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Differences in Growth of HIV-exposed Uninfected Infants in Ethiopia According to Timing of In-utero Antiretroviral Therapy Exposure. Pediatr Infect Dis J 2020; 39:730-736. [PMID: 32516280 PMCID: PMC7360102 DOI: 10.1097/inf.0000000000002678] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are concerns about the adverse effect of in-utero exposure to antiretroviral therapy (ART) on the growth of HIV exposed-uninfected (HEU) infants. We compared growth of HEU-infants according to the timing and type of ART exposure. METHODS A retrospective cohort study was conducted by abstracting clinical data from HIV-infected mothers and HEU-infants in Addis Ababa, Ethiopia between February 2013 and October 2016. Mixed-effects linear models were used to compare changes in weight and length and cox proportional hazard models were used to evaluate stunting (length-for-age z score <-2.0) and underweight (weight-for-age z score <-2.0). RESULTS A total of 624 HEU-infants were included in the analyses. Infants exposed to ART from conception had a lower rate of change in length [β = -0.54, 95% confidence interval (CI): -1.00 to -0.08] the first 3 months of life, as compared with infants exposed from late pregnancy. Risk of stunting was 51.9 per 100 person-years and risk of underweight was 26.7 per 100 person-years. Exposure to ART from conception was associated with a higher rate of stunting as compared with exposure from late pregnancy (adjusted hazard ratio = 1.95, 95% CI: 1.27-2.99). Infants born to mothers with advanced disease had a higher incidence of underweight compared with infants born to mothers with early-stage disease adjusted hazard ratio = 1.99, 95% CI: 1.32-3.03). CONCLUSIONS In HEU-infants, exposure to ART from conception was associated with decrease growth during early infancy and higher incidence of stunting compared with treatment exposure later in pregnancy. Close monitoring of HEU-infants' growth and prompt nutritional intervention is essential.
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Finkelstein JL, Herman HS, Plenty A, Mehta S, Natureeba P, Clark TD, Kamya MR, Ruel T, Charlebois ED, Cohan D, Havlir D, Young SL. Anemia and Micronutrient Status during Pregnancy, and Their Associations with Obstetric and Infant Outcomes among HIV-Infected Ugandan Women Receiving Antiretroviral Therapy. Curr Dev Nutr 2020; 4:nzaa075. [PMID: 32440638 PMCID: PMC7229869 DOI: 10.1093/cdn/nzaa075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/18/2020] [Accepted: 04/09/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Women living with HIV (WLHIV) are at higher risk of micronutrient deficiencies and adverse health outcomes. There are limited data on the burden or sequelae of micronutrient deficiencies among pregnant WLHIV receiving antiretroviral therapy (ART). OBJECTIVES We aimed to examine anemia and vitamin B-12, folate, and vitamin D deficiencies, and their associations with obstetric and infant outcomes, among pregnant WLHIV initiating combination antiretroviral therapy (cART) in rural Uganda. METHODS This was a prospective analysis among pregnant WLHIV (12-28 weeks of gestation) in PROMOTE-Pregnant Women and Infants (PIs), a randomized trial comparing the effects of protease inhibitor (PI)-based ART with those of a non-PI-based ART on placental malaria risk. We conducted a substudy on the burden of anemia [trimester 1/3: hemoglobin (Hb) <11.0 g/dL; trimester 2: Hb <10.5 g/dL; n = 367] and micronutrient deficiencies (n = 127) in pregnant WLHIV and their associations with obstetric and infant outcomes. Hb was measured by cyanmethemoglobin, vitamin B-12 and folate were measured via electrochemiluminescence, and vitamin D was measured by ELISA. Linear and binomial regression were used to evaluate associations between micronutrient status during pregnancy and perinatal outcomes. RESULTS 26.8% women were anemic, 30.2% were vitamin B-12 insufficient (<221.0 pmol/L), 66.1% were folate insufficient (<13.5 nmol/L), and 65.4% were vitamin D insufficient (<30.0 ng/mL) at enrollment. Anemia during pregnancy was associated with a greater risk of small for gestational age (SGA) (RR: 1.88; 95% CI: 1.28, 2.77; P = 0.001); each 1-g/dL decrease in Hb was associated with greater risk of SGA (RR: 0.76; 95% CI: 0.65, 0.90; P = 0.001). Multivariate models showed that increased vitamin D concentrations predicted lower risk of infant wasting (WLZ < -2; RR: 0.94; 95% CI: 0.89, 0.99; P = 0.04). Multivariate models also indicated that maternal vitamin B-12 and folate concentrations at enrollment predicted maternal (P < 0.001) and infant (P = 0.02) concentrations postpartum. CONCLUSIONS Anemia and micronutrient deficiencies are associated with a variety of adverse obstetric and infant outcomes and are an important public health concern in perinatal WLHIV on cART and their children.This trial was registered at clinicaltrials.gov as NCT00993031.
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Affiliation(s)
| | - Heather S Herman
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Albert Plenty
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
| | - Saurabh Mehta
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Paul Natureeba
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Tamara D Clark
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Moses R Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Theodore Ruel
- Division of Infectious Disease, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Deborah Cohan
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - Diane Havlir
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sera L Young
- Department of Anthropology and Global Health Studies, Northwestern University, Evanston, IL, USA
- Institute for Policy Research, Northwestern University, Evanston, IL, USA
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Locks LM, Mwiru RS, Mtisi E, Manji KP, McDonald CM, Liu E, Kupka R, Kisenge R, Aboud S, Gosselin K, Gillman M, Gewirtz AT, Fawzi WW, Duggan CP. Infant Nutritional Status and Markers of Environmental Enteric Dysfunction are Associated with Midchildhood Anthropometry and Blood Pressure in Tanzania. J Pediatr 2017; 187:225-233.e1. [PMID: 28499715 PMCID: PMC5533170 DOI: 10.1016/j.jpeds.2017.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/09/2017] [Accepted: 04/05/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To assess whether growth and biomarkers of environmental enteric dysfunction in infancy are related to health outcomes in midchildhood in Tanzania. STUDY DESIGN Children who participated in 2 randomized trials of micronutrient supplements in infancy were followed up in midchildhood (4.6-9.8 years of age). Anthropometry was measured at age 6 and 52 weeks in both trials, and blood samples were available from children at 6 weeks and 6 months from 1 trial. Linear regression was used for height-for-age z-score, body mass index-for-age z-score, and weight for age z-score, and blood pressure analyses; log-binomial models were used to estimate risk of overweight, obesity, and stunting in midchildhood. RESULTS One hundred thirteen children were followed-up. Length-for-age z-score at 6 weeks and delta length-for-age z-score from 6 to 52 weeks were associated independently and positively with height-for-age z-score and inversely associated with stunting in midchildhood. Delta weight-for-length and weight-for-age z-score were also positively associated with midchildhood height-for-age z-score. The 6-week and delta weight-for-length z-scores were associated independently and positively with midchildhood body mass index-for-age z-score and overweight, as was the 6-week and delta weight-for-age z-score. Delta length-for-age z-score was also associated with an increased risk of overweight in midchildhood. Body mass index-for-age z-score in midchildhood was associated positively with systolic blood pressure. Serum anti-flagellin IgA concentration at 6 weeks was also associated with increased blood pressure in midchildhood. CONCLUSIONS Anthropometry at 6 weeks and growth in infancy independently predict size in midchildhood, while anti-flagellin IgA, a biomarker of environmental enteric dysfunction, in early infancy is associated with increased blood pressure in midchildhood. Interventions in early life should focus on optimizing linear growth while minimizing excess weight gain and environmental enteric dysfunction. TRIAL REGISTRATION ClinicalTrials.gov: NCT00197730 and NCT00421668.
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Affiliation(s)
- Lindsey M. Locks
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | | | - Karim P. Manji
- Departments of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christine M. McDonald
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Enju Liu
- Clinical Research Center, Boston Children's Hospital, Boston, MA
| | - Roland Kupka
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA,UNICEF Headquarters, New York, NY
| | - Rodrick Kisenge
- Departments of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health Sciences, Dar es Salaam, Tanzania
| | - Kerri Gosselin
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA
| | - Matthew Gillman
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA,Department of Population Medicine, Harvard Medical School, Boston, MA
| | - Andrew T. Gewirtz
- Institute of Biomedical Sciences, Georgia State University, Atlanta, GA
| | - Wafaie W. Fawzi
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Christopher P. Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA,Departments of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA,Reprint requests: Christopher P. Duggan, MD, MPH, Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 333 Longwood Ave, Boston, MA 02115.Center for NutritionDivision of Gastroenterology, Hepatology and NutritionBoston Children's Hospital333 Longwood AveBostonMA02115
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High Burden of Morbidity and Mortality but Not Growth Failure in Infants Exposed to but Uninfected with Human Immunodeficiency Virus in Tanzania. J Pediatr 2017; 180:191-199.e2. [PMID: 27829511 PMCID: PMC5183465 DOI: 10.1016/j.jpeds.2016.09.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/16/2016] [Accepted: 09/14/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare health and growth outcomes in children infected with HIV, children exposed to but uninfected with HIV, and children unexposed to HIV. STUDY DESIGN Our cohort included 3554 Tanzanian children enrolled in 2 trials of micronutrient supplementation. Among infants born to mothers infected with HIV, 264 were infected with HIV and 2088 were exposed to but uninfected at 6 weeks of age. An additional 1202 infants were unexposed to HIV. Infants were followed until 18 months of age, death, or loss to follow-up. Morbidity and growth were assessed at monthly nurse visits. RESULTS Compared with unexposed infants, hazard ratios (95% CI) for all-cause mortality in infants infected with HIV and infants who were exposed to but uninfected with HIV were 28.99 (14.83-56.66) and 2.79 (1.41-5.53), respectively, after adjusting for demographic and nutritional covariates. Compared with infants unexposed to HIV, infants infected with HIV also had a significantly greater risk of all measured morbidities, while infants who were exposed to but uninfected with HIV were significantly more likely to suffer from cough, fever, unscheduled outpatient visits, and hospitalizations. Infants infected with HIV also were more likely to experience stunting, wasting, and underweight at baseline and during follow-up. Infants exposed to but uninfected with HIV were more likely to be underweight at baseline (adjusted relative risk, 2.05; 95% CI, 1.45-2.89), but on average, experienced slower declines in height-for-age z-score, weight-for-age z-score, and weight-for-height z-score as well as a lower rate of stunting over follow-up, compared with unexposed infants. CONCLUSION In addition to preventing and treating HIV infection in infants, prevention-of-mother-to-child-transmission of HIV and child health services should also target children exposed to but uninfected with HIV to improve health outcomes in this vulnerable population. TRIAL REGISTRATION Clinicaltrials.gov: NCT00197730 and NCT00421668.
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Locks LM, Manji KP, McDonald CM, Kupka R, Kisenge R, Aboud S, Wang M, Fawzi WW, Duggan CP. Effect of zinc and multivitamin supplementation on the growth of Tanzanian children aged 6-84 wk: a randomized, placebo-controlled, double-blind trial. Am J Clin Nutr 2016; 103:910-8. [PMID: 26817503 PMCID: PMC4763494 DOI: 10.3945/ajcn.115.120055] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/09/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Poor child growth increases risks of mortality and morbidity. Micronutrient supplements have the potential to improve child growth. OBJECTIVE We assessed the effect of daily zinc, multivitamin (vitamins C, E, and B-complex), and zinc and multivitamin (Zn+MV) supplementation on growth in infants in Tanzania. DESIGN In this randomized, 2 × 2 factorial, double-blind trial, 2400 infants were randomly assigned to receive zinc, multivitamins, Zn+MVs, or a placebo at 6 wk of age and were followed up for 18 mo with monthly growth measurements. Mixed-effects models with restricted cubic splines for the mean change in anthropometric z scores were fit for each group. Likelihood ratio tests were used to compare the effect of supplements on growth trajectories. Cox proportional hazards models were used to compare incidences of stunting, wasting, and underweight. RESULTS Children in all groups experienced growth faltering. At 19 mo of age, prevalences of stunting, wasting, and underweight were 19.8%, 6.0%, and 10.8%, respectively. Changes in weight-for-age z scores (WAZs) and weight-for-height z scores (WHZs) were significantly different across the 4 groups (P < 0.001 for both). The mean ± SE decline in the WAZ from baseline to the end of follow-up in the Zn+MV group was significantly less than in the placebo group (-0.36 ± 0.04 compared with -0.50 ± 0.04; P = 0.020), whereas the decline in the WHZ was significantly greater in the zinc-only group than in the placebo group (-0.57 ± 0.07 compared with -0.35 ± 0.07; P = 0.021). Supplements did not have a significant effect on mean change in the height-for-age z score or on rates of stunting, wasting, or underweight. CONCLUSIONS Although there were small but significant improvements in the WAZ in the Zn+MV group, daily zinc supplementation alone, multivitamin supplementation alone, and the combined Zn+MV did not reduce the incidences of underweight, stunting, or wasting in Tanzanian infants. Alternative approaches to prevent growth faltering should be pursued. This trial was registered at clinicaltrials.gov as NCT00421668.
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Affiliation(s)
| | | | - Christine M McDonald
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; and
| | - Roland Kupka
- Departments of Nutrition, UNICEF Headquarters, New York, NY
| | | | - Said Aboud
- Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Wafaie W Fawzi
- Departments of Nutrition, Epidemiology, and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Christopher P Duggan
- Departments of Nutrition, Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA; and
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Abstract
The 2010 Dietary Guidelines Advisory Committee was charged with the task of investigating the effects of multivitamin/mineral supplements on healthy populations and also on those with chronic disease. The evidence from which the committee prepared its conclusions was graded on 5 fundamental criteria: quality, consistency, quantity, clinical impact, and generalizability. The committee concluded that for the general healthy population, evidence was insufficient to make a multivitamin/mineral recommendation. On the other hand, the committee noted the value of some supplemental nutrients for at-risk populations such as iron, folic acid, and vitamin B-12. However, most of the studies referenced for the research used the conventional, all-encompassing, and oversimplified definition of a multivitamin/mineral as being a supplement containing 3 or more vitamins with or without minerals. In the few years since the committee released its 2010 report, several randomized clinical trials showing the benefits of daily multivitamin/mineral supplementation have been completed using supplements containing at least 10 or more vitamins and/or minerals, but there also continues to be some reports that do not find benefit from such supplements. Furthermore, several steps have been taken to advance the science behind these supplements so that consumers, physicians, and government agencies can all have more confidence in understanding the role of supplemental nutrition in the American diet. This review provides new evidence from 2010 onward addressing the committee's primary concerns about multivitamin/mineral research in regard to improving public health. It also includes several recent studies that may be of interest to future committees indicating the potential benefits of these supplements on improving the cognitive performance and mental well-being of healthy populations.
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