1
|
Doocy S, Ismail S, Lyles E, Altare C, Bauler S, Obali F, Atem D, Leidman E. Caregiver use of MUAC tapes in South Sudan: a three-group prospective comparison. Front Nutr 2024; 11:1324063. [PMID: 38379548 PMCID: PMC10877034 DOI: 10.3389/fnut.2024.1324063] [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: 10/19/2023] [Accepted: 01/12/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction Nutrition program modifications occurred globally in response to the COVID-19 pandemic. Within community management of acute malnutrition (CMAM), community screenings for acute malnutrition were replaced by caregivers monitoring child mid-upper arm circumference (MUAC), but questions remain about different MUAC tapes' performance and acceptability for caregiver use. Methods The study was conducted in Central Equatoria and Warrap States, South Sudan, between March 2022 and January 2023. A three-group prospective non-randomized design was used to compare the performance of three MUAC tapes (UNICEF 2009, UNICEF 2020, and GOAL MAMI) used by caregivers. The primary outcome was the false negative rate (i.e., the proportion of children not identified as wasted by the caregiver but classified as wasted by enumerators). Caregivers with children aged 5-53 months were assigned to and trained on the use of 1 of the 3 tapes and followed for 8 months, including three monitoring visits and baseline/endline surveys. Results Of the 2,893 enrolled children, 2,401 (83.0%) completed baseline, endline, and two or more monitoring visits. Only 3.7% of children were identified as wasted by caregivers and 3.8% by study team measurement. Cumulative measurement agreement between caregivers and enumerators was similar by tape. False negative and false positive rates were both <0.5% overall and similar among the tapes. There were differences in training needs and durability between the tapes, but all three were acceptable and performed equally well. Discussion Caregiver measurement of child MUAC is feasible in South Sudan. The three MUAC tapes were acceptable, and caregivers could measure accurately with minimal support. All tapes performed similarly and are appropriate for use in Family MUAC programs in South Sudan. There were indications that the UNICEF 2020 tape may be less durable; the GOAL MAMI tape has the added benefit of being suitable for assessments of infants <6 months of age.
Collapse
Affiliation(s)
- Shannon Doocy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Sule Ismail
- US Centers for Disease Control and Prevention, Juba, South Sudan
| | - Emily Lyles
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Chiara Altare
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Sarah Bauler
- World Vision International, London, United Kingdom
| | | | | | - Eva Leidman
- US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | |
Collapse
|
2
|
Lyles E, Ismail S, Ramaswamy M, Drame A, Leidman E, Doocy S. Simplified treatment protocols improve recovery of children with severe acute malnutrition in South Sudan: results from a mixed methods study. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2024; 43:21. [PMID: 38308364 PMCID: PMC10835937 DOI: 10.1186/s41043-024-00518-2] [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: 05/24/2023] [Accepted: 01/30/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND As part of COVID-19 mitigation strategies, emergency nutrition program adaptations were implemented, but evidence of the effects is limited. Compared to the standard protocol, the full adapted protocol included adapted admissions criteria, simplified dosing, and reduced visit frequency; partially adapted protocols consisting of only some of these modifications were also implemented. To enable evidence-based nutrition program modifications as the context evolved, this study was conducted to characterize how protocol adaptations in South Sudan affected Outpatient Therapeutic Feeding Program outcomes. METHODS A mixed methods approach consisting of secondary analysis of individual-level nutrition program data and key informant interviews was used. Analyses focused on program implementation and severe acute malnutrition treatment outcomes under the standard, full COVID-19 adapted, and partially adapted treatment protocols from 2019 through 2021. Analyses compared characteristics and outcomes by different admission types under the standard protocol and across four different treatment protocols. Regression models evaluated the odds of recovery and mean length of stay (LoS) under the four protocols. RESULTS Very few (1.6%; n = 156) children admitted based on low weight-for-height alone under the standard protocol would not have been eligible for admission under the adapted protocol. Compared to the full standard protocol, the partially adapted (admission only) and partially adapted (admission and dosing) protocols had lower LoS of 28.4 days (CI - 30.2, - 26.5) and 5.1 days (CI - 6.2, - 4.0); the full adapted protocol had a decrease of 3.0 (CI - 5.1, - 1.0) days. All adapted protocols had significantly increased adjusted odds ratios (AOR) for recovery compared to the full standard protocol: partially adapted (admission only) AOR = 2.56 (CI 2.18-3.01); partially adapted (admission + dosing) AOR = 1.78 (CI 1.45-2.19); and fully adapted protocol AOR = 2.41 (CI 1.69-3.45). CONCLUSIONS This study provides evidence that few children were excluded when weight-for-height criteria were suspended. LoS was shortest when only MUAC was used for entry/exit but dosing and visit frequency were unchanged. Significantly shorter LoS with simplified dosing and visit frequency vs. under the standard protocol indicate that protocol adaptations may lead to shorter recovery and program enrollment times. Findings also suggest that good recovery is achievable with reduced visit frequency and simplified dosing.
Collapse
Affiliation(s)
- Emily Lyles
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Suite E8132, Baltimore, MD, 21205, USA
| | - Sule Ismail
- Integral Global Consulting, Atlanta, GA, USA
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Maya Ramaswamy
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Aly Drame
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eva Leidman
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Shannon Doocy
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Suite E8132, Baltimore, MD, 21205, USA.
| |
Collapse
|
3
|
Feyling AC, Kamalo PD, Hanche-Olsen T, Chikumbanje SS, Zsidek AS, Ponzi E, Raeder J. Preventing hypothermia in pediatric neurosurgery in Africa-A randomized controlled non-inferiority trial of insulation versus active warming. Acta Anaesthesiol Scand 2024; 68:167-177. [PMID: 37882145 DOI: 10.1111/aas.14341] [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: 06/09/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE The objective of this study was to compare the efficacy of a low-cost heat-preserving method in preventing intraoperative hypothermia with that of forced-air warming in a resource-limited setting. METHODS In this randomized controlled non-inferiority trial, we recruited children younger than 12 years scheduled for cranial neurosurgery in a large East-African hospital. Patients were block-randomized by age to intraoperative warming measures using Hibler's method (intervention) or warm air (comparator). Hibler's group patients were circumferentially wrapped in transparent plastic sheeting (providing a vapor-trap) over a layer of cotton blankets, then laid on an insulating foam mattress. Warm air group patients were treated with forced-air convection via an underlying Snuggle Warm™ Pediatric Full Body mattress. Allocated warming measures were initiated in the operating theatre and discontinued upon anesthesia emergence. Perioperative temperatures were measured using noninvasive forehead probes (SpotOn™). The primary outcome was incidence of hypothermia (core temperature < 36.0° for longer than 5 min). Our null hypothesis was that Hibler's method is inferior in efficacy to the warm air method by a margin exceeding 20%. Among secondary outcomes were duration of hypothermia as proportion of surgical duration, incidence of postoperative shivering and rescue measure requirements. RESULTS We analyzed data for 77 participants (Hibler's = 38; warm air = 39). There was no significant difference between the Hibler's and warm air arms of the study in the primary outcome of incidence of hypothermia (59.0% vs. 60.5% respectively; OR 1.07; 95% CI 0.43-2.65; p = .890). However, the risk difference (1.55%; 95% CI -0.20 to -0.24) exceeded the 0.2 margin and non-inferiority could not be declared. There was considerable need for rescue measures in both groups (71.1 0% vs. 69.2%; OR 1.09; 95% CI 0.41-2.90; p = .861). There was no statistically significant difference between groups for any prespecified secondary outcome. CONCLUSION Although perioperative core temperatures were not significantly different, we could not declare an inexpensive heat-preserving method non-inferior to warm air convection in preventing intraoperative hypothermia in children undergoing anesthesia for cranial neurosurgery in a resource-limited setting. The extensive need for rescue measures may have masked important differences. TRIAL REGISTRATION US National Institutes of Health Clinicaltrials.gov database (ID no. NCT02975817).
Collapse
Affiliation(s)
- Anders C Feyling
- Department of Anaesthesia and Intensive Care, Division of Emergencies & Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research & Development, Division of Emergencies & Critical Care, Oslo University Hospital, Oslo, Norway
| | - Patrick D Kamalo
- Queen Elizabeth Central Hospital, Blantyre, Malawi
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Terje Hanche-Olsen
- Department of Anaesthesia and Intensive Care, Division of Emergencies & Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Aina S Zsidek
- Department of Anaesthesia and Intensive Care, Acute Care Division, Oslo University Hospital, Oslo, Norway
| | - Erica Ponzi
- Oslo Center for Biostatistics & Epidemiology, University of Oslo, Oslo, Norway
- Department for Research Support for Clinical Trials, Oslo University Hospital, Oslo, Norway
| | - Johan Raeder
- Department of Anaesthesia and Intensive Care, Division of Emergencies & Critical Care, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Ouattara M, Sié A, Bountogo M, Boudo V, Dah C, Lebas E, Hu H, Porco TC, Arnold BF, Lietman TM, Oldenburg CE. Anthropometric Differences in Community- Versus Clinic-Recruited Infants Participating in a Trial of Azithromycin for Prevention of Childhood Mortality in Burkina Faso. Am J Trop Med Hyg 2023; 109:1187-1191. [PMID: 37783457 PMCID: PMC10622465 DOI: 10.4269/ajtmh.23-0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/06/2023] [Indexed: 10/04/2023] Open
Abstract
Clinic-based recruitment for preventative interventions for child health may select for healthier populations compared with community-based outreach. Nutritional status during infancy as measured by anthropometry is predictive of mortality, growth faltering later in life, and poor cognitive development outcomes. We evaluated baseline differences in infant nutritional status among children recruited directly in their community versus clinic recruitment among infants participating in a trial of azithromycin compared with placebo for prevention of mortality in three districts of Burkina Faso. Infants between 5 and 12 weeks of age were recruited in their community of residence via vaccine outreach teams or in primary health-care clinics during vaccine clinics. Weight, height, and mid upper arm circumference were measured. We used linear and logistic regression models to compare anthropometric outcomes among community and clinic recruited infants, adjusting for age at enrollment, gender, and season. Among 32,877 infants enrolled in the trial, 21,273 (64.7%) were recruited via community outreach. Mean weight-for-age z-score (WAZ) was -0.60 ± 1.2 (SD), weight-for-length z-score (WLZ) was -0.16 ± 1.5, and length-for-age z-score was-0.53 ± 1.3. Infants enrolled in the community had lower WAZ (mean difference, -0.12; 95% CI, -0.20 to -0.04) and WLZ (mean difference, -0.21; 95% CI, -0.32 to -0.09). Community-recruited infants were more often underweight (WAZ < -2; odds ratio [OR], 1.25; 95% CI, 1.09-1.43) and wasted (WLZ < -2; OR, 1.54; 95% CI, 1.31-1.79). There was no evidence of a difference in height-based measures. Community and clinic recruitment likely reach different populations of children.
Collapse
Affiliation(s)
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Huiyu Hu
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Travis C. Porco
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Benjamin F. Arnold
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Thomas M. Lietman
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Hayes J, Quiring M, Kerac M, Smythe T, Tann CJ, Groce N, Gultie Z, Nyesigomwe L, DeLacey E. Mid-upper arm circumference (MUAC) measurement usage among children with disabilities: A systematic review. Nutr Health 2023:2601060231181607. [PMID: 37338528 DOI: 10.1177/02601060231181607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used for monitoring and evaluating children's nutritional status. Evidence is limited on optimal nutritional assessment for children with disabilities, who are at high risk for malnutrition. Aim: This study describes MUAC use among children with disabilities. Methods: Four databases (Embase, Global Health, Medline, and CINHAL) were searched from January 1990 through September 2021 using a predefined search strategy. Of the 305 publications screened, 32 papers were included. Data included children 6 months to 18 years old with disabilities. Data including general study characteristics, methods for MUAC measurement, terminology, and measurement references were extracted into Excel. Due to heterogeneity of the data, a narrative synthesis was used. Results: Studies from 24 countries indicate that MUAC is being used as part of nutritional assessment, but MUAC measurement methods, references, and cutoffs were inconsistent. Sixteen (50%) reported MUAC as a mean ± standard deviation (SD), 11 (34%) reported ranges or percentiles, 6 (19%) reported z-scores, and 4 (13%) used other methods. Fourteen (45%) studies included both MUAC and weight-for-height but nonstandard reporting limited comparability of the indicators for identifying those at risk of malnutrition. Conclusion: Although its speed, simplicity, and ease of use afford MUAC great potential for assessing children with disabilities, more research is needed to understand its appropriateness, and how it performs at identifying nutritionally high-risk children in comparison to other measures. Without validated inclusive measures to identify malnutrition and monitor growth and health, millions of children could have severe consequences for their development.
Collapse
Affiliation(s)
- Julia Hayes
- Nutrition and Health Services, Holt International, Eugene, Oregon, USA
| | - Michael Quiring
- Nutrition and Health Services, Holt International, Eugene, Oregon, USA
| | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, UK
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, UK
| | - Tracey Smythe
- International Centre for Evidence in Disability, Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, UK
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - Cally J Tann
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, UK
- Infectious Disease Epidemiology & International Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, University of London, London, UK
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
- Neonatal Medicine, University College London Hospitals NHS Trust, London, UK
| | - Nora Groce
- UCL International Disability Research Centre, Department of Epidemiology and Health Care, University College London, London UK
| | | | | | - Emily DeLacey
- Nutrition and Health Services, Holt International, Eugene, Oregon, USA
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, University of London, London, UK
- Centre for Maternal, Adolescent, Reproductive, & Child Health (MARCH), London School of Hygiene & Tropical Medicine, University of London, London, UK
| |
Collapse
|
8
|
Kangas ST, Coulibaly IN, Tausanovitch Z, Ouologuem B, Marron B, Radin E, Ritz C, Dembele S, Ouédraogo CT, Bailey J. Post-Recovery Relapse of Children Treated with a Simplified, Combined Nutrition Treatment Protocol in Mali: A Prospective Cohort Study. Nutrients 2023; 15:nu15112636. [PMID: 37299599 DOI: 10.3390/nu15112636] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
The present study aimed to determine the 6-month incidence of relapse and associated factors among children who recovered from acute malnutrition (AM) following mid-upper arm circumference (MUAC)-based simplified combined treatment using the ComPAS protocol. A prospective cohort of 420 children who had reached a MUAC ≥ 125 mm for two consecutive measures was monitored between December 2020 and October 2021. Children were seen at home fortnightly for 6 months. The overall 6-month cumulative incidence of relapse [95%CI] into MUAC < 125 mm and/or edema was 26.1% [21.7; 30.8] and 1.7% [0.6; 3.6] to MUAC < 115 mm and/or edema. Relapse was similar among children initially admitted to treatment with a MUAC < 115 mm and/or oedema and among those with a MUAC ≥ 115 mm but <125 mm. Relapse was predicted by lower anthropometry both at admission to and discharge from treatment, and a higher number of illness episodes per month of follow-up. Having a vaccination card, using an improved water source, having agriculture as the main source of income, and increases in caregiver workload during follow-up all protected from relapse. Children discharged as recovered from AM remain at risk of relapsing into AM. To achieve reduction in relapse, recovery criteria may need to be revised and post-discharge strategies tested.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Christian Ritz
- National Institute of Public Health, Copenhagen, Denmark
| | | | | | | |
Collapse
|
9
|
Ngaboyeka G, Bisimwa G, Neven A, Mwene-Batu P, Kambale R, Kingwayi PP, Chiribagula C, Battisti O, Dramaix M, Donnen P. Association between diagnostic criteria for severe acute malnutrition and hospital mortality in children aged 6-59 months in the eastern Democratic Republic of Congo: the Lwiro cohort study. Front Nutr 2023; 10:1075800. [PMID: 37293673 PMCID: PMC10246449 DOI: 10.3389/fnut.2023.1075800] [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: 10/26/2022] [Accepted: 04/17/2023] [Indexed: 06/10/2023] Open
Abstract
Background Few studies have assessed the relationship between weight-for-height (WHZ) and mid-upper arm circumference (MUAC) with hospital mortality considering confounders. The particularity of MUAC for age (MUACZ) is less documented. Objective This study aims to investigate this relationship in a region endemic for severe acute malnutrition (SAM). Methods This is a retrospective cohort based on a database of children admitted from 1987 to 2008 in South Kivu, eastern DRC. Our outcome was hospital mortality. To estimate the strength of the association between mortality and nutritional indices, the relative risk (RR) with its 95% confidence interval (95% CI) was calculated. In addition to univariate analyses, we constructed multivariate models from binomial regression. Results A total of 9,969 children aged 6 to 59 months were selected with a median age of 23 months. 40.9% had SAM (according to the criteria WHZ < -3 and/or MUAC<115 mm and/or the presence of nutritional edema) including 30.2% with nutritional edema and 35.2% had both SAM and chronic malnutrition. The overall hospital mortality was 8.0% and was higher at the beginning of data collection (17.9% in 1987). In univariate analyses, children with a WHZ < -3 had a risk almost 3 times higher of dying than children without SAM. WHZ was more associated with in-hospital mortality than MUAC or MUACZ. Multivariate models confirmed the univariate results. The risk of death was also increased by the presence of edema. Conclusion In our study, WHZ was the indicator more associated with hospital death compared with MUAC or MUACZ. As such, we recommend that all criteria shall continue to be used for admission to therapeutic SAM programs. Efforts should be encouraged to find simple tools allowing the community to accurately measure WHZ and MUACZ.
Collapse
Affiliation(s)
- Gaylord Ngaboyeka
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
- Nutritional Department, Centre de Recherche en Sciences Naturelles, Lwiro, Democratic Republic of Congo
| | - Ghislain Bisimwa
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Nutritional Department, Centre de Recherche en Sciences Naturelles, Lwiro, Democratic Republic of Congo
| | - Anouk Neven
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
- Competence Center for Methodology and Statistics, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Pacifique Mwene-Batu
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Hôpital Provincial General de Reference de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Faculté de Médecine, Université de Kaziba, Kaziba, Democratic Republic of Congo
| | - Richard Kambale
- Hôpital Provincial General de Reference de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | | | - Christian Chiribagula
- Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Oreste Battisti
- Hôpital Provincial General de Reference de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Département de sciences cliniques, Faculté de médecine, Université de Liège, Liège, Belgium
| | - Michèle Dramaix
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe Donnen
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
10
|
Kodish SR, Allen BGS, Salou H, Schwendler TR, Isanaka S. Conceptualising factors impacting nutrition services coverage of treatment for acute malnutrition in children: an application of the Three Delays Model in Niger. Public Health Nutr 2023; 26:1074-1081. [PMID: 34620262 PMCID: PMC10346043 DOI: 10.1017/s1368980021004286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The Three Delays Model is a conceptual model traditionally used to understand contributing factors of maternal mortality. It posits that most barriers to health services utilisation occur in relation to one of three delays: (1) Delay 1: delayed decision to seek care; (2) Delay 2: delayed arrival at health facility and (3) Delay 3: delayed provision of adequate care. We applied this model to understand why a community-based management of acute malnutrition (CMAM) services may have low coverage. DESIGN We conducted a Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) over three phases using mixed methods to estimate programme coverage and barriers to care. In this manuscript, we present findings from fifty-one semi-structured interviews with caregivers and programme staff, as well as seventy-two structured interviews among caregivers only. Recurring themes were organised and interpreted using the Three Delays Model. SETTING Madaoua, Niger. PARTICIPANTS Totally, 123 caregivers and CMAM program staff. RESULTS Overall, eleven barriers to CMAM services were identified in this setting. Five barriers contribute to Delay 1, including lack of knowledge around malnutrition and CMAM services, as well as limited family support, variable screening services and alternative treatment options. High travel costs, far distances, poor roads and competing demands were challenges associated with accessing care (Delay 2). Finally, upon arrival to health facilities, differential caregiver experiences around quality of care contributed to Delay 3. CONCLUSIONS The Three Delays Model was a useful model to conceptualise the factors associated with CMAM uptake in this context, enabling implementing agencies to address specific barriers through targeted activities.
Collapse
Affiliation(s)
- Stephen R Kodish
- Pennsylvania State University, Departments of Nutritional Sciences and Biobehavioral Health, 110 Chandlee Lab, University Park, PA16802, USA
| | - Ben GS Allen
- Technical Support Team, GNC Technical Alliance, Action Against Hunger Canada, Toronto, Canada
| | | | - Teresa R Schwendler
- Pennsylvania State University, Departments of Nutritional Sciences and Biobehavioral Health, 110 Chandlee Lab, University Park, PA16802, USA
| | - Sheila Isanaka
- Epicentre, Research Department, Paris, France
- Harvard T.H. Chan School of Public Health, Departments of Nutrition and Global Health and Population, Boston, MA, USA
| |
Collapse
|
11
|
Jensen N, Lepariyo W, Alulu V, Sibanda S, Kiage BN. Assessing Mbiotisho: A smartphone application used to collect high-frequency health and nutrition data from difficult-to-reach populations. MATERNAL & CHILD NUTRITION 2023:e13496. [PMID: 36876924 DOI: 10.1111/mcn.13496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/19/2023] [Accepted: 02/15/2023] [Indexed: 03/07/2023]
Abstract
There is an urgent need for improved and timely health and nutrition data. We developed and tested a smartphone application that caregivers from a pastoral population used to measure, record and submit high-frequency and longitudinal health and nutrition information on themselves and their children. The data were assessed by comparing caregiver-submitted measurements of mid-upper arm circumference (MUAC) to several benchmark data sets, including data collected by community health volunteers from the participating caregivers during the project period and data generated by interpreting photographs of MUAC measurements submitted by all participants. We found that the caregivers participated frequently and consistently over the 12-month period of the project; most of them made several measurements and submissions in at least 48 of the 52 weeks of the project. The evaluation of data quality was sensitive to which data set was used as the benchmark, but the results indicate that the errors in the caregivers' submissions were similar to that of enumerators in other studies. We then compare the costs of this alternative approach to data collection through more conventional methods, concluding that conventional methods can be more cost-effective for large socioeconomic surveys that value the breadth of the survey over the frequency of data, while the alternative we tested is favoured for those with objectives that are better met by high-frequency observations of a smaller number of well-defined outcomes.
Collapse
Affiliation(s)
- Nathaniel Jensen
- Sustainable Livestock Systems, International Livestock Research Institute, Nairobi, Kenya
| | - Watson Lepariyo
- Sustainable Livestock Systems, International Livestock Research Institute, Nairobi, Kenya
| | - Vincent Alulu
- Sustainable Livestock Systems, International Livestock Research Institute, Nairobi, Kenya
| | - Simbarashe Sibanda
- Nutrition Sensitive Agriculture, Food, Agriculture and Natural Resources Policy Analysis, Pretoria, South Africa
| | - Beatrice N Kiage
- Nutrition Sensitive Agriculture, Food, Agriculture and Natural Resources Policy Analysis, Pretoria, South Africa.,Department of Human Nutrition and Dietetics, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| |
Collapse
|
12
|
Aydın K, Dalgıç B, Kansu A, Özen H, Selimoğlu MA, Tekgül H, Ünay B, Yüce A. The significance of MUAC z-scores in diagnosing pediatric malnutrition: A scoping review with special emphasis on neurologically disabled children. Front Pediatr 2023; 11:1081139. [PMID: 36950173 PMCID: PMC10025394 DOI: 10.3389/fped.2023.1081139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/16/2023] [Indexed: 03/24/2023] Open
Abstract
This review by a panel of pediatric gastroenterology-hepatology-nutrition and pediatric neurology experts aimed to address the significance of mid-upper arm circumference (MUAC) assessment in diagnosis of pediatric malnutrition. Specifically, the potential utility of recently developed MUAC z-score tape in clinical practice for larger patient populations was addressed including the neurologically disabled children. In accordance with the evidence-based data, four statements were identified by the participating experts on the utility of MUAC z-score tape, including (1) MUAC z-scores correlate with body mass index (BMI) and weight for height/length (WFH/l) z-scores in diagnosing malnutrition; (2) MUAC z-score tape offers a higher sensitivity to diagnose the mild and moderate malnutrition and better ability to track the changes in nutritional status over time than the other single datapoint measurements; (3) Using single-step MUAC z-score tape in children with cerebral palsy (CP) seems to provide more reliable data on anthropometry; and (4) The clinical value of the tool in classifying secondary malnutrition in CP should be investigated in large-scale populations. In conclusion, enabling single-step estimation of nutritional status in a large-scale pediatric population regardless of age and within a wide range of weight, without formal training or the need for ancillary reference charts and calculators, MUAC z-tape offers a favorable tool for easier and earlier diagnosis of pediatric malnutrition. Nonetheless, further implementation of MUAC z-score screening in larger-scale and/or special populations is necessary to justify its utility in relation to other primary anthropometric indicators in diagnosis of malnutrition as well as in treatment monitoring in the community and hospital setting.
Collapse
Affiliation(s)
- Kürşad Aydın
- Department of Pediatric Neurology, Medipol University Faculty of Medicine, Istanbul, Türkiye
| | - Buket Dalgıç
- Department of Pediatric Gastroenterology, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Aydan Kansu
- Department of Pediatric Gastroenterology, Ankara University Faculty of Medicine, Ankara, Türkiye
| | - Hasan Özen
- Department of Pediatric Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
- Correspondence: Hasan Özen
| | - Mukadder Ayşe Selimoğlu
- Department of Pediatric Gastroenterology, Memorial Atasehir and Bahcelievler Hospitals, Istanbul, Türkiye
| | - Hasan Tekgül
- Department of Pediatric Neurology, Ege University Faculty of Medicine, Izmir, Türkiye
| | - Bülent Ünay
- Department of Pediatric Neurology, Gulhane Faculty of Medicine, Ankara, Türkiye
| | - Aysel Yüce
- Department of Pediatric Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| |
Collapse
|
13
|
Shragai T, Talley L, Summers A, Behringer H, Wrabel M, Stobaugh H, Leidman E. Outcomes after Acute Malnutrition Program Adaptations to COVID-19, Uganda, Ethiopia, and Somalia. Emerg Infect Dis 2022; 28:S288-S298. [PMID: 36502417 DOI: 10.3201/eid2813.212266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
At the onset of the COVID-19 pandemic, protocols for community-based management of acute malnutrition (CMAM) were implemented to support continuity of essential feeding services while mitigating COVID-19 transmission. To assess correlations between adaptation timing and CMAM program indicators, we evaluated routine program data in Uganda, Ethiopia, and Somalia for children 6-59 months of age. We specifically analyzed facility-level changes in total admissions, average length of stay (ALOS), total children screened for admission, and recovery rates before and after adaptations. We found no statistically significant changes in program indicators after adaptations. For Somalia, we also analyzed child-level changes in ALOS and in weight and mid-upper arm circumference at admission and discharge. ALOS significantly increased immediately after adaptations and then decreased to preadaptation levels. We found no meaningful changes in either weight or mid-upper arm circumference at admission or discharge. These findings indicate that adapted CMAM programs can remain effective.
Collapse
|
14
|
Codjia P, Kutondo E, Kamudoni P, Munga J, Ahluwalia A, Sharma I, de Jong Y, Amolo T, Maina-Gathigi L, Mwenda V, Chaudhry H, Bukania Z. Mid-term evaluation of Maternal and Child Nutrition Programme (MCNP II) in Kenya. BMC Public Health 2022; 22:2191. [PMID: 36443721 PMCID: PMC9702643 DOI: 10.1186/s12889-022-14627-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 11/14/2022] [Indexed: 11/29/2022] Open
Abstract
Background Kenya is faced with a triple burden of malnutrition which is multi-faceted with health and socio-economic implications. Huge geographical disparities exist, especially, in the arid and semi-arid lands exacerbated by inadequate resource allocation to the nutrition sector and challenges in multi-sectoral coordination and nutrition governance. UNICEF’s Maternal and Child Nutrition Programme is a four-year (2018–2022) resilience-building, multi-sectoral program focused on pregnant and lactating women, mothers of children under five years and children under five years. The objective of the mid-term evaluation was to establish the relevance, effectiveness, efficiency, and sustainability of the programme. Methods The field evaluation conducted between June and July 2021, adopted a concurrent mixed-methods approach, where qualitative information was gathered through 29 key informant interviews and 18 focus group discussions (6 FGDs per population group; women of reproductive age, adolescent girls and men). Quantitatively, data were obtained through desk review of secondary data from programme reports, budgets, and project outputs where descriptive analysis was undertaken using Excel software. Qualitative information was organized using Nvivo software and analyzed thematically. Results The findings provide evidence of the relevance of the Maternal and Child Nutrition Programme II to the nutrition situation in Kenya and its alignment with the Government of Kenya and donor priorities. Most planned programme targets were achieved despite operating in a COVID-19 pandemic environment. The use of innovative approaches such as family mid-upper arm circumference, integrated management of acute malnutrition surge model, Malezi bora and Logistic Management Information Management System contributed to the realization of effective outputs and outcomes. Stringent financial management strategies contributed toward programme efficiencies; however, optimal utilization of the resources needs further strengthening. The programme adopted strategies for strengthening local capacity and promoting ownership and long-term sustainability. Conclusion The programme is on track across the four evaluation criteria. However, a few suggestions are recommended to improve relevance, effectiveness, efficiency, and sustainability. A formal transition strategy needs to be developed in consultation with multi-stakeholder groups and implemented in phases. UNICEF Nutrition section should explore a more integrated programming mode of delivery through joint initiatives with other agencies under the Delivery as One UN agenda, along the more gender transformative approaches with more systematic involvement of males and females in gender-based discussions. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14627-2.
Collapse
|
15
|
Effectiveness of Acute Malnutrition Treatment at Health Center and Community Levels with a Simplified, Combined Protocol in Mali: An Observational Cohort Study. Nutrients 2022; 14:nu14224923. [PMID: 36432609 PMCID: PMC9699530 DOI: 10.3390/nu14224923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022] Open
Abstract
A simplified, combined protocol was created that admits children with a mid-upper-arm circumference (MUAC) of <125 mm or edema to malnutrition treatment with ready-to-use therapeutic food (RUTF) that involves prescribing two daily RUTF sachets to children with MUAC < 115 mm or edema and one daily sachet to those with 115 mm ≤ MUAC < 125 mm. This treatment was previously shown to result in non-inferior programmatic outcomes compared with standard treatment. We aimed at observing its effectiveness in a routine setting at scale, including via delivery by community health workers (CHWs). A total of 27,800 children were admitted to the simplified, combined treatment. Treatment resulted in a 92% overall recovery, with a mean length of stay of 40 days and a mean RUTF consumption of 62 sachets per child treated. Among children admitted with MUAC < 115 mm or edema, 87% recovered with a mean length of stay of 55 days and consuming an average of 96 RUTF sachets. The recovery in all sub-groups studied exceeded 85%. Treatment by CHWs resulted in a similar (94%) recovery to treatment by formal healthcare workers (92%). The simplified, combined protocol resulted in high recovery and low RUTF consumption per child treated and can safely be adopted by CHWs to provide treatment at the community level.
Collapse
|
16
|
Charle-Cuéllar P, Espí-Verdú L, Goyanes J, Bunkembo M, Samake S, Traore M, Coulibaly AB, Landouré A, Diawara F, Dougnon AO, Vargas A, López-Ejeda N. Scaling severe acute malnutrition treatment with community health workers: a geospatial coverage analysis in rural Mali. HUMAN RESOURCES FOR HEALTH 2022; 20:74. [PMID: 36271427 PMCID: PMC9587545 DOI: 10.1186/s12960-022-00771-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND In 2015, the Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated Community Case Management (iCCM). This paper aims to analyze the impact of including community health workers (CHWs) as treatment providers outside the Health Facilities (HFs) on the coverage of SAM treatment when scaling up the intervention in the three largest districts of the Kayes Region in Mali. METHODS A baseline coverage assessment was conducted in August 2017 in the three districts before the CHWs started treating SAM. The end-line assessment was conducted one year later, in August 2018. Coverage was assessed by the standardized methodology called Semi-Quantitative Evaluation of Access and Coverage (SQUEAC). The primary outcome was treatment coverage and other variables evaluated were the geographical distribution of the HFs, CHW's sites and overlapping between both health providers, the estimation of children with geographical access to health care and the estimation of children screened for acute malnutrition in their communities. RESULTS Treatment coverage increased in Kayes (28.7-57.1%) and Bafoulabé (20.4-61.1%) but did not in Kita (28.4-28.5%). The decentralization of treatment has not had the same impact on coverage in all districts, with significant differences. The geospatial analyses showed that Kita had a high proportion of overlap between HFs and/or CHWs 48.7% (39.2-58.2), a high proportion of children without geographical access to health care 70.4% (70.1-70.6), and a high proportion of children not screened for SAM in their communities 52.2% (51.9-52.5). CONCLUSIONS Working with CHWs in SAM increases treatment coverage, but other critical aspects need to be considered by policymakers if this intervention model is intended to be scaled up at the country level. To improve families' access to nutritional health care, before establishing decentralized treatment in a whole region it must be considered the geographical location of CHWs. This previous assessment will avoid overlap among health providers and ensure the coverage of all unserved areas according to their population densities need. TRIAL REGISTRATION ISRCTN registry with ID 1990746. https://doi.org/10.1186/ISRCTN14990746.
Collapse
Affiliation(s)
| | - Lidia Espí-Verdú
- Action Against Hunger Spain, C/ Duque de Sevilla No. 3. 28002, Madrid, Spain
| | - Juan Goyanes
- Action Against Hunger Spain, C/ Duque de Sevilla No. 3. 28002, Madrid, Spain
| | | | | | - Mamadou Traore
- Nutrition Direction of the Ministry of Hygiene and Public Health, BP 232, Bamako, Mali
| | - Adama Balla Coulibaly
- Nutrition Direction of the Ministry of Hygiene and Public Health, BP 232, Bamako, Mali
| | - Aly Landouré
- Institut National de Recherche en Santé Publique, BP 235, Bamako, Mali
| | - Fatou Diawara
- Institut National de Recherche en Santé Publique, BP 235, Bamako, Mali
| | | | - Antonio Vargas
- Action Against Hunger Spain, C/ Duque de Sevilla No. 3. 28002, Madrid, Spain
| | - Noemí López-Ejeda
- EPINUT Research Group (Ref. 920325), Faculty of Biological Sciences, Department of Biodiversity, Ecology and Evolution, Unit of Physical Anthropology, Complutense University of Madrid, Jose Antonio Novais, 12, 8th Floor, 28040 Madrid, Spain
| |
Collapse
|
17
|
Wrabel M, Stokes‐Walters R, King S, Funnell G, Stobaugh H. Programmatic adaptations to acute malnutrition screening and treatment during the COVID‐19 pandemic. MATERNAL & CHILD NUTRITION 2022; 18:e13406. [PMID: 35929509 PMCID: PMC9480950 DOI: 10.1111/mcn.13406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
The COVID‐19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community‐based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid‐upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow‐up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well‐accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID‐19 disruptions; however, challenges included long‐term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme. Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi‐year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences. COVID‐19 CMAM programme adaptations enabled service continuity despite pandemic‐related challenges. Further evidence is needed on long‐term impacts. Family MUAC was well‐accepted and addressed screening gaps from COVID‐19 disruptions. Challenges included sustaining caregiver measurement accuracy; handling inaccurate self‐referrals to encourage health‐seeking behaviours; and limited programme design and monitoring guidance and tools. Modified admission criteria and therapeutic food dosage reduced contact between staff and children and streamlined logistics and implementation. Concerns remained about effects on programme admissions and outcomes. Reduced frequency of follow‐up visits successfully reduced facility crowding and need for caregiver travel. However, infrequent monitoring of childrenmay miss deterioration.
Collapse
Affiliation(s)
| | | | - Sarah King
- Action Against Hunger USA Washington, DC USA
| | | | - Heather Stobaugh
- Action Against Hunger USA Washington, DC USA
- Friedman School of Nutrition Science and Policy Tufts University Boston Massachusetts USA
| |
Collapse
|
18
|
Hendrixson DT, Lasowski PN, Koroma AS, Manary MJ. Newborn Mid-Upper Arm Circumference Identifies Low-Birth Weight and Vulnerable Infants: A Secondary Analysis. Curr Dev Nutr 2022; 6:nzac138. [PMID: 36475019 PMCID: PMC9718650 DOI: 10.1093/cdn/nzac138] [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: 06/23/2022] [Revised: 08/25/2022] [Accepted: 09/03/2022] [Indexed: 04/22/2024] Open
Abstract
Background Low birth weight (LBW) infants are at increased risk of morbidity and mortality. Identification of LBW may not occur in settings where access to reliable scales is limited. Mid-upper arm circumference (MUAC) may be an accessible, low-cost measure to identify LBW and vulnerable infants. Objectives We explored the validity of newborn MUAC in identifying LBW and vulnerable newborns in rural Sierra Leone. Methods This study was a secondary analysis of infant data from a randomized controlled clinical trial of supplementary food and anti-infective therapies compared with standard care for undernourished pregnant women. Data for singleton liveborn infants with birth measurement and 6-mo survival data were included in this analysis. The primary outcome was validity of MUAC in identifying low-birth weight (LBW) neonates. Secondary outcomes included validity of MUAC and head circumference (HC) in identifying weight-for-length z-score (WLZ) <-2, length-for-age z-score (LAZ) <-2, neonatal mortality, and mortality within the first 6 mo of life. Results The study population included 1167 infants, 229 (19.6%) with LBW. Birth MUAC (r = 0.817) and HC (r = 0.752) were highly correlated with birth weight. MUAC (AUC: 0.905; 95% CI: 0.884, 0.925) performed superiorly to HC (AUC: 0.88; 95% CI: 0.856, 0.904) in identifying LBW. The MUAC for identifying LBW was 9.6 cm (sensitivity: 0.86; specificity: 0.78). Neither MUAC nor HC reliably identified newborns with WLZ <-2 or LAZ <-2. MUAC ≤9.0 cm was the ideal cutoff for neonatal mortality (sensitivity: 53.3%; specificity: 89.7%; HR: 9.57; 95% CI: 1.86, 49.30). Birth anthropometrics did not reliably identify infants at risk of death in the first 6 mo of life. Conclusions MUAC was used successfully to identify LBW infants and infants at risk of neonatal mortality in Sierra Leone. Further evidence is needed to support increased use of newborn MUAC measurement to identify LBW infants and infants at risk of neonatal mortality in community settings where scales are not available. Primary trial was registered at clinicaltrials.gov as NCT03079388. Lay Summary Mid-upper arm circumference (MUAC) can be used to identify infants with low birth weight and infants at risk for neonatal mortality, with an MUAC ≤9.0 cm indicating the highest risk.
Collapse
Affiliation(s)
| | | | - Aminata Shamit Koroma
- Ministry of Health and Sanitation, The Republic of Sierra Leone, Freetown, Sierra Leone
| | - Mark J Manary
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| |
Collapse
|
19
|
Niang M, Moha M, Ridde V, Gautier L. La pérennité d’un projet de prévention et de prise en charge de la malnutrition au Niger. CANADIAN JOURNAL OF PUBLIC HEALTH 2022; 113:636-646. [PMID: 35437698 PMCID: PMC9263011 DOI: 10.17269/s41997-022-00631-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 03/18/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This article is a case study of a capacity-building project to reduce malnutrition, implemented by a non-governmental organization (NGO) in Niger. It aims to generate a set of lessons learned on the processes of sustaining health interventions in vulnerable contexts. METHODS Using a theoretical framework on sustainability, we carried out a thematic analysis on semi-structured individual interviews (n = 124) collected, between 2016 and 2017, during the evaluative research of the NGO project. RESULTS The data analysis revealed several risks and opportunities to sustain the project activities, classified according to the characteristics of a routine identified in the theoretical framework: memory, routines, values, and rules. Our findings show a low level of sustainability of the project. Several activities were stopped at the end of the project and others may not continue in the long term. Indeed, local realities-poverty and political fragility-combined with the 'short-term' and vertical logics of the project's implementation have hindered the project activities' sustainability. CONCLUSION In vulnerable environments, sustainability should not simply be seen as an outcome to be achieved at the end of the project. The sustainability process must be activated by key stakeholders, focusing not only on the resources stabilizing but also on the resilience of the structures and systems in which interventions are embedded.
Collapse
Affiliation(s)
- Marietou Niang
- Faculté des sciences infirmières, Santé communautaire, Université Laval, Québec, Québec, Canada
| | - Mahaman Moha
- Laboratoire d'Études et de Recherches sur les Dynamiques Sociales et le Développement Local, Niamey, Niger
| | - Valéry Ridde
- Centre Population et Développement (Ceped), Institut de recherche pour le développement (IRD) et Université Paris Cité, Inserm ERL 1244, Paris, France
| | - Lara Gautier
- École de santé publique de l'Université de Montréal (ESPUM), Montréal, Québec, Canada.
- Centre de recherche en santé publique, Université de Montréal et CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montréal, Québec, Canada.
| |
Collapse
|
20
|
Kang Y, Wu LSF, Shaikh S, Ali H, Shamim AA, Christian P, Labrique A, West KP. Birth anthropometry predicts neonatal and infant mortality in rural Bangladesh: a focus on circumferential measurements. Am J Clin Nutr 2022; 115:1334-1343. [PMID: 35021206 PMCID: PMC9071409 DOI: 10.1093/ajcn/nqab432] [Citation(s) in RCA: 2] [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: 06/25/2021] [Accepted: 12/29/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Low birth weight predicts risk of infant death. However, several birth measurements may be equally predictive, for which cutoffs and associated risks are less explored. OBJECTIVES We assessed and optimized population cutoffs of birth length, weight, and midupper arm circumference (MUAC), head circumference (HC), and chest circumference (CC) for predicting neonatal (≤28 d) and infant (≤365 d) mortality in northwest Bangladesh. METHODS Among 28,026 singletons born in an antenatal micronutrient supplement trial, 21,174 received anthropometry ≤72 h after birth, among whom 583 died in infancy. Optimization for predicting mortality for each measurement was guided by the Youden Index (sensitivity + specificity - 1). Relative risk ratios (RRRs) and positive predictive values (PPVs) were calculated across cutoff ranges for individual and any pair of measurements. RESULTS Optimal cutoffs, harmonized to 100-g or 0.5-cm readings, for neonatal and infant mortality were 44.5 cm for length, 2200 g for weight, 9.0 cm for MUAC, 31.0 cm for HC, and 28.5 cm for CC, below which all predicted mortality. However, a CC <28.5 cm, alone and combined with HC <31.0 cm, yielded the highest RRR [9.68 (95% CI: 7.84, 11.94) and 15.74 (95% CI: 12.54, 19.75), respectively] and PPV (11.3% and 10.7%) for neonatal mortality and highest RRR [6.02 (95% CI: 5.15, 7.02) and 9.19 (95% CI: 7.72, 10.95)] and PPV (16.3% and 14.5%) for infant mortality. Pairs of measurements revealed a higher RRR for neonatal and infant mortality than individual measurements of any one pair, although the ranges of PPV remained comparable. CONCLUSIONS In Bangladesh, multiple birth measurements alone or in combination, particularly chest circumference, predict neonatal and infant mortality.
Collapse
Affiliation(s)
- Yunhee Kang
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lee Shu Fune Wu
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Hasmot Ali
- The JiVitA Project, Gaibandha, Bangladesh
| | - Abu Ahmed Shamim
- The JiVitA Project, Gaibandha, Bangladesh
- James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alain Labrique
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Keith P West
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
21
|
Rana R, Barthorp H, McGrath M, Kerac M, Myatt M. Mid-Upper Arm Circumference Tapes and Measurement Discrepancies: Time to Standardize Product Specifications and Reporting. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:1011-1014. [PMID: 34933994 PMCID: PMC8691892 DOI: 10.9745/ghsp-d-21-00273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 09/09/2021] [Indexed: 11/15/2022]
Abstract
Mid-upper arm circumference (MUAC) is a widely used anthropometric measure to identify children with acute malnutrition. The use of different tapes of varied materials and thicknesses to measure MUAC has led to discrepancies. This indicates the need for global standardization of MUAC tape design. In recent years, community-based management of acute malnutrition (CMAM) has revolutionized the care for children by increasing treatment coverage. Critical to the success of CMAM is early case identification. Mid-upper arm circumference (MUAC) measurement is a widely used, practical anthropometric measure used at the community level for the identification and admission of cases to appropriate treatment services. Globally, many organizations and government services use MUAC tapes for early case detection. However, there is no one universal MUAC tape specification, and it has been observed that using different MUAC tapes results in different measurements. In this article, we aim to: (1) present the measurement discrepancies; (2) discuss design specifications and their effect on case identification and admissions; (3) present a call to action to agree on common design specifications and standardized reporting. We hope this article will catalyze discussion and practical actions among nutrition and health stakeholders to ensure we have common MUAC tape design specifications so that all eligible at-risk children will get an equal chance to be identified early for critical treatment.
Collapse
Affiliation(s)
- Ritu Rana
- GOAL Global, Dublin, Ireland.
- Indian Institute of Public Health Gandhinagar, Gujarat, India
| | | | - Marie McGrath
- Emergency Nutrition Network, Kidlington, Oxford, United Kingdom
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mark Myatt
- Brixton Health, Llwyngwril, Gwynedd, Wales, United Kingdom
| |
Collapse
|
22
|
Hoehn C, Lelijveld N, Mwangome M, Berkley JA, McGrath M, Kerac M. Anthropometric Criteria for Identifying Infants Under 6 Months of Age at Risk of Morbidity and Mortality: A Systematic Review. Clin Med Insights Pediatr 2021; 15:11795565211049904. [PMID: 34707425 PMCID: PMC8543668 DOI: 10.1177/11795565211049904] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/01/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND There is increasing global focus on small and nutritionally at-risk infants aged <6 months (<6 m). Current WHO guidelines recommend weight-for-length z-score (WLZ) for enrolment to malnutrition treatment programmes but acknowledge a weak evidence-base. This review aims to inform future guidelines by examining which anthropometric criteria best identify infants <6 m at high risk of mortality/morbidity. METHODS We searched Medline, EMBASE, CINAHL, Global Health, Cochrane Library and POPLINE for studies conducted in low- and middle-income countries and published between 1990 and October 2020. We included studies reporting anthropometric assessment of nutritional status in infants <6 m and assessed the association with subsequent morbidity or mortality. RESULTS A total of 19 studies were included in the final review, covering 20 countries, predominantly in sub-Saharan Africa. WLZ had poor reliability and poor prognostic ability to identify infants at risk of death. Mid-upper arm circumference (MUAC) and weight-for-age z-score (WAZ) were better at identifying infants at risk of mortality/morbidity. MUAC-for-age z-score did not perform better than using a single MUAC cut-off. Suggested MUAC cut-offs for this age group varied by context, ranging from 10.5 to 11.5 cm. The assessment for reliability showed that length was difficult to measure, making WLZ the least reliable indicator overall. CONCLUSION Evidence from our review suggests that a change in current practice is necessary. To better identify small and nutritionally at-risk infants <6 m WAZ and/or MUAC rather than WLZ should be used. Future research should explore possible benefits for programme coverage, impact and cost-effectiveness. Research should also examine if context-specific MUAC thresholds are needed.
Collapse
Affiliation(s)
| | | | - Martha Mwangome
- Kenya Medical Research Institute/Wellcome Trust Research Program, Kilifi, Kenya
| | - James A Berkley
- Kenya Medical Research Institute/Wellcome Trust Research Program, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
| | | | - Marko Kerac
- London School of Hygiene and Tropical Medicine, London, UK
- Centre for Maternal, Adolescent & Reproductive Child Health, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
23
|
Strysko JP, Steenhoff AP. Biomarkers Make the Case for a Comprehensive Approach to Diagnosing Severe Acute Malnutrition. Pediatrics 2021; 147:peds.2021-050215. [PMID: 34021064 DOI: 10.1542/peds.2021-050215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jonathan P Strysko
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; .,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; and.,Department of Paediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Andrew P Steenhoff
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana; and.,Department of Paediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| |
Collapse
|
24
|
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: 7] [Impact Index Per Article: 2.3] [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.
Collapse
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
| |
Collapse
|
25
|
Response to Malnutrition Treatment in Low Weight-for-Age Children: Secondary Analyses of Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial. Nutrients 2021; 13:nu13041054. [PMID: 33805040 PMCID: PMC8064102 DOI: 10.3390/nu13041054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5–12.5 cm) and a severely low WAZ (<−3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<−3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < −3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < −3.0.
Collapse
|
26
|
Impact of Different Levels of Supervision on the Recovery of Severely Malnourished Children Treated by Community Health Workers in Mali. Nutrients 2021; 13:nu13020367. [PMID: 33530333 PMCID: PMC7911749 DOI: 10.3390/nu13020367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/16/2021] [Accepted: 01/21/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated community case management (iCCM). This paper evaluates the most effective model of supervision for treating SAM using community health workers (CHWs). Methods (2): This study was a prospective non-randomized community intervention trial with two intervention groups and one control group with different levels of supervision. It was conducted in three districts in rural areas of the Kayes Region. In the high supervision group, CHWs received supportive supervision for the iCCM package and nutrition-specific supervision. In the light supervision group, CHWs received supportive supervision based on the iCCM package. The control group had no specific supervision. (3) Results: A total of 6112 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 81.4% in those treated by CHWs in the high supervision group, 86.2% in the light supervision group, and 66.9% in the control group. Children treated by the CHWs who received some supervision had better outcomes than those treated by unsupervised CHWs (p < 0.001). There was no difference between areas with light and high supervision, although those with high supervision performed better in most of the tasks analyzed. (4) Conclusions: Public policies in low-income countries should be adapted, and their model of supervision of CHWs for SAM treatment in the community should be evaluated.
Collapse
|
27
|
Ndiaye A, Suneson K, Njuguna I, Ambler G, Hanke T, John-Stewart G, Jaoko W, Reilly M. Growth patterns and their contributing factors among HIV-exposed uninfected infants. MATERNAL AND CHILD NUTRITION 2020; 17:e13110. [PMID: 33269548 PMCID: PMC7988866 DOI: 10.1111/mcn.13110] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 06/11/2020] [Accepted: 10/25/2020] [Indexed: 02/06/2023]
Abstract
With expanded HIV treatment and prevention programmes, most infants born to HIV‐positive women are uninfected, but the patterns and determinants of their growth are not well described. This study aimed to assess growth patterns in a cohort of HIV‐exposed uninfected (HEU) infants who participated in an experimental HIV vaccine trial and to test for associations with maternal and infant factors, including in‐utero exposure to antiretroviral therapy (ART), mode of delivery, exclusive breastfeeding, mother's education and receipt of the vaccine. Infants in the trial were seen at regular clinic visits from birth to 48 weeks of age. From the anthropometric measurements at these visits, weight‐for‐age z‐scores (WAZ), weight‐for‐length z‐scores (WLZ) and length‐for‐age z‐scores (LAZ) were computed using World Health Organization (WHO) software and reference tables. Growth patterns were investigated with respect to maternal and infant factors, using linear mixed regression models. From 94 infants included at birth, growth data were available for 75.5% at 48 weeks. The determinants of infant growth in this population are multifactorial: infant LAZ during the first year was significantly lower among infants delivered by caesarean section (p = 0.043); both WAZ and LAZ were depressed among infants with longer exposure to maternal ART (WAZ: p = 0.015; LAZ: p < 0.0001) and among infants of mothers with lower educational level (WAZ: p = 0.038; LAZ: p < 0.0001); the effect of maternal education was modified by breastfeeding practice, with no differences seen in exclusively breastfed infants. These findings inform intervention strategies to preserve growth in this vulnerable infant population.
Collapse
Affiliation(s)
- Aminata Ndiaye
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Klara Suneson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.,Faculty of Medicine, Department of Clinical Sciences, Psychiatry, Lund University, Lund, Sweden
| | - Irene Njuguna
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya.,Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Gwen Ambler
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Tomas Hanke
- Jenner Institute, University of Oxford, Oxford, UK
| | - Grace John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Departments of Global Health, Pediatrics, and Medicine, University of Washington, Seattle, Washington, USA
| | - Walter Jaoko
- KAVI-Institute of Clinical Research, University of Nairobi, Nairobi, Kenya
| | - Marie Reilly
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
28
|
Phong RY, Taylor SL, Robinson BA, Jhawar S, Nandalike K. Utility of Mid-Upper Arm Circumference in Diagnosing Malnutrition in Children With Cystic Fibrosis. Nutr Clin Pract 2020; 35:1094-1100. [PMID: 33078441 DOI: 10.1002/ncp.10593] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Standardized diagnostic indicators for malnutrition using growth percentile z-scores (weight for length or body mass index [BMI]) and mid-upper arm circumference (MUAC) z-scores are being used in clinical practice; however, their application to the pediatric cystic fibrosis (CF) population is not well described. In this study, we aim to compare growth percentile z-scores and MUAC z-scores in diagnosing and classifying malnutrition in children with CF and assess the relationship between their degree of malnourishment and corresponding pulmonary function tests (PFTs). METHODS In this retrospective observational outpatient study of 49 pediatric CF patients, data were collected on baseline characteristics, anthropometrics, and PFTs over 12 months. Agreement in malnutrition diagnoses was quantified by Cohen κ statistics. Pearson test assessed the correlation between MUAC and BMI z-scores as well as PFTs and anthropometrics. Serial anthropometrics and PFTs were obtained and compared for a subset of patients (n = 28). RESULTS Growth percentile and MUAC z-scores were positively correlated in diagnosing malnutrition (Pearson correlation r = 0.87), but MUAC z-scores identified more patients as malnourished compared with growth percentile z-scores (49% vs 12%, Cohen κ of 0.22 [95% CI, 0.04-0.40]). There was no significant relationship between anthropometrics and PFTs. MUAC z-scores increased significantly over time, but BMI z-scores did not show this trend. CONCLUSIONS Our small-scale data suggest a promising role for MUAC z-scores in classifying malnutrition and in measuring changes in nutrition status over time in pediatric CF.
Collapse
Affiliation(s)
- Rachel Y Phong
- Department of Food and Nutrition Services, University of California Davis Health, Sacramento, California, USA
| | - Sandra L Taylor
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Sacramento, California, USA
| | - Brandt A Robinson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of California Davis Health, Sacramento, California, USA
| | - Sanjay Jhawar
- Division of Pulmonary Medicine, Department of Pediatrics, University of California Davis Health, Sacramento, California, USA
| | - Kiran Nandalike
- Division of Pulmonary Medicine, Department of Pediatrics, University of California Davis Health, Sacramento, California, USA
| |
Collapse
|
29
|
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.
Collapse
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
| |
Collapse
|
30
|
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: 18] [Impact Index Per Article: 4.5] [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.
Collapse
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
| |
Collapse
|
31
|
Ghimire U, Aryal BK, Gupta AK, Sapkota S. Severe acute malnutrition and its associated factors among children under-five years: a facility-based cross-sectional study. BMC Pediatr 2020; 20:249. [PMID: 32456624 PMCID: PMC7249365 DOI: 10.1186/s12887-020-02154-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/19/2020] [Indexed: 12/03/2022] Open
Abstract
Background Despite consistent efforts to enhance child nutrition, poor nutritional status of children continues to be a major public health problem in Nepal. This study identified the predictors of severe acute malnutrition (SAM) among children aged 6 to 59 months in the two districts of Nepal. Methods We used data from a cross-sectional study conducted among 6 to 59 months children admitted to the Outpatient Therapeutic Care Centers (OTCC). The nutritional status of children was assessed using mid-upper arm circumference (MUAC) measurement. To determine which variables predict the occurrence of SAM, adjusted odds ratio was computed using multivariate logistic regression and p-value < 0.05 was considered as significant. Results Out of 398 children, 5.8% were severely malnourished and the higher percentage of female children were malnourished. Multivariate analysis showed that severe acute malnutrition was significantly associated with family size (five or more members) (Adjusted Odds Ratio [AOR]: 3.96; 95% Confidence Interval [CI]: 1.23–12.71). Children from severely food insecure households (AOR: 4.04; 95% CI: 1.88–10.53) were four times more likely to be severely malnourished. Higher odds of SAM were found among younger age-group (AOR: 12.10; 95% CI: 2.06–71.09) children (0–12 vs. 24–59 months). Conclusions The findings of this study indicated that household size, household food access, and the child’s age were the major predictors of severe acute malnutrition. Engaging poor families in kitchen gardening to ensure household food access and nutritious diet to the children, along with health education and promotion to the mothers of young children are therefore recommended to reduce child undernutrition.
Collapse
Affiliation(s)
- Umesh Ghimire
- New ERA, Kalopul, Rudramati Marga, Kathmandu, 44600, Nepal.
| | | | | | - Suman Sapkota
- Partnership for Social Development, Kathmandu, 446006, Nepal
| |
Collapse
|
32
|
Hossain A, Niroula B, Duwal S, Ahmed S, Kibria MG. Maternal profiles and social determinants of severe acute malnutrition among children under-five years of age: A case-control study in Nepal. Heliyon 2020; 6:e03849. [PMID: 32420471 PMCID: PMC7218020 DOI: 10.1016/j.heliyon.2020.e03849] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/09/2020] [Accepted: 04/21/2020] [Indexed: 11/27/2022] Open
Abstract
Background Addressing the determinants of severe acute malnutrition (SAM) among children remains a challenge in Nepal. This study investigated the effect of maternal and social determinants of SAM among under-five children of Nepal. Methods We conducted a hospital-based unmatched case-control study with 256 under-five children (128 cases and 128 controls). The children aged 6–59 months were taken, and the cases and controls were defined based on mid-upper arm circumference (MUAC). Results Backward Stepwise logistic regression analysis of 6–59 months children showed that the odds of SAM were lower among male children (AOR = 0.50, 95% CI = 0.27–0.92), mothers from high socioeconomic status (AOR = 0.469, 95% CI = 0.26–0.83), breastfeeding 6–12 months (AOR = 0.21, 95% CI = 0.05–0.68), breastfeeding ≥13 months (AOR = 0.18, 95% CI = 0.05–0.54) and optimal complementary feeding (AOR = 0.40, 95% CI = 0.22–0.70). SAM was significantly higher among children of the age group 6–24 months (AOR = 2.57, 95% CI = 1.30–5.22) and children with a history of diarrhea (AOR = 1.75, 95% CI = 0.92–3.39). Conclusions In order to reduce the children's SAM, it is necessary to scale up services to improve the socioeconomic status which includes the education, occupation, and monthly income of the mother. Girls of age group 6–24 months were more likely to develop SAM. Two contributing factors to decrease SAM are the importance of exclusive breastfeeding practices and the availability and usage of soap in hand washing, which are ideal for low cost interventions. To reduce SAM in Nepal, a focus on enhancing complementary feeding through increased affordability of nutritious foods is also needed.
Collapse
Affiliation(s)
- Ahmed Hossain
- Department of Public Health, North South University, Bashundhara, Dhaka 1229, Bangladesh.,Centre for Development Action, Dhaka 1216, Bangladesh
| | - Bhupendra Niroula
- Department of Public Health, North South University, Bashundhara, Dhaka 1229, Bangladesh.,Kathmandu University, Dhulikhel, Kathmandu 45200, Nepal
| | - Sangita Duwal
- Department of Public Health, North South University, Bashundhara, Dhaka 1229, Bangladesh.,Kathmandu University, Dhulikhel, Kathmandu 45200, Nepal
| | - Shakil Ahmed
- Department of Public Health, North South University, Bashundhara, Dhaka 1229, Bangladesh
| | - Md Golam Kibria
- Department of Public Health, North South University, Bashundhara, Dhaka 1229, Bangladesh.,Centre for Development Action, Dhaka 1216, Bangladesh
| |
Collapse
|
33
|
Tessema M, Laillou A, Tefera A, Teklu Y, Berger J, Wieringa FT. Routinely MUAC screening for severe acute malnutrition should consider the gender and age group bias in the Ethiopian non-emergency context. PLoS One 2020; 15:e0230502. [PMID: 32271790 PMCID: PMC7144967 DOI: 10.1371/journal.pone.0230502] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/03/2020] [Indexed: 11/24/2022] Open
Abstract
Early identification of children <5 years with severe acute malnutrition (SAM) is a high priority to reduce child mortality and improved health outcomes. Current WHO guidelines for community screening for SAM recommend a Mid-Upper-Arm Circumference (MUAC) of less than 115 mm to identify children with SAM, but this cut-off does not identify a significant number of children with a weight-for-height Z-score <-3. To establish new specific MUAC cut-offs, pooled data was obtained for 25,755 children from 49 SMART recent surveys in Ethiopia (2016–2019). Sensitivity, proportion of false positive, and areas under receiver-operator characteristic curves (AUC) were calculated. MUAC below 115mm alone identified 55% of children with SAM identified with both methodologies. MUAC was worse in identifying older children (21%), those from a pastoral region (42%) and boys (41%). Using current WHO cut-offs, the sensitivity (Se) of MUAC below 115mm to identify the children severly malnourished screened through Weight-for-height below-3 was 16%. Analysing the ROC curve and Youden Index, Se and Specificity (Sp) were maximal at a MUAC < 133 mm cut-off to identify SAM (respectively Se 61.1%, Sp 81.4%). However, given the high proportion of false-positive children, according to gender, region and age groups, a cut-off around 125 mm to screen SAM could be the optimal one. In Ethiopia, implementation of a MUAC-only screening program for the identification of severe acute malnutrition with the actual cut-off of 115 mm would be unethical as it will lead to many children remaining undiagnosed and untreated. In addition, future study on implementation challenge on screening children with a higher cut-off or gender/age sensitive ones should be assessed with the collection of mortality and morbidity data to ensure that the most in need are being taking care of.
Collapse
Affiliation(s)
| | - Arnaud Laillou
- UNICEF Ethiopia, UNECA Compound, Addis Ababa, Ethiopia
- * E-mail:
| | - Abiy Tefera
- UNICEF Ethiopia, UNECA Compound, Addis Ababa, Ethiopia
| | - Yoseph Teklu
- UNICEF Ethiopia, Emergency Nutrition Coordination Unit (ENCU), UNECA Compound, Addis Ababa, Ethiopia
| | - Jacques Berger
- Institut de Recherche pour le Development (IRD), Montpellier, France
| | - Frank T. Wieringa
- Institut de Recherche pour le Development (IRD), Montpellier, France
| |
Collapse
|
34
|
Murphy-Alford AJ, Prasad M, Slone J, Stein K, Mosby TT. Perspective: Creating the Evidence Base for Nutritional Support in Childhood Cancer in Low- and Middle-Income Countries: Priorities for Body Composition Research. Adv Nutr 2020; 11:216-223. [PMID: 31529044 PMCID: PMC7442409 DOI: 10.1093/advances/nmz095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/04/2019] [Accepted: 08/13/2019] [Indexed: 01/07/2023] Open
Abstract
There is a striking disparity in survival rates for children in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Many of the contributing factors are preventable, including the comorbidity of malnutrition. There are emerging data that malnutrition, as reflected in body composition changes, impacts survival of cancer. However, not enough priority is given to nutrition management of children with cancer, particularly in LMICs. The primary purpose of this article is to review the current knowledge on childhood cancer and body composition in LMICs and identify priorities for future research into the interlinking associations between cancer, body composition, and clinical outcomes for childhood cancer patients. Evidence will ensure feasible and effective nutrition management is prioritized in childhood cancer centers in LMICs and contribute to improving outcomes for children with cancer.
Collapse
Affiliation(s)
- Alexia J Murphy-Alford
- Nutritional and Health-Related Environmental Studies Section, International Atomic Energy Agency, Vienna, Austria,Address correspondence to AJM-A (e-mail: )
| | - Maya Prasad
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Jeremy Slone
- Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Katja Stein
- Civil Hospital of Guadalajara Dr Juan I Menchaca, University Center of Health Sciences, University of Guadalajara, Guadalajara, Mexico
| | - Terezie T Mosby
- Department of Food Science, Nutrition and Health Promotion, Mississippi State University, Mississippi State, MS, USA
| |
Collapse
|
35
|
Miller MA, Mallory K, Escobedo M, Tarot AC, Abdel-Rahman S. Assessing effectiveness of a novel mid-upper arm circumference Z-score tape in a community setting in Guatemala. ACTA ACUST UNITED AC 2019; 77:44. [PMID: 31592316 PMCID: PMC6777036 DOI: 10.1186/s13690-019-0370-0] [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: 05/31/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022]
Abstract
Background Mid-Upper Arm Circumference (MUAC) is an independent anthropometric measurement used to identify malnutrition in children. While much research has been dedicated to applying fixed estimates of MUAC to identify cases of malnutrition in children under 5 years of age, far less has been done with age-specific MUAC Z-score values across the continuum of age from birth through adolescence. Methods The present study examined the effectiveness of a novel MUAC Z-score tape, in the hands of community health volunteers, to identify children over the age of 5 who would benefit from nutritional rehabilitation. In January of 2019, 112 community health volunteers working within Children International in Guatemala were trained to use the MUAC Z-score tape and asked to collect measurements on children or youth in their communities. Results Of the 818 MUAC Z-score tape measurements obtained by volunteers, 88.26% (722/818) were concordant with nutritional risk status as predicted by BMI Z-score, and 90.95% (744/818) were concordant with MUAC Z-score tape measurements made by field medical staff. MUAC Z-scores identified 87.10% (27/31) of the severely or moderately undernourished children as determined by the BMI Z-score who would be candidates for the nutrition rehabilitation program (Z-score ≤ − 2) along with an additional six children that would not have been classified as such with BMI Z-score. A qualitative survey distributed to the volunteers showed moderate rates of understanding of nutritional risk using the tape, and 62.50% reported the tape was easy to use. Conclusions These quantitative and qualitative findings suggest that with more in-depth training and education the MUAC Z-score tape is a viable, low-cost, low-burden alternative for community-level nutritional status assessment among the population served by Children International in Guatemala. Supplementary information Supplementary information accompanies this paper at (10.1186/s13690-019-0370-0).
Collapse
|
36
|
Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali. PLoS Med 2019; 16:e1002892. [PMID: 31454356 PMCID: PMC6711497 DOI: 10.1371/journal.pmed.1002892] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. METHODS AND FINDINGS A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6-23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers' participation and supplement children's diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. CONCLUSIONS Incorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated. TRIAL REGISTRATION ClinicalTrials.gov NCT02323815.
Collapse
|