosis were associated with longer time to recovery. Conclusion: Among wasted children discharged from hospital and managed in compliance with wasting guidelines, food insecurity and dietary diversity were not major determinants of recovery.
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Affiliation(s)
| | | | | | - Abdoulaye H. Diallo
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Blaise S. Gnoumou
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Roseline M. Bamouni
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Wieger P. Voskuijl
- Amsterdam UMC, University of Amsterdam, Amsterdam Centre for Global Child Health & Emma Children’s Hospital, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Meta van den Heuvel
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Emmie Mbale
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 265, Malawi
| | - Christina L. Lancioni
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA
| | - Ezekiel Mupere
- Uganda-CWRU Research Collaboration, Kampala P.O. Box 663, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala P.O. Box 7072, Uganda
| | - John Mukisa
- Uganda-CWRU Research Collaboration, Kampala P.O. Box 663, Uganda
| | | | | | - Mohammod J. Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Abu S.M.S.B. Shahid
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Ali F. Saleem
- Department of Pediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Zaubina Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | | | - Pholona Amam
- Kenya Medical Research Institute, Nairobi 54840, Kenya
| | - Mary Masheti
- Kenya Medical Research Institute, Nairobi 54840, Kenya
| | - James A. Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi 80108, Kenya
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi 184742, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LG, UK
| | - Judd L. Walson
- Departments of Global Health, University of Washington, Seattle, WA 98195, USA
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi 184742, Kenya
| | - Kirkby D. Tickell
- Departments of Global Health, University of Washington, Seattle, WA 98195, USA
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14
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Rashid MY, Kebira JY, Oljira L, Dheresa M. 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. Front Public Health 2022; 10:914837. [PMID: 35910899 PMCID: PMC9330372 DOI: 10.3389/fpubh.2022.914837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jemal Yusuf Kebira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- *Correspondence: Jemal Yusuf Kebira
| | - Lemessa Oljira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Merga Dheresa
- School Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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15
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Johansen ØH, Abdissa A, Zangenberg M, Mekonnen Z, Eshetu B, Sharew B, Moyo S, Sommerfelt H, Langeland N, Robertson LJ, Hanevik K. A comparison of risk factors for cryptosporidiosis and non-cryptosporidiosis diarrhoea: A case-case-control study in Ethiopian children. PLoS Negl Trop Dis 2022; 16:e0010508. [PMID: 35666717 PMCID: PMC9203008 DOI: 10.1371/journal.pntd.0010508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 06/16/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Cryptosporidiosis is a major cause of diarrhoea in young children in low-and-middle-income countries. New interventions should be informed by evidence pertaining to risk factors and their relative importance. Inconsistencies in the literature may to some extent be explained by choice of methodology, furthermore, most previous risk factor studies compared cryptosporidiosis cases to diarrhoea cases of other aetiologies rather than with controls without diarrhoea.
Methodology/Principal findings
We investigated a broad set of factors in under-2-year-olds presenting with diarrhoea to a hospital and a health center in southwestern Ethiopia. We applied quantitative cut-offs to distinguish between cryptosporidiosis and incidental Cryptosporidium infection or carriage, a hierarchical causal framework to minimize confounding and overadjustment, and a case-case-control design, to describe risk factors for both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Moderate and severe acute malnutrition were strongly associated with both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Previous healthcare attendance and low maternal education were only associated with cryptosporidiosis, whereas unsafe child stool disposal, prematurity and early cessation of exclusive breastfeeding were significantly associated with non-cryptosporidiosis diarrhoea only. By estimation of population attributable fractions, socioeconomic factors—specifically low maternal education—and public tap water use, were apparently more important risk factors for cryptosporidiosis than for non-cryptosporidiosis diarrhoea.
Conclusions/Significance
Nutritional management of moderate acute malnutrition may be an effective intervention against cryptosporidiosis, particularly if combined with targeted therapy for cryptosporidiosis which, again, may mitigate nutritional insult. Focused caregiver education in healthcare settings and follow-up of children with acute malnutrition may prevent or improve outcomes of future episodes of cryptosporidiosis.
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Affiliation(s)
- Øystein Haarklau Johansen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
- * E-mail:
| | - Alemseged Abdissa
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Mike Zangenberg
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Zeleke Mekonnen
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Beza Eshetu
- Department of Paediatrics, Jimma Medical Centre, Jimma University, Jimma, Ethiopia
| | - Bizuwarek Sharew
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Sabrina Moyo
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
- Cluster for Global Health, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Nina Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lucy J. Robertson
- Parasitology, Department of Paraclinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | - Kurt Hanevik
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
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16
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Simplifying and optimising the management of uncomplicated acute malnutrition in children aged 6–59 months in the Democratic Republic of the Congo (OptiMA-DRC): a non-inferiority, randomised controlled trial. THE LANCET GLOBAL HEALTH 2022; 10:e510-e520. [DOI: 10.1016/s2214-109x(22)00041-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/22/2021] [Accepted: 01/24/2022] [Indexed: 12/20/2022] Open
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17
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Bwakura‐Dangarembizi M, Dumbura C, Amadi B, Chasekwa B, Ngosa D, Majo FD, Sturgeon JP, Chandwe K, Kapoma C, Bourke CD, Robertson RC, Nathoo KJ, Ntozini R, Norris SA, Kelly P, Prendergast AJ. Recovery of children following hospitalisation for complicated severe acute malnutrition. MATERNAL & CHILD NUTRITION 2022; 18:e13302. [PMID: 34939325 PMCID: PMC8932709 DOI: 10.1111/mcn.13302] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
Nutritional recovery and hospital readmission following inpatient management of complicated severe acute malnutrition (SAM) are poorly characterised. We aimed to ascertain patterns and factors associated with hospital readmission, nutritional recovery and morbidity, in children discharged from hospital following management of complicated SAM in Zambia and Zimbabwe over 52‐weeks posthospitalization. Multivariable Fine‐Gray subdistribution hazard models, with death and loss to follow‐up as competing risks, were used to identify factors associated with hospital readmission; negative binomial regression to assess time to hospitalisation and ordinal logistic regression to model factors associated with nutritional recovery. A total of 649 children (53% male, median age 18.2 months) were discharged to continue community nutritional rehabilitation. All‐cause hospital readmission was 15.4% (95% CI 12.7, 18.6) over 52 weeks. Independent risk factors for time to readmission were cerebral palsy (adjusted subhazard ratio (aSHR): 2.96, 95% CI 1.56, 5.61) and nonoedematous SAM (aSHR: 1.64, 95%CI 1.03, 2.64). Unit increases in height‐for‐age Z‐score (HAZ) (aSHR: 0.82, 95% CI 0.71, 0.95) and enrolment in Zambia (aSHR: 0.52, 95% CI 0.28, 0.97) were associated with reduced subhazard of time to readmission. Young age, SAM at discharge, nonoedematous SAM and cerebral palsy were associated with poor nutritional recovery throughout follow‐up. Collectively, nonoedematous SAM, ongoing SAM at discharge, cerebral palsy and low HAZ are independent risk factors for readmission and poor nutritional recovery following complicated SAM. Children with these high‐risk features should be prioritised for additional convalescent care to improve long‐term outcomes. One‐in‐six children managed for SAM were readmitted into hospital over the first year after discharge and one‐in‐eight remained undernourished by 52 weeks of follow‐up. Nonoedematous SAM, ongoing SAM at the time of discharge and underlying cerebral palsy were independent risk factors for hospital readmission and poor nutritional recovery. Low HAZ was a risk factor for hospital readmission and poor nutritional recovery. Postdischarge care should focus on children with disability, nonoedematous SAM at initial hospitalisation and have ongoing SAM at the time of discharge. Stunting should be considered in the management of children with SAM.
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Affiliation(s)
- Mutsa Bwakura‐Dangarembizi
- University of Zimbabwe College of Health Sciences Harare Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- University of Witwatersrand Johannesburg South Africa
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Jonathan P. Sturgeon
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Claire D. Bourke
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Ruairi C. Robertson
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Kusum J. Nathoo
- University of Zimbabwe College of Health Sciences Harare Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | | | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
- Blizard Institute, Queen Mary University of London London UK
| | - Andrew J. Prendergast
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
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18
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Nane D, Hatløy A, Lindtjørn B. Barriers to Management of Moderate Acute Malnutrition Among Children Aged 6 to 59 Months in Damot Pulassa, Wolaita, South Ethiopia: A Phenomenological Study of Mothers and Health Service Providers. Food Nutr Bull 2022; 43:323-339. [PMID: 35362335 DOI: 10.1177/03795721221088817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Management of children with moderate acute malnutrition (MAM) needs to improve to reduce the transition from MAM to severe acute malnutrition (SAM). OBJECTIVE This study aimed to assess barriers to management of MAM among children aged 6 to 59 months in Damot Pulassa, Wolaita, South Ethiopia. METHOD This descriptive phenomenological design used 6 focus group discussions with mothers or caregivers of children aged 6 to 59 months and 10 in-depth interviews with health service providers. Data were analyzed using Colaizzi's descriptive phenomenological method. RESULT Six themes were identified: Possible reasons for MAM; identification of a child with MAM; management services of MAM; maternal-level barriers; service provider-level barrier; and suggestions to improve the service. Shortage of food and money, selling out of self-produced food without having sufficient reserves at home, large household size, shame on having children with malnutrition, occasional house-to-house screening for MAM, family-initiated screening, leaving the management responsibility of children with MAM to the family, no provision of supplementary food, and lack of repeated follow-up visits were the main obstacles for managing MAM. CONCLUSION Maternal-level barriers and service provider-level barriers affect the management of MAM negatively in Damot Pulassa, Wolaita. Children with MAM living in the area ineligible for food supplementation could deteriorate to SAM. The provision of nutrition counseling to the mothers of children with MAM without food supplementation placed children with MAM at increased risk of negative outcomes. Thus, the government should give more attention and facilitation in promoting supplementary food into the existing management of MAM.
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Affiliation(s)
- Debritu Nane
- Hawassa University, Hawassa, Ethiopia.,University of Bergen, Centre for International Health, Bergen, Norway.,Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Anne Hatløy
- University of Bergen, Centre for International Health, Bergen, Norway.,Fafo Institute for Labor and Social Research, Oslo, Norway
| | - Bernt Lindtjørn
- Hawassa University, Hawassa, Ethiopia.,University of Bergen, Centre for International Health, Bergen, Norway
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19
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Rajabi T, Schell SK, Agapova SE, Hassan A, Zalta M, Wegner DR, Callaghan-Gillespie M, Koroma A, Kamara MT, Manary MJ, Stephenson KB. Supplementary Feeding of Moderately Wasted Children in Sierra Leone Reduces Severe Acute Malnutrition and Death When Compared to Nutrition Counseling: a Retrospective Cohort Study. J Nutr 2022; 152:1149-1158. [PMID: 36967172 DOI: 10.1093/jn/nxab451] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/02/2021] [Accepted: 12/28/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is uncertainty about whether children with moderate wasting should receive supplementary feeding. OBJECTIVES We examined whether supplementary feeding compared to counseling alone in children with moderate wasting prevented progression to severe acute malnutrition (SAM) or death. METHODS This was a retrospective, dual cohort study in which 1,791 children with moderate wasting were drawn from two prior randomized controlled trials that took place in the same location in rural Sierra Leone. 1,077 children received supplementary feeding, while 714 children received counseling alone. Children in both cohorts were followed for at least 24 weeks from enrollment. The primary outcome was time to SAM or death using Kaplan-Meier analysis. Secondary outcomes included time to death as well as proportions of children with healthy mid-upper arm circumference (MUAC), moderate wasting, SAM, or death at 6, 12, and 24 weeks from enrollment. RESULTS Children who received supplementary feeding were less likely to develop SAM or die across the entire follow-up period (HR 0.53, 95% CI 0.44, 0.65, P < 0.001). Time to event for death alone also revealed a lower risk for children who received supplementary feeding (HR 0.52, 95% CI 0.28, 0.94, P = 0.03). Children who received supplementary feeding were more likely to have a healthy MUAC at 6 weeks (RR 2.0, 95% CI 1.7, 2.2) and 12 weeks (RR 1.3, 95% CI 1.2, 1.5), were less likely to develop SAM at 6 (RR 0.7, 95% CI 0.6, 0.9), 12 (RR 0.5, 95% CI 0.3, 0.8), and 24 weeks (RR 0.2, 95% CI 0.1, 0.5), and had higher rates of gain in weight and MUAC at 6 and 12 weeks. CONCLUSIONS Supplementary feeding of children with moderate wasting reduces risk of SAM and death across 24 weeks of follow-up.
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Affiliation(s)
| | | | - Sophia E Agapova
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Amir Hassan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Max Zalta
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Donna R Wegner
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | | | - Aminata Koroma
- Ministry of Health and Sanitation, Government of Sierra Leone, Freetown, Sierra Leone
| | | | - Mark J Manary
- Project Peanut Butter, Freetown, Sierra Leone.,Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,United States Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center, Houston, TX, USA
| | - Kevin B Stephenson
- Department of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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20
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Gluning I, Kerac M, Bailey J, Bander A, Opondo C. The management of moderate acute malnutrition in children aged 6-59 months in low- and middle-income countries: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2021; 115:1317-1329. [PMID: 34535798 DOI: 10.1093/trstmh/trab137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/11/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malnutrition is a leading cause of morbidity and mortality in children aged <5 y, especially in low- and middle-income countries (LMICs). Unlike severe acute malnutrition, moderate acute malnutrition (MAM) affects greater numbers globally, and guidelines lack a robust evidence base. This systematic review and meta-analysis assessed the evidence for lipid-based nutrient supplements (LNSs), fortified blended flours (FBFs) and nutrition counselling, in the treatment of MAM. METHODS Four databases were systematically searched for studies conducted in LMICs that compared the effectiveness of food-based products with any comparator group in promoting recovery from MAM in children aged 6-59 mo. Where appropriate, pooled estimates of effect were estimated using random-effects meta-analyses. RESULTS A total of 13 trials were identified for inclusion. All used active controls. There was evidence of increased probability of recovery (gaining normal weight-for-height and/or mid-upper arm circumference) among children treated with LNSs compared with children treated with FBFs (risk ratio 1.05, 95% CI 1.01 to 1.09, p=0·009). CONCLUSION Based on a relatively small number of studies mainly from Africa, LNSs are superior to FBFs in improving anthropometric recovery from MAM. Current evidence for the use of food supplements in MAM treatment is based on comparisons with active controls. Future studies should assess a wider range of comparator groups, such as nutrition education/counselling alone, and outcomes, including body composition, morbidity and development.
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Affiliation(s)
- Imara Gluning
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Brighton and Sussex University Hospitals Trust, Brighton, BN2 5BE, UK
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Centre for MARCH (Maternal, Reproductive, Adolescent & Child Health Centre), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Jeanette Bailey
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,International Rescue Committee, New York, NY, 10168-1289, USA
| | - Amela Bander
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, OX3 7LF, UK
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21
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Nane D, Hatløy A, Lindtjørn B. A local-ingredients-based supplement is an alternative to corn-soy blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: A randomized controlled non-inferiority trial in Wolaita, Southern Ethiopia. PLoS One 2021; 16:e0258715. [PMID: 34710105 PMCID: PMC8553037 DOI: 10.1371/journal.pone.0258715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Globally, moderate acute malnutrition (MAM) affects approximately 5% of children below five years of age. MAM is a persistent public health problem in Ethiopia. The current approach in Ethiopia for managing MAM is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. The objective of the study was to compare a local-ingredients-based supplement (LIBS) with the standard corn-soy blend plus (CSB+) in treating MAM among children aged 6 to 59 months to test the hypothesis that the recovery rate achieved with LIBS will not be more than 7% worse than that achieved with CSB+. METHODS AND FINDINGS We used an individual randomized controlled non-inferiority trial design with two arms, involving 324 children with MAM aged 6 to 59 months in Wolaita, Southern Ethiopia. One hundred and sixty-two children were randomly assigned to each of the two arms. In the first arm, 125.2 g of LIBS with 8 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. In the second arm, 150 g of CSB+ with 16 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. Each child was provided with a daily ration of either LIBS or CSB+ for 12 weeks. Both intention-to-treat (ITT) and per-protocol (PP) analyses were done. ITT and PP analyses showed non-inferiority of LIBS compared with CSB+ for recovery rate [ITT risk difference = 4.9% (95% CI: -4.70, 14.50); PP risk difference = 3.7% (95% CI: -5.91, 13.31)]; average weight gain [ITT risk difference = 0.10 g (95% CI: -0.33 g, 0.53 g); PP risk difference = 0.04 g (95% CI: -0.38 g, 0.47 g)]; and recovery time [ITT risk difference = -2.64 days (95% CI: -8.40 days, 3.13 days); PP difference -2.17 days (95% CI: -7.97 days, 3.64 days]. Non-inferiority in MUAC gain and length/height gain was also observed in the LIBS group compared with the CSB+ group. CONCLUSIONS LIBS can be used as an alternative to the standard CSB+ for the treatment of MAM. Thus, the potential of scaling up the use of LIBS should be promoted. TRIAL REGISTRATION Pan-African Clinical Trial Registration number: PACTR201809662822990.
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Affiliation(s)
- Debritu Nane
- School of Public and Environmental Health, Hawassa University, Awassa, Ethiopia
- Centre for International Health, University of Bergen, Bergen, Norway
- Wolaita Sodo University, Wolaita Sodo, Ethiopia
| | - Anne Hatløy
- Centre for International Health, University of Bergen, Bergen, Norway
- Fafo Institute for Labour and Social Research, Oslo, Norway
| | - Bernt Lindtjørn
- School of Public and Environmental Health, Hawassa University, Awassa, Ethiopia
- Centre for International Health, University of Bergen, Bergen, Norway
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22
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David SM, Ragasudha PN, Taneja S, Mohan SB, Iyengar SD, Pricilla RA, Martines J, Sachdev HS, Suhalka V, Mohan VR, Mazumder S, Chowdhury R, Bahl R, Bose A. Predictors of recovery in children aged 6-59 months with uncomplicated severe acute malnutrition: a multicentre study. Public Health Nutr 2021; 24:4899-4907. [PMID: 33222710 PMCID: PMC11094385 DOI: 10.1017/s1368980020004723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/30/2020] [Accepted: 11/16/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To identify predictors of recovery in children with uncomplicated severe acute malnutrition (SAM). DESIGN This is a secondary data analysis from an individual randomised controlled trial, where children with uncomplicated SAM were randomised to three feeding regimens, namely ready-to-use therapeutic food (RUTF) sourced from Compact India, locally prepared RUTF or augmented home-prepared foods, under two age strata (6-17 months and 18-59 months) for 16 weeks or until recovery. Three sets of predictors that could influence recovery, namely child, family and nutritional predictors, were analysed. SETTING Rural and urban slum areas of three states of India, namely Rajasthan, Delhi and Tamil Nadu. PARTICIPANTS In total, 906 children (age: 6-59 months) were analysed to estimate the adjusted hazard ratio (AHR) using the Cox proportional hazard ratio model to identify various predictors. RESULTS Being a female child (AHR: 1·269 (1·016, 1·584)), better employment status of the child's father (AHR: 1·53 (1·197, 1·95)) and residence in a rental house (AHR: 1·485 (1·137, 1·94)) increased the chances of recovery. No hospitalisation (AHR: 1·778 (1·055, 2·997)), no fever, (AHR: 2·748 (2·161, 3·494)) and ≤ 2 episodes of diarrhoea (AHR: 1·579 (1·035, 2·412)) during the treatment phase; availability of community-based peer support to mothers for feeding (AHR: 1·61 (1·237, 2·097)) and a better weight-for-height Z-score (WHZ) at enrolment (AHR: 1·811 (1·297, 2·529)) predicted higher chances of recovery from SAM. CONCLUSION The probability of recovery increases in children with better WHZ and with the initiation of treatment for acute illnesses to avoid hospitalisation, availability of peer support and better employment status of the father.
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Affiliation(s)
- Sam Marconi David
- Department of Community Health, Christian Medical College, Vellore, TN, India
| | - Preethi N Ragasudha
- Department of Community Health, Christian Medical College, Vellore, TN, India
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | | | - Sharad D Iyengar
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | | | - Jose Martines
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | | | - Virendra Suhalka
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | | | - Sarmila Mazumder
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Ranadip Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
| | - Anuradha Bose
- Department of Community Health, Christian Medical College, Vellore, TN, India
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23
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Lelijveld N, Godbout C, Krietemeyer D, Los A, Wegner D, Hendrixson DT, Bandsma R, Koroma A, Manary M. Treating high-risk moderate acute malnutrition using therapeutic food compared with nutrition counseling (Hi-MAM Study): a cluster-randomized controlled trial. Am J Clin Nutr 2021; 114:955-964. [PMID: 33963734 PMCID: PMC8921644 DOI: 10.1093/ajcn/nqab137] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 04/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND There is a lack of consensus on what is the most appropriate treatment of moderate acute malnutrition (MAM). OBJECTIVES We aimed to determine if provision of ready-to-use-therapeutic food (RUTF) and antibiotics to "high-risk" MAM (HR-MAM) children in addition to nutritional counseling would result in higher recovery and less deterioration than nutrition counseling alone. METHODS At the 11 intervention clinics, HR-MAM children were given RUTF and amoxicillin along with standard nutrition counseling, for 2-12 wk. All others received 6 wk of nutrition counseling alone. HR-MAM was defined as midupper arm circumference (MUAC) <11.9 cm, weight-for-age z score (WAZ) <-3.5, mother not the main caregiver, or a child <2 y old not being breastfed. Outcomes were compared using intention-to-treat analysis. RESULTS Analysis included 573 children at the intervention sites and 714 children at the control sites. Of the intervention group, 317 (55%) were classified as HR-MAM. Short-term recovery was greater at the intervention sites [48% compared with 39% at week 12; risk difference (rd): 0.08; 95% CI: 0.03, 0.13]. The intervention group had lower risk of deteriorating to severe acute malnutrition (SAM) (18% compared with 24%; rd: -0.07; 95% CI: -0.11, -0.04), lower risk of dying (1.8% compared with 3.1%; rd: -0.02; 95% CI: -0.03, -0.00), and greater gains in MUAC and weight than did children at the control sites. However, by 24 wk, the risk of SAM was similar between the 2 arms (31% compared with 34%; rd: -0.03; 95% CI: -0.09, 0.02). Control group data identified recent illness, MUAC <12.0 cm, WAZ <-3, dropping anthropometry, age <12 mo, being a twin, and a history of previous SAM as risk factors for deterioration. CONCLUSIONS Provision of RUTF and antibiotics to HR-MAM children improved short-term recovery and reduced short-term risk of deterioration. However, recovery rates were still suboptimal and differences were not sustained by 6 mo post enrollment.This trial was registered at clinicaltrials.gov as NCT03647150.
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Affiliation(s)
- Natasha Lelijveld
- Centre for Global Child Health, Hospital for Sick Kids,
Toronto, Ontario, Canada
- Emergency Nutrition Network, Oxford, United Kingdom
| | - Claire Godbout
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
| | - Destiny Krietemeyer
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
| | - Alyssa Los
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
| | - Donna Wegner
- Washington University School of Medicine, St. Louis, MO,
USA
| | | | - Robert Bandsma
- Centre for Global Child Health, Hospital for Sick Kids,
Toronto, Ontario, Canada
| | | | - Mark Manary
- Project Peanut Butter, Freetown, Sierra
Leone
- Washington University School of Medicine, St. Louis, MO,
USA
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24
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Hossain MI, Huq S, Ahmed T. Changes in Nutritional Status and Morbidities Among Children Having Severe Acute Malnutrition Attending a Nutrition Follow-Up Unit in Bangladesh Who Did Not Receive Any Food Supplementation. Food Nutr Bull 2021; 42:399-405. [PMID: 34212780 DOI: 10.1177/03795721211028545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The problem of severe acute malnutrition (SAM) among <5 years old (U-5) children in Bangladesh is awful with higher risk of death or morbidities. However, there is no nationwide program where these children are managed with take-home therapeutic/supplementary food as recommended by World Health Organization. OBJECTIVE This study aimed to identify the changes in nutritional status and morbidities over 3 months of U-5 children having severe wasting (ie, SAM) whose parents refused to admit their children in the residential nutrition rehabilitation unit of the Dhaka Hospital of icddr, b, instead attended the nutrition follow-up unit (NFU), and thus did not receive any food supplementation during nutritional rehabilitation. METHODS At the NFU, these SAM children on every visit (fortnightly to monthly) received health and nutrition education, multivitamins, zinc and iron supplements, and treatment of illnesses if any. RESULTS During the study period, a total 180 U-5 SAM children came regularly for NFU visit for at least 3 months, and they comprised our study sample. Their age at first NFU visit (baseline) was 13.4 ± 7.8 months and 46% were female. Over these 3 month follow-up period, the rate of weight gain was 2.2 ± 1.9 g/kg/d, change in mid upper arm circumference was from 105 to 115 mm, and change in weight-for-length or weight-for-height z-score was from -2.70 ± 0.94 to -1.95 ± 1.00. During the prior 14 days to the 4 NFU follow-up visit, 13.6% to 22.8% had common cold and/or cough, and 12.2% to 15.1% had pneumonia. CONCLUSION Because the rate of weight gain was far below the expected ∼5 g/kg/d, the NFU visits without food supplementation are insufficient in terms of catchup growth. Thus, additional efforts are required to improve the management of these SAM children for their catchup growth.
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Affiliation(s)
- Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Mohakhali, Dhaka, Bangladesh.,Faculty, James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Sayeeda Huq
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Mohakhali, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Mohakhali, Dhaka, Bangladesh.,Faculty, James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
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Schaefer R, Mayberry A, Briend A, Manary M, Walker P, Stobaugh H, Hanson K, McGrath M, Black R. Relapse and regression to severe wasting in children under 5 years: A theoretical framework. MATERNAL & CHILD NUTRITION 2021; 17:e13107. [PMID: 33145990 PMCID: PMC7988852 DOI: 10.1111/mcn.13107] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/04/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
Systematic reviews have highlighted that repeated severe wasting after receiving treatment is likely to be common, but standardised measurement is needed urgently. The Council of Research & Technical Advice for Acute Malnutrition (CORTASAM) released recommendations on standard measurement of relapse (wasting within 6 months after exiting treatment as per recommended discharge criteria), regression (wasting within 6 months after exiting treatment before reaching recommended discharge criteria) and reoccurrence (wasting after 6 months of exit from treatment as per recommended discharge criteria). We provide a theoretical framework of post-treatment relapse and regression to severe wasting to guide discussions, risk factor analyses, and development and evaluations of interventions. This framework highlights that there are factors that may impact risk of relapse and regression in addition to the impact of contextual factors associated with incidence and reoccurrence of severe wasting more generally. Factors hypothesised to be associated with relapse and regression relate specifically to the nutrition and health status of the child on admission to, during and exit from treatment and treatment interventions, platforms and approaches as well as type of exit from treatment (e.g., before reaching recommended criteria). These factors influence whether children reach full recovery, and poorer nutritional and immunological status at exit from treatment are more proximate determinants of risk of severe wasting after treatment, although post-treatment interventions may modify risks. The evidence base for many of these factors is weak. Our framework can guide research to improve our understanding of risks of relapse and regression and how to prevent them and inform programmes on what data to collect to evaluate relapse. Implementation research is needed to operationalise results in programmes and reduce post-treatment severe wasting at scale.
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Affiliation(s)
| | - Amy Mayberry
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - André Briend
- Center for Child Health ResearchTampere UniversityTampereFinland
- Department of Nutrition, Exercise and SportsUniversity of CopenhagenCopenhagenDenmark
| | - Mark Manary
- Department of PediatricsWashington University in St. LouisSt. LouisMissouriUSA
- School of Public Health and Family Medicine, College of MedicineUniversity of MalawiBlantyreMalawi
| | - Polly Walker
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - Heather Stobaugh
- Action Against Hunger USNew YorkNew YorkUSA
- Friedman School Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | | | | | - Robert Black
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
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Cazes C, Phelan K, Hubert V, Alitanou R, Boubacar H, Izie Bozama L, Tshibangu Sakubu G, Beuscart A, Yao C, Gabillard D, Kinda M, Augier A, Anglaret X, Shepherd S, Becquet R. Simplifying and optimising management of acute malnutrition in children aged 6 to 59 months: study protocol for a community-based individually randomised controlled trial in Kasaï, Democratic Republic of Congo. BMJ Open 2020; 10:e041213. [PMID: 33268424 PMCID: PMC7713214 DOI: 10.1136/bmjopen-2020-041213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Acute malnutrition (AM) is a continuum condition, arbitrarily divided into moderate and severe AM (SAM) categories, funded and managed in separate programmes under different protocols. Optimising acute MAlnutrition (OptiMA) treatment aims to simplify and optimise AM management by treating children with mid-upper arm circumference (MUAC) <125 mm or oedema with one product-ready-to-use therapeutic food-at a gradually tapered dose. Our main objective was to compare the OptiMA strategy with the standard nutritional protocol in children 6-59 months presenting with MUAC <125 mm or oedema without additional complications, as well as in children classified as uncomplicated SAM (ie, MUAC <115 mm or weight-for-height Z-score (WHZ) <-3 or with oedema). METHODS AND ANALYSIS This study was a non-inferiority, individually randomised controlled clinical trial conducted at community level in the Democratic Republic of Congo. Children 6-59 months presenting with MUAC <125 mm or WHZ <-3 or with bipedal oedema and without medical complication were included after signed informed consent in outpatient health facilities. All participants were followed for 6 months. Success in both arms was defined at 6 months post inclusion as being alive, not acutely malnourished per the definition applied at inclusion and without an additional episode of AM throughout the 6-month observation period. Recovery among children with uncomplicated SAM was the main secondary outcome. For the primary objective, 890 participants were needed, and 480 children with SAM were needed for the main secondary objective. We will perform non-inferiority analyses in per-protocol and intention-to-treat basis for both outcomes. ETHICS AND DISSEMINATION Ethics approvals were obtained from the National Health Ethics Committee of the Democratic Republic of Congo and from the Ethics Evaluation Committee of Inserm, the French National Institute for Health and Medical Research (Paris, France). We will submit results for publication to a peer-reviewed journal and disseminate findings in international and national conferences and meetings. TRIAL REGISTRATION NUMBER NCT03751475. Registered 19 September 2018, https://clinicaltrials.gov/ct2/show/NCT03751475.
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Affiliation(s)
- Cécile Cazes
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Kevin Phelan
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Victoire Hubert
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Rodrigue Alitanou
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Harouna Boubacar
- The Alliance for International Medical Action (ALIMA), Kamuesha, Democratic Republic of Congo
| | - Liévin Izie Bozama
- National Nutrition Programme (PRONANUT), Ministry of Health, Kinshasa, Democratic Republic of Congo
| | - Gilbert Tshibangu Sakubu
- Kamuesha Health Zone in the Kasaï Province, Ministry of Health, Kamuesha, Democratic Republic of Congo
| | - Aurélie Beuscart
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Cyrille Yao
- PACCI Research Programme, University Hospital of Treichville, Abidjan, Côte d'Ivoire
| | - Delphine Gabillard
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Moumouni Kinda
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Augustin Augier
- The Alliance for International Medical Action (ALIMA), Paris, France
| | - Xavier Anglaret
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
| | - Susan Shepherd
- The Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Renaud Becquet
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), Bordeaux Population Health Research Center, Team IDLIC, UMR 1219, Bordeaux, France
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Nane D, Hatløy A, Lindtjørn B. Development and nutritional evaluation of local ingredients-based supplements to treat moderate acute malnutrition among children aged below five years: A descriptive study from rural Wolaita, Southern Ethiopia. Food Sci Nutr 2020; 8:6287-6295. [PMID: 33282278 PMCID: PMC7684584 DOI: 10.1002/fsn3.1927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/11/2020] [Accepted: 09/13/2020] [Indexed: 11/07/2022] Open
Abstract
In Ethiopia, moderate acute malnutrition (MAM) is a persistent public health problem. The current management approaches for MAM among children are counseling in food-secure settings and food supplementation in chronically food-insecure areas. The objective of this study was to develop a local ingredients-based supplement (LIBS) for treating MAM among children. Collection of food ingredients (pumpkin seed, amaranth grain, flaxseed, peanut, and emmer wheat) was made. Sorting, soaking, drying, roasting, and milling of ingredients were done. Nutrient analysis was done using triplicate measurements of each nutrient. One-way ANOVA was used to analyze differences in means with ± standard deviation of nutrient measurements among the supplements. The nutrient content of four developed LIBS ranged from 20.3 g to 22.5 g for protein, 29.3 g to 33.5 g for fat, 509.5 kcal to 570.0 for kcal, 6.0 g to 8.5 g for fiber, 2.8 g to 3.7 g for moisture, and 2.1 g to 4.3 g for ash. The mineral and antinutrient components ranged from 75.6 mg to 115.6 mg for calcium, 473.1 mg to 570.2 mg for potassium, 79.3 mg to 114.4 mg for sodium, 4.1 mg to 5.6 mg for zinc, 8.2 mg to 10.2 mg for iron, 442.6 mg to 470.4 mg for phosphorous, and 2.1 mg to 4.3 mg for phytate. The LIBS with the highest portion of pumpkin seed had significantly highest amounts of protein, fat, calories, iron, zinc, and potassium. The results found were within the recommended range of required nutrients for the treatment of children with MAM. Therefore, LIBS may be used for the management of children with MAM.
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Affiliation(s)
- Debritu Nane
- School of Public and Environmental HealthHawassa UniversityHawassaEthiopia
- Centre for International HealthUniversity of BergenBergenNorway
| | - Anne Hatløy
- Centre for International HealthUniversity of BergenBergenNorway
- Fafo Institute for Labour and Social ResearchOsloNorway
| | - Bernt Lindtjørn
- School of Public and Environmental HealthHawassa UniversityHawassaEthiopia
- Centre for International HealthUniversity of BergenBergenNorway
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Raihan MJ, Choudhury N, Haque MA, Farzana FD, Ali M, Ahmed SMT, Rahman SS, Faruque ASG, Ahmed T. Factors associated with moderate wasting among marginalized 6 to 23-month aged children in Bangladesh: Findings of the Suchana program baseline survey data. PLoS One 2020; 15:e0236786. [PMID: 32817621 PMCID: PMC7440651 DOI: 10.1371/journal.pone.0236786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 07/15/2020] [Indexed: 11/19/2022] Open
Abstract
Suchana-a large-scale, 7-year nutrition program that started in 2015-is being implemented in 250,000 households in the marginalized segment in north-east Bangladesh, with the aim of improving childhood nutrition status. Untreated childhood moderate wasting may develop to severe wasting, which is associated with a 10-fold higher risk of mortality compared to children of normal weight relative to height/length. Identifying the diverse, age-specific risk factors for moderate wasting may help such programs to formulate tailored interventions to prevent and treat childhood malnutrition in rural communities. The objective of this study was to identify the age-specific factors associated with moderate wasting among 6‒23-month-old children in beneficiary households. Cross-sectional data on 4,400 children was collected through systematic sampling between November 2016 and February 2017 using the Suchana beneficiary list. In total, 8.1% of 6‒11 month-olds and 10.3% of 12‒23 month-olds suffered moderate wasting; 12‒23-month-olds had a 1.3-fold higher risk of moderate wasting than 6‒11-month-olds. Our results of logistic regression models suggest that larger household size, higher maternal body mass index (BMI), and maternal food consumption status more than usual during the recent pregnancy were associated with a reduced risk of moderate wasting among 6‒11-month-olds. Higher maternal BMI, normal maternal food consumption status during last pregnancy, being female and maternal knowledge on diarrheal management, were associated with a reduced risk of moderate wasting among 12‒23-month-olds. In conclusion, beyond maternal BMI and maternal food consumption status during the last pregnancy, the factors associated with moderate wasting among 6‒23-month-olds in the poorest households in Bangladesh are age-specific.
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Affiliation(s)
| | - Nuzhat Choudhury
- Nutrition and Clinical Services Division, Mohakhali, Dhaka, Bangladesh
- Department of Anthropology, Durham University, Durham, United Kingdom
| | - Md Ahshanul Haque
- Nutrition and Clinical Services Division, Mohakhali, Dhaka, Bangladesh
| | | | - Mohammad Ali
- Nutrition and Clinical Services Division, Mohakhali, Dhaka, Bangladesh
| | | | | | - A. S. G. Faruque
- Nutrition and Clinical Services Division, Mohakhali, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, Mohakhali, Dhaka, Bangladesh
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Bailey J, Opondo C, Lelijveld N, Marron B, Onyo P, Musyoki EN, Adongo SW, Manary M, Briend A, Kerac M. A simplified, combined protocol versus standard treatment for acute malnutrition in children 6-59 months (ComPAS trial): A cluster-randomized controlled non-inferiority trial in Kenya and South Sudan. PLoS Med 2020; 17:e1003192. [PMID: 32645109 PMCID: PMC7347103 DOI: 10.1371/journal.pmed.1003192] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 06/09/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Malnutrition underlies 3 million child deaths worldwide. Current treatments differentiate severe acute malnutrition (SAM) from moderate acute malnutrition (MAM) with different products and programs. This differentiation is complex and costly. The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6-59 months. Eliminating the need for separate products and protocols could improve the impact of programs by treating children more easily and cost-effectively, reaching more children globally. METHODS AND FINDINGS A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm. Standard care clinics treated SAM with weight-based RUTF rations, and MAM with ready-to-use supplementary food (RUSF). The primary outcome was nutritional recovery. Secondary outcomes included cost-effectiveness, coverage, defaulting, death, length of stay, and average daily weight and MUAC gains. Main analyses were per-protocol, with intention-to-treat analyses also conducted. The non-inferiority margin was 10%. From 8 May 2017 to 31 March 2018, 2,071 children were enrolled in 12 combined protocol clinics (mean age 17.4 months, 41% male), and 2,039 in 12 standard care clinics (mean age 16.7 months, 41% male). In total, 1,286 (62.1%) and 1,202 (59.0%), respectively, completed treatment; 981 (76.3%) on the combined protocol and 884 (73.5%) on the standard protocol recovered, yielding a risk difference of 0.03 (95% CI -0.05 to 0.10, p = 0.52; per-protocol analysis, adjusted for country, age, and sex). The amount of ready-to-use food (RUTF or RUSF) required for a child with SAM to reach full recovery was less in the combined protocol (122 versus 193 sachets), and the combined protocol cost US$123 less per child recovered (US$918 versus US$1,041). There were 23 (1.8%) deaths in the combined protocol arm and 21 (1.8%) deaths in the standard protocol arm (adjusted risk difference 95% CI -0.01 to 0.01, p = 0.87). There was no evidence of a difference between the protocols for any of the other secondary outcomes. Study limitations included contextual factors leading to defaulting, a combined multi-country power estimate, and operational constraints. CONCLUSIONS Combined treatment for SAM and MAM is non-inferior to standard care. Further research should focus on operational implications, cost-effectiveness, and context (Asia versus Africa; emergency versus food-secure settings). This trial is complete and registered at ISRCTN (ISRCTN30393230). TRIAL REGISTRATION The trial is registered at ISRCTN, trial number ISRCTN30393230.
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Affiliation(s)
- Jeanette Bailey
- International Rescue Committee, New York, New York, United States of America
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Bethany Marron
- International Rescue Committee, New York, New York, United States of America
| | | | | | | | - Mark Manary
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - André Briend
- Department of International Health, University of Tampere, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Maternal, Adolescent, Reproductive, & Child Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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30
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Chase RP, Kerac M, Grant A, Manary M, Briend A, Opondo C, Bailey J. 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. PLoS One 2020; 15:e0230452. [PMID: 32492023 PMCID: PMC7269364 DOI: 10.1371/journal.pone.0230452] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/01/2020] [Indexed: 01/31/2023] Open
Abstract
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.
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Affiliation(s)
- Rachel P. Chase
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Marko Kerac
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Angeline Grant
- Action Against Hunger-USA, New York, New York, United States of America
| | - Mark Manary
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States of America
| | - André Briend
- University of Tampere, University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Jeanette Bailey
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
- International Rescue Committee, New York, New York, United States of America
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Abitew DB, Yalew AW, Bezabih AM, Bazzano AN. Predictors of relapse of acute malnutrition following exit from community-based management program in Amhara region, Northwest Ethiopia: An unmatched case-control study. PLoS One 2020; 15:e0231524. [PMID: 32320426 PMCID: PMC7176369 DOI: 10.1371/journal.pone.0231524] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 03/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Community-based management of acute malnutrition (CMAM) is an effective program to manage children with acute malnutrition, including both severe and moderate acute malnutrition. However, little is known about continued child nutritional status after discharge from community based management of acute malnutrition programs in Ethiopia. OBJECTIVE The study aimed to identify factors associated with relapse of acute malnutrition among children 6-59 months after been discharged recovered from community based management program in South Gondar Zone, Northwest Ethiopia. METHODS A case-control study was conducted in three districts of South Gondar Zone by tracing children age 6-59 months who were reported as recovered from the community based management program. Sample size calculated for the first objective of assessing prevalence of severe acute malnutrition among children following discharge as recovery using Epi- Info version 7.1.3.3 StatCalc taking 95% CL, 17.8% post discharge relapse (Ashraf H, et al. (2012), 3% margin of error, design effect of 2 and adding 5% non-response rate was the largest sample size and used to this study. Children with Mid Upper Arm Circumference (MUAC) <12.5cm constituted cases and children with > = 12.5cm served as controls. Data were collected from 10 November 2017 to 30 January 2018 using a survey questionnaire and families were asked to bring children to a health facility for anthropometric measurements, following which data were entered and analyzed. Bivariate and multivariable logistic regression models were utilized to measure association between the risk factors and acute malnutrition. RESULTS Overall, 1,273 participants were interviewed. The mean age in months of children was 23.1 (±9.1 SD) for cases and 23.1 (±8.9 SD) for controls. About 40% of the cases and 50% of the controls were female children. The factors associated with acute malnutrition were: male children (AOR = 1.84, 95% CI: 1.42-2.39), living in a food insecure household (AOR = 1.67, 95% CI:1.15-2.44), non-receipt of Vitamin A supplement (AOR = 1.76, 95% CI: 1.28-2.41), prelacteal feeding (AOR = 2.81 (95%CI, 1.57-5.05), distance to water source more than 15 walk (AOR = 1.88, 95% CI:1.32-2.71), less frequent self-reported hand washing (AOR = 1.35, 95% CI:1.05-1.75), mother not having consumed extra food during this pregnancy/lactation (AOR = 1.36, 95% CI: 1.03-1.78), and respondent age above 30 years (AOR = 1.43, 95% CI:1.10-1.87). CONCLUSION The key factors contributing to relapse of acute malnutrition were related to childcare and feeding practices. Social and behavior change communication strategies targeting families at risk of undernutrition, along with improved food security and integrated programming are recommended to prevent relapse of acute malnutrition.
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Affiliation(s)
| | | | | | - Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States of America
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Lassi ZS, Rind F, Irfan O, Hadi R, Das JK, Bhutta ZA. Impact of Infant and Young Child Feeding (IYCF) Nutrition Interventions on Breastfeeding Practices, Growth and Mortality in Low- and Middle-Income Countries: Systematic Review. Nutrients 2020; 12:E722. [PMID: 32164187 PMCID: PMC7146402 DOI: 10.3390/nu12030722] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/21/2023] Open
Abstract
Undernutrition is associated with 45% of total infant deaths, totalling 2.7 million globally per year. The vast majority of the burden is felt in low- and middle-income countries (LMICs). This review aims to assess the effectiveness of infant and young child feeding (IYCF) interventions. We searched multiple databases including Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE. Title/abstract screening and full-text screening and data extraction filtered 77 studies for inclusion. Breastfeeding education interventions (n = 38) showed 20% increase in rates of early initiation of breastfeeding, 102% increase in exclusive breastfeeding (EBF) at 3 months and 53% increase in EBF at 6 months and 24% decreases in diarrheal diseases. Complementary feeding education intervention (n=12) showed a 0.41 standard deviation (SD) increase in WAZ, and 0.25 SD in HAZ in food secure setting. Complementary food provision with or without education (n=17) showed a 0.14 SD increase in HAZ and 36% decrease in stunting. Supplementary food interventions (n=12) showed a significant 0.15 SD increase in WHZ. Subgroup analyses showed healthcare professional led interventions were largely more effective, especially on breastfeeding outcomes. We believe this is a comprehensive review of the existing literature on IYCF studies in LMICs. Though breastfeeding education is well supported in its effectiveness on breastfeeding practices, limited evidence exists for growth outcomes. Supplementation interventions seem to have better effects at improving growth. However, more research is required to reach more substantial conclusions.
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Affiliation(s)
- Zohra S. Lassi
- Robinson Research Institute, University of Adelaide, Adelaide 5005, Australia
| | - Fahad Rind
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (F.R.); (Z.A.B.)
| | - Omar Irfan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada;
| | - Rabia Hadi
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi 74800, Pakistan; (R.H.); (J.K.D.)
| | - Jai K. Das
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi 74800, Pakistan; (R.H.); (J.K.D.)
| | - Zulfiqar A. Bhutta
- Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan; (F.R.); (Z.A.B.)
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada;
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Nane D, Hatløy A, Tadesse E, Lindtjørn B. Research protocol local ingredients-based supplementary food as an alternative to corn-soya blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: a randomized controlled non-inferiority trial in Wolaita. BMC Public Health 2019; 19:1689. [PMID: 31842852 PMCID: PMC6916533 DOI: 10.1186/s12889-019-8031-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 12/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Ethiopia, 12.5% of children below 5 years are wasted, and 9.7% are moderately wasted. The present strategy for the management of moderate acute malnutrition (MAM) is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. This randomized controlled non-inferiority trial examines if Local ingredients-based supplement (LIBS) is as effective as corn-soya blends plus (CSB+) in treating moderate acute malnutrition among children aged 6-59 months. METHODS A randomized controlled non-inferiority trial will be conducted with moderately wasted children aged 6 to 59 months in Wolaita, Ethiopia. The calculated sample size is 324 (i.e. with 162 children in each of two arms, to be assigned by randomization). The daily ration will be: 100 g of LIBS plus 25.2 g of sugar with 8 ml oil in the intervention group, and 150 g of CSB+ with 16 ml of oil in the control group. These interventions will be provided for a maximum period of 12 weeks, with follow-up performed on a weekly basis. Data analysis will be done using SPSS and STATA software. Both intention-to-treat and per protocol analyses will be done. Hazard ratio and Kaplan-Meier (log rank) curves of survival analysis will be done to predict the probability of recovery rate. Logistic regression will be used to test for interactions between independent and dependent variables. Analysis of variances, t-tests, fisher's exact test and chi-square tests will be used to assess baseline characteristics. CONCLUSIONS This paper will introduce to the existing research locally available nutritious foods which have the potential to enhance recovery from moderate acute malnutrition and to reduce the burden of malnutrition. The perceptions of mothers on feeding children with local ingredient-based supplementary food to assist recovery from moderate acute malnutrition will be the focus of in a qualitative study to follow; this will provide a further contribution in an evolving area of research. TRIAL REGISTRATION Pan-African Clinical Trial Registration number: PACTR201809662822990, retrospectively registered on 11/09/2018.
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Affiliation(s)
- Debritu Nane
- Hawassa University, School of Public and Environmental Health, PO Box 5, Hawassa, Ethiopia
- Centre for International Health, University of Bergen, PO Box 7800, 5020 Bergen, Norway
| | - Anne Hatløy
- Centre for International Health, University of Bergen, PO Box 7800, 5020 Bergen, Norway
- Fafo Institute for Labour and Social Research, PO Box 2947, 0608 Oslo, Norway
| | - Elazar Tadesse
- Kotebe Metropolitan University, PO Box 31228, Addis Ababa, Ethiopia
| | - Bernt Lindtjørn
- Centre for International Health, University of Bergen, PO Box 7800, 5020 Bergen, Norway
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Mamo WN, Derso T, Gelaye KA, Akalu TY. Time to recovery and determinants of severe acute malnutrition among 6-59 months children treated at outpatient therapeutic programme in North Gondar zone, Northwest Ethiopia: a prospective follow up study. Ital J Pediatr 2019; 45:136. [PMID: 31684989 PMCID: PMC6829982 DOI: 10.1186/s13052-019-0732-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the available interventions to tackle nutritional problems, there is scarce information on time to recovery and its determinants among children with SAM in Ethiopia. OBJECTIVE This study was aimed at finding the time to recovery and determinants among 6-59 months children with severe acute malnutrition treated at an outpatient therapeutic programme in North Gondar zone, northwest Ethiopia. METHODS Facility based prospective follow up study was conducted from March 24 to May 24, 2017. A total of 408 children with the age of 6-59 months were included in the study. Structured interviewer administered questionnaire was used. Anthropometric measurements were conducted every week. The median time of recovery, Kaplan Meier (KM) curve, and log rank test were computed. Both bi-variable and multivariable Cox regression model was fitted. To establish an association between time to recovery and its determinants 95% confidence interval (CI) and p-value < 0.05 were used. Proportional hazard assumption was checked graphically and using Schoenfeld residual test. RESULTS Out of 389 children, 254 (65.3%) recovered. The median time to recovery was 38.5 ± IQR of 14 days. Children with diarrhoea AHR = 0.81 with 95% CI (0.73, 0.99), children taken amoxicillin AHR = 2.304 with 95% CI (1.68-3.161), and had vomiting at admission AHR = 0.430 with 95% CI (0.205, 0.904) were significant predictors of time to recovery. CONCLUSIONS AND RECOMMENDATIONS The overall time to recovery has not met the minimum sphere international standard which was lower than 75%. It is advisable to give emphasis to patients with diarrhoea and vomiting.
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Affiliation(s)
| | - Terefe Derso
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kassahun Alemu Gelaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Temesgen Yihunie Akalu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
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Lelijveld N, Beedle A, Farhikhtah A, Elrayah EE, Bourdaire J, Aburto N. Systematic review of the treatment of moderate acute malnutrition using food products. MATERNAL AND CHILD NUTRITION 2019; 16:e12898. [PMID: 31667981 PMCID: PMC7038867 DOI: 10.1111/mcn.12898] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/02/2019] [Accepted: 09/25/2019] [Indexed: 01/05/2023]
Abstract
There is currently a lack of international guidance on the most appropriate treatment for moderate acute malnutrition (MAM), and discrepancies in national treatment guidelines exist. We aimed to explore whether food interventions are effective for MAM children 6–59 months old and whether they result in better outcomes compared with no treatment or management with nutrition counselling. A systematic literature search was conducted in October 2018, identifying studies that compared treating MAM children with food products versus management with counselling or no intervention. A total of 673 abstracts were screened, 101 full texts were read, and one study was identified that met our inclusion criteria. After broadening the criteria to include micronutrients in the control group and enrolment based on out‐dated anthropometric criteria, 11 studies were identified for inclusion. Seven of these found food products to be superior for anthropometric outcomes compared with counselling and/or micronutrient supplementation; two of the studies found no significant benefit of a food product intervention; and two studies were inconclusive. Hence, the majority of studies in this review found that food products resulted in greater anthropometric gains than counselling or micronutrient interventions. This was especially true if the supplementary food provided was of suitable quality and provided for an adequate duration. Improving quality of and adherence to counselling may improve its effectiveness, particularly in food secure contexts. There is currently a paucity of comparable studies on this topic as well as a lack of studies that include important functional outcomes beyond anthropometric proxies.
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Affiliation(s)
- Natasha Lelijveld
- School of Human Development and Health, University of Southampton, Southampton, UK
| | - Alexandra Beedle
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Nancy Aburto
- United National World Food Programme, Rome, Italy
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Desyibelew HD, Baraki AG, Dadi AF. Mortality rate and predictors of time to death in children with severe acute malnutrition treated in Felege-Hiwot Referral Hospital Bahir Dar, Northwest Ethiopia. BMC Res Notes 2019; 12:409. [PMID: 31307556 PMCID: PMC6631743 DOI: 10.1186/s13104-019-4467-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives This study aimed to determine mortality rate, time to death and factors affecting the time to death among children with severe acute malnutrition admitted to therapeutic feeding unit of Felege Hiwot Referral Hospital, Bahirdar. Result A total of 401 children with severe acute malnutrition who were admitted to therapeutic feeding units from September 2012 to January 2016 were included in the study. The incidence of death rate was 8.47% (95% CI 6.11%, 11.65%). The median time to death was 3 days (Inter Quartile Range of 4 days). Children’s of age > 24 months (AHR = 0.27; 95% CI 0.1, 0.73), fully vaccinated status (AHR = 0.16; 95% CI 0.07, 0.36), HIV infection (AHR = 3.82; 95% CI 1.3, 11.15) and congestive heart failure (AHR = 6.98; 95% CI 2.42, 20.09) were significant predictors of mortality among children admitted for severe acute malnutrition.
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Affiliation(s)
- Hanna Demelash Desyibelew
- Department of Public Health Nutrition, College of Medicine and Health Sciences, Bahirdar University, Bahir Dar, Ethiopia
| | - Adhanom Gebreegziabher Baraki
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Abel Fekadu Dadi
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.,Flinders University, Health Sciences Building, Sturt Road, Bedford Park, Adelaide, SA, 5001, Australia
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Mark H, Been JV, Sonko B, Faal A, Ngum M, Hasan J, Prentice AM, Unger SA. Nutritional status and disease severity in children acutely presenting to a primary health clinic in rural Gambia. BMC Public Health 2019; 19:668. [PMID: 31146716 PMCID: PMC6543667 DOI: 10.1186/s12889-019-6959-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 05/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accurate and timely data on the health of a population are key for evidence-based decision making at both the policy and programmatic level. In many low-income settings, such data are unavailable or outdated. Using an electronic medical records system, we determined the association between nutritional status and severe illness and mortality among young children presenting to a rural primary health care facility in the Gambia. METHODS Clinical data collected over five years (2010-2014) on children aged under 60 months making acute visits to a primary health care clinic in the rural Gambian district of Kiang West were retrospectively extracted from the medical records system. Generalised estimating equation models were used to investigate associations between nutritional status and illness severity, accounting for repeat visits, gender, age and access to transport to the clinic. The Population Attributable Fraction (PAF) was used to determine the proportion of severe illness likely attributable to different grades of malnutrition. RESULTS 3839/5021 (77%) children under 60 months of age living in Kiang West presented acutely to the clinic at least once, yielding 21,278 visits (47% girls, median age 20.2 months (Interquartile Range (IQR) 23.92 months)) and 26,001 diagnoses, 86% being infectious diseases. Severe illness was seen in 4.5% of visits (961/21,278). Wasting was associated with an increased risk of severe illness in a dose-dependent manner, ('WHZ < -1' adjusted Odds Ratio (aOR) 1.68, 95% CI:1.43-1.98, p < 0.001, 'WHZ <-2 and ≥-3' aOR 2.78, 95% CI:2.31-3.36, p < 0.001 and 'WHZ < -3' aOR 7.82, 95% CI:6.40-9.55, p < 0.001) the PAF for wasting (WHZ < -2) was 0.21 (95% CI: 0.18-0.24). Stunting, even in the most severe form (HAZ < -3), was not significantly associated with severe illness (aOR 1.19 95% CI:0.94-1.51) but was associated with a significantly increased risk of death (aOR 6.04 95% CI:1.94-18.78). CONCLUSION In this population-based cohort of young children in rural Gambia, wasting was associated with disease severity in a dose-dependent manner. Further research is needed into strategies to identify and reach these children with effective interventions to improve their nutritional status.
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Affiliation(s)
- Henry Mark
- MRC Unit The Gambia, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Jasper V. Been
- Division of Neonatology, Department of Paediatrics, and Department of Obstetrics and Gynaecology, Erasmus MC – Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Bakary Sonko
- MRC Unit The Gambia, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Abdoulie Faal
- MRC Unit The Gambia, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Mohammed Ngum
- MRC Unit The Gambia, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Jahid Hasan
- MRC Unit The Gambia, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
| | - Andrew M. Prentice
- MRC Unit The Gambia, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Stefan A. Unger
- MRC Unit The Gambia, Atlantic Boulevard, Fajara, P.O. Box 273, Banjul, The Gambia
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
- Department of Child Life and Health, University of Edinburgh, 20 Sylvan Place, Edinburgh, EH9 1UW UK
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Hosseinzadeh-Attar MJ, Belay GD, Ardalan A, Assen M, Khoei EM, Ostadtaghizadeh A. Assessment of malnutrition and anthropometric measurement among 0-59 months aged children in Amibara and Awash Fentale districts, afar national regional state of Ethiopia. Hum Antibodies 2019; 27:43-52. [PMID: 30958342 DOI: 10.3233/hab-190371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Famines and food shortages are one of the most common long time histories of Ethiopia. Hence, malnutrition has been persisted at alarming raters in the country. Moreover, it is a major cause of morbidity and mortality in Afar National Regional State of Ethiopia. Specifically, in Amibara and Awash Fentale districts. The anthropometric data were presented on height, weight, MUAC, weight/height/Age and Body Mass Index (BMI) of under-five children. METHODS A cross-sectional descriptive survey was conducted from March 01, 2017 to June 15, 2018. The data was collected by using anthropometric measurement. A multi stage random sampling procedure was applied in order to recruit the required sample size. The data collections were conducted at two selected districts in Afar region by trained interviewers and health care providers. The data were analyzed by using SPSS Version 23. Bivariate analysis between dependent and independent variables was employed. Multivariate analysis was also done to control for possible confounding variable by selecting variable which show statistically significant association (P< 0.05). RESULTS Out of 410 under five children's anthropometric finding, the majorities (62.7%) of those registered under five children were male and (33.3%) were female. The majority (46.8%) of under five children were less than or equal to 50 cm by their height. Most (54.1%) of under five children were less than or equal to 12.5 cm by their MUAC. It indicated that they were diagnosed with severe malnutrition based on anthropometric measurements. Meanwhile, majority (64%) of under five children were less than 60% their weight/age. Regression analysis result indicated that all of the variables were not significant predictors of BMI for under five children (P> 0.05). Based on ANOVA result, there was significant difference between sex and other predictors (P= 0.031). This finding implies that improvement in food aid and poverty alleviation programs are very important. Based on the finding, it is important to provide high quality and quantity of food. Moreover, less access to assets and health services commonly contributed for malnutrition. Highlighting under five children's malnutrition will help to develop and design future policies and programs in Ethiopia.
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Affiliation(s)
| | - Gosaye Degu Belay
- Department of Health in Emergencies and Disasters, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Disaster and Emergency Health, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Ardalan
- Department of Health in Emergencies and Disasters, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammed Assen
- Department of Geography and Environmental Studies, Addis Ababa University, Addis Ababa, Ethiopia
| | - Effat Merghati Khoei
- The National Center for Addiction Studies (INCAS); Tehran University of Medical Sciences (TUMS); Family and Sexual Health Division, Brian and Spinal Injury Research Center (BASIR), Neuroscience Institution, TUMS, Tehran, Iran
| | - Abbas Ostadtaghizadeh
- Department of Health in Emergencies and Disasters, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Abate KH, Belachew T. Chronic Malnutrition Among Under Five Children of Ethiopia May Not Be Economic. A Systematic Review and Meta-Analysis. Ethiop J Health Sci 2019; 29:265-277. [PMID: 31011275 PMCID: PMC6460457 DOI: 10.4314/ejhs.v29i2.14] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 09/10/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Ethiopia is one of the four low income countries in achieving MDG4, however, minimizing child undernutrition became critical undertaking thus far. This review aimed at identifying the predictors of under-5 children nutrition in Ethiopia. METHODS Databases searched were Med Line, HINARY, MedNar and Embase. Furthermore, gray literatures were also sought. All papers selected for inclusion in the review were subjected to a rigorous critical appraisal using standardized critical appraisal instruments from the Joanna Briggs Institute. Quantitative papers were pooled for statistical analysis and narrative synthesis. Odds ratios and their 95% confidence intervals were calculated for analysis. Papers of optimal quality but without optimal data set for meta-analysis were subjected for narrative synthesis. RESULTS Nonadherence towards Optimal feeding recommendations was the most reported predictor of stunting and wasting, while, maternal education and 'Water, Sanitation and Hygiene' factors were the second. The findings of the Meta-analysis showed no evidence of association between household income/wealth and stunting of children in Ethiopia (OR=1.14, 95% CI= 0.97, 1.34), heterogeneity test: i2 = 92%, df = 20, (P < 0.00001). On the other hand, children in low income/wealth group were 1.73 times more likely to have wasting compared to children of the higher income/wealth households (OR=1.73, 95% C I= 1.51, 1.97) heterogeneity test: i2 = 71%, df = 20, (P < 0.00001). CONCLUSION An over-reliance on macroeconomic growth as a solitary factor towards undernutrition should not be the way forward. Supplementary and more focused nutrition specific and sensitive interventions are needed in Ethiopia.
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Affiliation(s)
- Kalkidan Hassen Abate
- Department of Population and Family Health, Institute of Health Sciences, Jimma University
| | - Tefera Belachew
- Department of Population and Family Health, Institute of Health Sciences, Jimma University
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Stobaugh H. Maximizing Recovery and Growth When Treating Moderate Acute Malnutrition with Whey-Containing Supplements. Food Nutr Bull 2018; 39:S30-S34. [PMID: 30238798 DOI: 10.1177/0379572118774492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Much debate exists about the utility of dairy ingredients in the supplementary foods used to treat childhood moderate acute malnutrition (MAM). OBJECTIVE To review the evidence regarding the effectiveness of dairy-containing supplements, particularly specially formulated foods containing whey permeate and whey protein concentrate, in treating children with MAM. METHODS A summary of a conference presentation regarding an overview of current evidence behind the use of whey in supplementary foods, including results of a randomized double-blinded clinical effectiveness trial involving 2259 Malawian children treated for MAM using either a soy ready-to-use supplementary food (RUSF) or a novel whey RUSF treatment. RESULTS While the majority of the evidence base only suggests potential benefits of including whey in supplementary foods to treat MAM, a recent study specifically demonstrates that a whey RUSF produced superior recovery and growth outcomes in treating children with MAM when compared with a soy RUSF. CONCLUSIONS The use of whey ingredients has been shown to improve outcomes in the treatment of MAM; however, further research is needed to identify the ideal amount and type of dairy protein required to produce the best outcomes for the lowest cost.
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Fabiansen C, Phelan KPQ, Cichon B, Yaméogo CW, Iuel-Brockdorff AS, Kurpad A, Wells JC, Ritz C, Filteau S, Briend A, Christensen VB, Michaelsen KF, Shepherd S, Friis H. Short Malnourished Children and Fat Accumulation With Food Supplementation. Pediatrics 2018; 142:peds.2018-0679. [PMID: 30143567 DOI: 10.1542/peds.2018-0679] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In moderate acute malnutrition programs, it is common practice to not measure mid-upper arm circumference (MUAC) of children whose length is <67 cm. This is based on expert opinion that supplementation of shorter children with low MUAC and weight-for-height z score ≥-2 may increase risk of excessive fat accumulation. Our aim was to assess if shorter children gain more fat than taller children when treated for moderate acute malnutrition diagnosed by low MUAC alone. METHODS In this observational study, we included children aged 6 to 23 months with a MUAC between 115 and 125 mm and a weight-for-height z score ≥-2. On the basis of length at admission, children were categorized as short if <67 cm and long if ≥67 cm. Linear mixed-effects models were used to assess body composition on the basis of deuterium dilution and skinfold thickness. RESULTS After 12 weeks of supplementation, there was no difference in change in fat mass index (-0.038 kg/m2, 95% confidence interval [CI]: -0.257 to 0.181, P = .74) or fat-free mass index (0.061 kg/m2, 95% CI: -0.150 to 0.271, P = .57) in short versus long. In absolute terms, the short children gained both less fat-free mass (-230 g, 95% CI: -355 to -106, P < .001) and fat mass (-97 g, 95% CI: -205 to 10, P = .076). There was no difference in changes in absolute subscapular and triceps skinfold thickness and z scores (P > .5). CONCLUSIONS Short children with low MUAC do not gain excessive fat during supplementation. With these data, we support a recommendation for policy change to include all children ≥6 months with low MUAC in supplementary feeding programs, regardless of length. The use of length as a criterion for measuring MUAC to determine treatment eligibility should be discontinued in policy and practice.
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Affiliation(s)
- Christian Fabiansen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark; .,Médecins Sans Frontières, Denmark, Copenhagen, Denmark
| | | | - Bernardette Cichon
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,Médecins Sans Frontières, Denmark, Copenhagen, Denmark
| | - Charles W Yaméogo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,Département Biomédical et Santé Publique, Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
| | - Ann-Sophie Iuel-Brockdorff
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,Médecins Sans Frontières, Denmark, Copenhagen, Denmark
| | - Anura Kurpad
- Division of Nutrition, St John's Research Institute, Koramangala, Bangalore, India
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Suzanne Filteau
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,Tampere Center for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland; and
| | - Vibeke B Christensen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark.,Department of Paediatrics, Rigshospitalet, Copenhagen, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Sénégal
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
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Dale NM, Salim L, Lenters L, Sadruddin S, Myatt M, Zlotkin SH. Recovery and relapse from severe acute malnutrition after treatment: a prospective, observational cohort trial in Pakistan. Public Health Nutr 2018; 21:2193-2199. [PMID: 29615143 PMCID: PMC11106019 DOI: 10.1017/s1368980018000745] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 02/21/2018] [Accepted: 03/02/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Millions of children suffer from severe acute malnutrition (SAM) in low- and middle- income countries. Much is known about the effectiveness of community treatment programmes (CMAM) but little is known about post-discharge outcomes after successful treatment. The present study aimed to evaluate post-discharge outcomes of children cured of SAM. DESIGN Prospective, observational cohort study. Children with SAM who were discharged as cured were followed monthly for 6 months or until they experienced relapse to SAM. 'Cure' was defined as a child achieving a mid-upper arm circumference (MUAC) of ≥115 mm with ≥15 % weight gain after loss of oedema. Relapse was defined as a child with MUAC<115 mm and/or oedema at any monthly visit. SETTING Save the Children CMAM programme in Swabi, Pakistan, from January 2012 to December 2014. SUBJECTS Children aged 6-59 months (n 117) discharged as cured from the CMAM programme were eligible for the study and followed for 6 months. RESULTS One hundred children (92·6 %) remained free of SAM, eight (7·4 %) relapsed to SAM, nine (8·3 %) were lost to follow-up and none died. Most relapses occurred within 3 months of discharge (mean time to relapse 73·4 (sd 36·2) d). At enrolment, 90 % had moderate acute malnutrition (MAM) and 10 % were not malnourished. By the end of 6 months, 35 % persisted with MAM and the remaining were not malnourished. CONCLUSIONS In rural Pakistan, fewer than 10 % of children cured of SAM relapsed. The first 3 months is the most vulnerable time.
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Affiliation(s)
- Nancy M Dale
- 1Tampere Centre for Child Health Research,University of Tampere and Tampere University Hospital,Tampere,Finland
| | | | | | - Salim Sadruddin
- 5Global Malaria Programme,World Health Organization,Geneva,Switzerland
| | | | - Stanley H Zlotkin
- 2Centre for Global Child Health,Hospital for Sick Children,525 University Avenue,Suite 701,Toronto,Ontario,Canada,M5G 2L3
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Stobaugh HC, Rogers BL, Rosenberg IH, Webb P, Maleta KM, Manary MJ, Trehan I. Children with Poor Linear Growth Are at Risk for Repeated Relapse to Wasting after Recovery from Moderate Acute Malnutrition. J Nutr 2018; 148:974-979. [PMID: 29726948 DOI: 10.1093/jn/nxy033] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/30/2018] [Indexed: 02/06/2023] Open
Abstract
Background Nutrition programs frequently approach wasting and stunting as 2 separate conditions with distinct causes and effects. Although several cross-sectional studies have identified an association between the 2 conditions, longitudinal studies are useful to quantify the risk of acute malnutrition based on the trajectory of linear growth. Objective We analyzed data from a longitudinal study to explore associations between linear growth and relapse to acute malnutrition in high-risk children during the year after recovery from moderate acute malnutrition (MAM). Methods This was a secondary data analysis from a cluster randomized trial involving 1487 Malawian children 6-62 mo old treated for MAM and enrolled upon recovery. Children were followed for 1 y, during which data were collected on anthropometric progress, symptoms of illness, and household food security. Multivariate fixed-effects logistic regression was used to identify associations between linear growth and relapse to acute malnutrition. Results Children who have recovered from MAM proved to be a high-risk population, with nearly half experiencing a decrease in height-for-age z score (HAZ) for 12 mo. Children whose HAZ was declining were more likely to relapse to MAM or SAM than were those whose linear growth rate maintained or increased their HAZ (P < 0.001). Mean changes of +0.15, -0.03, -0.17, and -0.53 in HAZ were observed for those who sustained recovery, relapsed to MAM once, relapsed to MAM multiple times, and developed SAM, respectively. Conclusion Our results add to the body of evidence suggesting that acute wasting is a harbinger of subsequent stunting. Children who experience poor linear growth after MAM are more likely to experience relapse. Given this bidirectional relation between wasting and stunting, supplementary feeding programs should consider both when designing protocols, aiming to optimize linear growth and achieve acute weight gain, as a means of reducing relapse. This trial was registered at clinicaltrials.gov as NCT02351687.
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Affiliation(s)
- Heather C Stobaugh
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA.,RTI International, Research Triangle Park, NC
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Irwin H Rosenberg
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Kenneth M Maleta
- School of Public Health and Family Medicine, and Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,School of Public Health and Family Medicine, and Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi.,Children's Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.,Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi.,Lao Friends Hospital for Children, Luang Prabang, Lao PDR
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Ngari MM, Mwalekwa L, Timbwa M, Hamid F, Ali R, Iversen PO, Fegan GW, Berkley JA. Changes in susceptibility to life-threatening infections after treatment for complicated severe malnutrition in Kenya. Am J Clin Nutr 2018; 107:626-634. [PMID: 29635501 PMCID: PMC6134064 DOI: 10.1093/ajcn/nqy007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/08/2018] [Indexed: 12/15/2022] Open
Abstract
Background Goals of treating childhood severe acute malnutrition (SAM), in addition to anthropometric recovery and preventing short-term mortality, include reducing the risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation are unknown but could inform improving the design and scope of interventions. Objective The aim of this study was to investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM. Design This was a secondary analysis of a clinical trial including 1778 HIV-uninfected Kenyan children aged 2-59 mo with complicated SAM, enrolled after the inpatient stabilization phase of treatment, and followed for 12 mo. The main outcome was LTEs, defined as infections requiring rehospitalization or causing death. We examined anthropometric variables measured at months 1, 3, and 6 after enrollment in relation to LTEs occurring during the 6 mo after each of these time points. Results Over 12 mo, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months 1, 3, and 6, 557 (34%), 764 (49%), and 842 (56%) children had a weight-for-height or -length z score (WHZ) ≥-2, respectively, which, compared with a WHZ <-3, was associated with lower risks of subsequent LTEs [adjusted HRs (95% CIs): 0.50 (0.40, 0.64), 0.30 (0.23, 0.39), and 0.23 (0.16, 0.32), respectively]. However, children with a WHZ ≥-2 at 1, 3, and 6 mo still had 39 (95% CI: 32, 47), 26 (95% CI: 22, 32), and 15 (95% CI: 12, 20) LTEs/100 child-years of observation during the following 6 mo. WHZ at study enrollment predicted subsequent WHZ but not the risk of LTEs. Changes in height-for-age z score did not predict LTEs. Conclusions Anthropometric response was associated with a rapid and substantial reduction in risk of LTEs. However, reduction in susceptibility lagged behind anthropometric improvement. Disease events, together with anthropometric assessment, may provide a clearer picture of the effectiveness of interventions. Robust protocols for detecting and treating poor anthropometric recovery and addressing broader vulnerabilities that complicated SAM indicates may save lives. This trial was registered at www.clinicaltrials.gov as NCT00934492.
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Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | | | - Molline Timbwa
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Fauzat Hamid
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Rehema Ali
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Per Ole Iversen
- Department of Nutrition, IBM, University of Oslo, Norway
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Greg W Fegan
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Gizaw Z, Woldu W, Bitew BD. Acute malnutrition among children aged 6-59 months of the nomadic population in Hadaleala district, Afar region, northeast Ethiopia. Ital J Pediatr 2018; 44:21. [PMID: 29415750 PMCID: PMC5803907 DOI: 10.1186/s13052-018-0457-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 01/16/2018] [Indexed: 01/12/2023] Open
Abstract
Background Acute malnutrition to be a major health burden in the world, particularly in the developing world. Acute malnutrition is associated with more than one third of the global disease burden for children. Malnourished children are physically, emotionally and intellectually less productive and suffer more from chronic illnesses and disabilities. The nature, magnitude and determinants of acute malnutrition are determined among the general populations; however, there is a lack of evidence in the nomadic communities. Methods A cross-sectional study was conducted to assess the magnitude and factors associated with acute malnutrition among children aged 6–59 months in Hadaleala district, Afar Region. A total of 591 under-five children were included in this study, and subjects were recruited by the multistage cluster sampling technique. Data were collected by a pre-tested questionnaire and a simple anthropometric index so called mid-upper arm circumference (MUAC). The multivariable binary logistic regression analysis was used to identify factors associated with acute malnutrition on the basis of adjusted odds ratio (AOR) with 95% confidence interval (CI) and p < 0.05. Results The prevalence of acute malnutrition was 11.8% (95% CI = 9.3, 14.8%). The highest prevalence (50%) of acute malnutrition occurred among children aged between 12.0–23.0 months. Childhood acute malnutrition was associated with the presence of two (AOR = 2.49, p < 0.05) and three (AOR = 12.87, p < 0.001) children in each household, unprotected drinking water sources (AOR = 3.78, p < 0.05), absence of the latrine (AOR = 5.24, p < 0.05), hand washing with soap (AOR = 0.21, p < 0.05), childhood diarrheal disease (AOR = 2.72, p < 0.05), and child vaccination (AOR = 0.15, p < 0.001). Conclusion The prevalence of acute malnutrition among children aged 6-59 months was was higher than the national prevalence. The number of children in each household, drinking water sources, latrine availability, hand washing practice before food preparation and child feeding, childhood diarrheal disease, and child vaccination were identified as factors affecting the childhood acute malnutrition in the nomadic community. Protecting drinking water sources from possible contaminants, improving hand washing practices, utilization of latrine, preventing diarrheal diseases and vaccinating children integrated with the access of nutrition education is important to improve nutrition of children of the nomadic people.
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Affiliation(s)
- Zemichael Gizaw
- Department of Environmental and Occupational Health and Safety, University of Gondar, Gondar, Ethiopia.
| | - Wondwoson Woldu
- Hadaleala District Health Office, Hadaleala District, Afar Regional State, Ethiopia
| | - Bikes Destaw Bitew
- Department of Environmental and Occupational Health and Safety, University of Gondar, Gondar, Ethiopia
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Lassi ZS, Irfan O, Hadi R, Das JK, Bhutta ZA. PROTOCOL: Effects of interventions for infant and young child feeding (IYCF) promotion on optimal IYCF practices, nutrition, growth and health in low- and middle-income countries: a systematic review. CAMPBELL SYSTEMATIC REVIEWS 2018; 14:1-26. [PMID: 37131389 PMCID: PMC8427994 DOI: 10.1002/cl2.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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Adamu W, Jara D, Alemayehu M, Burrowes S. Risk factors associated with poor health outcomes for children under the age of 5 with moderate acute malnutrition in rural fagita lekoma district, Awi Zone, Amhara, Ethiopia, 2016. BMC Nutr 2017; 3:88. [PMID: 32153864 PMCID: PMC7050731 DOI: 10.1186/s40795-017-0208-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Left untreated, moderate acute malnutrition (MAM) in children can lead to severe acute malnutrition, stunting, developmental delays, and death. Despite recent progress the prevalence of malnutrition remains high throughout Ethiopia. The ability to make accurate prognoses and develop effective treatment strategies for children with MAM is currently limited and, as result, a significant proportion of children with MAM fail to recover even with treatment. We seek to address this limitation by assessing the risk factors for poor outcomes among children under the age of 5 with MAM in a rural area of Ethiopia's Amhara Region. This region is considered relatively food secure and does not have food supplementation treatment programs. METHODS We conducted a prospective cohort study of 404 randomly sampled children, 0-59 months old stratified by household food security status. We followed the study children for approximately 2 months, assessing their health status; and used bivariate and multivariate Cox-proportional hazard regression models to identify risk factors for poor health outcomes. RESULTS Household food security was significantly associated with low recovery from MAM: 191 (60%) of children in food-insecure and 129 (40%) of children in food-secure households had poor health outcomes. The risk factors found to be significantly associated with poor health outcomes included the duration of exclusive breastfeeding (AHR 1.50, 95%CI: 1.05, 2.15), dietary diversity (AHR 1.74, 95%CI: 1.18, 2.54), and maternal mid-upper arm circumference (AHR=1.36, 95% CI: 1.04, 1.86). Children from pregnancies that were wanted but unplanned had 80% higher incidence of poor health outcomes than others, and children from pregnancies that were both unwanted and unplanned had more than double the incidence of poor health outcomes compared to their counterparts. CONCLUSION We found that without treatment, the majority of children from food insecure households and over a third of children from food secure households did not recover from MAM. Maternal factors particularly the mother's ability to plan her pregnancy were the main determinants of recovery in this study. Together these findings support arguments for targeting of nutrition support programs to vulnerable households regardless of regional food security status, and for closely integrating robust family planning, and antenatal care services with nutrition interventions.
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Affiliation(s)
| | - Dube Jara
- Department of Public Health, College of Medicine and Health Science Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Mulunesh Alemayehu
- Department of Public Health, College of Medicine and Health Science Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Sahai Burrowes
- Public Health Program, College of Education and Health Sciences, Touro University California, 1310 Club Drive, Mare Island Vallejo, CA 94592 USA
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48
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Bahwere P, James P, Abdissa A, Getu Y, Getnet Y, Sadler K, Girma T. Use of tuberculin skin test for assessment of immune recovery among previously malnourished children in Ethiopia. BMC Res Notes 2017; 10:570. [PMID: 29115985 PMCID: PMC5688824 DOI: 10.1186/s13104-017-2909-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 11/01/2017] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To compare levels of immunity in children recovering from severe acute malnutrition (cases) against those of community controls (controls). RESULTS At baseline children recovering from severe acute malnutrition had lower, mid upper arm circumference (122 mm for cases and 135 mm for controls; p < 0.001), weight-for-height Z-score (- 1.0 for cases and - 0.5 for controls; p < 0.001), weight-for-age Z-score (- 2.8 for cases and - 1.1 for controls; p < 0.001) and height/length-for-age Z-score (- 3.6 for cases and - 1.4 for controls; p < 0.001), than controls. Age and gender matched community controls. At baseline, prevalence of a positive tuberculin skin test, assessed by cutaneous delayed-type hypersensitivity reaction skin test, was very low in both cases (3/93 = 3.2%) and controls (2/94 = 2.1%) and did not significantly increase at 6 months follow up (6/86 = 7.0% in cases and 3/84 = 3.4% in controls). The incidences of common childhood morbidities, namely fever, diarrhoea and cough, were 1.7-1.8 times higher among cases than controls. In conclusion, these results show that tuberculin skin test does not enable any conclusive statements regarding the immune status of patients following treatment for severe acute malnutrition. The increased incidence of infection in cases compared to controls suggests persistence of lower resistance to infection even after anthropometric recovery is achieved.
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Affiliation(s)
- Paluku Bahwere
- Valid International, 35, Leopold Street, Oxford, OX4 1TW UK
- Research Centre in Epidemiology, Biostatistics and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
| | - Philip James
- Valid International, 35, Leopold Street, Oxford, OX4 1TW UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Alemseged Abdissa
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Jimma, Oromia Ethiopia
| | - Yesufe Getu
- Save Children Federation, Addis Ababa, Ethiopia
| | | | - Kate Sadler
- Valid International, 35, Leopold Street, Oxford, OX4 1TW UK
| | - Tsinuel Girma
- Department of Paediatrics and Child Health, Jimma University, Jimma, Oromia Ethiopia
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Brits H, Joubert G, Eyman K, De Vink R, Lesaoana K, Makhetha S, Moeketsi K. An assessment of the integrated nutrition programme for malnourished children aged six months to five years at primary healthcare facilities in Mangaung, Free State, South Africa. S Afr Fam Pract (2004) 2017. [DOI: 10.1080/20786190.2017.1340252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Hanneke Brits
- Faculty of Health Sciences, Department of Family Medicine, University of the Free State, Bloemfontein, South Africa
| | - Gina Joubert
- Faculty of Health Sciences, Department of Biostatistics, University of the Free State, Bloemfontein, South Africa
| | - Keshia Eyman
- Faculty of Health Sciences, School of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Rosie De Vink
- Faculty of Health Sciences, School of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Katleho Lesaoana
- Faculty of Health Sciences, School of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Sello Makhetha
- Faculty of Health Sciences, School of Medicine, University of the Free State, Bloemfontein, South Africa
| | - Katiso Moeketsi
- Faculty of Health Sciences, School of Medicine, University of the Free State, Bloemfontein, South Africa
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