Evaluation of malnutrition and screening tools in hospitalized children

BACKGROUND & AIMS

Detecting malnutrition and its related risk factors are crucial, in hospitalized children. Anthropometric z scores are used to assess malnutrition. Screening tools also aim to detect the presence of malnutrition and the developing risk of malnutrition in hospitalized children to determine who may benefit from nutritional support. Therefore, the aims of the study are to detect malnutrition and its related demographic and clinical risk factors in hospitalized children and determining the sensitivity of Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) and Pediatric Yorkhill Malnutrition Score (PYMS) screening tools.

METHODS

A total of 130 hospitalized children aged between 0 and 18 years were included in to study. A survey including demographic and clinical characteristics, STAMP and PYMS were applied to parents of the children. Patients were classified into nutritional risk groups through screening tools. Anthropometric measurements (body weight, length/height, and middle upper arm circumference (MUAC) of the children were taken. Body mass index-for-age and height-for-age z scores were calculated to assess acute and chronic malnutrition prevalence. MUAC-for-age z scores were calculated as well. To detect independent risk factors for acute and chronic malnutrition multivariable logistic regression models were constructed.

RESULTS

A total of 14.6% of hospitalized children had acute malnutrition, 21.5% of children had chronic malnutrition and 27.7% of them had low MUAC standard deviation score (SDS) (less than -2). The independent risk factors for acute malnutrition were younger maternal age at birth and long length of stay (p < 0.05). The independent risk factors for chronic malnutrition were being female, younger maternal age at birth, longer illness duration and having urological or allergy and immunological diseases (p < 0.05). However, MUAC for age SDS groups were not related to any demographic and clinical factors, in children of all ages (p > 0.05). Regarding the screening tools, PYMS displayed 100% sensitivity against acute malnutrition. While PYMS displayed better sensitivity to identify acute malnutrition than STAMP, STAMP was more sensitive than PYMS to detect chronic malnutrition and low MUAC SDS.

CONCLUSIONS

Low MUAC for age SDS was not related to any demographic and clinical factors, in hospitalized children of all ages, unlike acute and chronic malnutrition, in this study. Pediatric screening tools mainly PYMS did not have high sensitivity to detect chronic malnutrition and low MUAC SDS, in hospitalized children. Therefore, the tools have to be used along with z scores of anthropometric parameters.

Implementation of a nutritional supplementation program in a population of Cambodian children and its impact on statural growth

BACKGROUND

Stunting is a major health problem in low-income countries. We aimed to describe the implementation of a lipid-based nutrient supplement (LNS) program in a rural neighborhood in Cambodia and to assess its impact on statural growth.

METHOD

This was a before-after comparative study. The program was promoted by the Pédiatres du Monde (PDM) organization between 2011 and 2019 in six villages in a rural area in Cambodia. The supplementation program consisted of daily administration of LNS during the third semester of pregnancy for the mothers and then between 6 and 24 months of age for the toddlers. Anthropometric data of the children were recorded during PDM visits before and after the program implementation, which allowed us to compare child growth in the two groups: control and intervention groups. Primary outcome was height-for-age between 24 and 35 months of age.

RESULTS

Overall, 198 data were collected for children between 24 and 35 months of age in the control group. A total of 347 pregnant women were enrolled in the intervention phase. A total of 188 data were collected for children between 24 and 35 months of age in the intervention group. The mean height-for-age z-score in the population receiving LNS was higher than in the control group (-1.14 vs. -1.60, p < 0.001). There was no significant difference between the two groups regarding the weight-for-height z-score (WHZ; -1.11 vs. -1.26, p = 0.18) and children in the intervention group had a higher middle upper-arm circumference z-score (MUACZ; -0.75 vs.. -1.1, p < 0.001).

CONCLUSION

LNS supplementation significantly and increased the HAZ between 24 and 35 months of age. However, the fight against malnutrition is complex and needs intervention on multiple levels.

Early childhood stunting and later life outcomes: A longitudinal analysis

Using longitudinal data from four countries-Ethiopia, India, Peru and Vietnam- we show that early childhood stunting is highly persistent as measured by the association between stunting status in early childhood and stunting status at age 15. Stunting in early childhood is associated with lower grade completion by age 22 and has a negative relationship with cognition as measured by math, language and reading scores at ages 8, 12 and 15. Stunting in early childhood is also associated with poorer subjective assessment of a child's health at age 15. Analyzing determinants, we show that lack of preventive care and economic shocks are associated with an increase in the probability of stunting in early childhood.

Nutritional status in young children prior to the malaria transmission season in Burkina Faso and Mali, and its impact on the incidence of clinical malaria

BACKGROUND

Malaria and malnutrition remain major problems in Sahel countries, especially in young children. The direct effect of malnutrition on malaria remains poorly understood, and may have important implications for malaria control. In this study, nutritional status and the association between malnutrition and subsequent incidence of symptomatic malaria were examined in children in Burkina Faso and Mali who received either azithromycin or placebo, alongside seasonal malaria chemoprevention.

METHODS

Mid-upper arm circumference (MUAC) was measured in all 20,185 children who attended a screening visit prior to the malaria transmission season in 2015. Prior to the 2016 malaria season, weight, height and MUAC were measured among 4149 randomly selected children. Height-for-age, weight-for-age, weight-for-height, and MUAC-for-age were calculated as indicators of nutritional status. Malaria incidence was measured during the following rainy seasons. Multivariable random effects Poisson models were created for each nutritional indicator to study the effect of malnutrition on clinical malaria incidence for each country.

RESULTS

In both 2015 and 2016, nutritional status prior to the malaria season was poor. The most prevalent form of malnutrition in Burkina Faso was being underweight (30.5%; 95% CI 28.6-32.6), whereas in Mali stunting was most prevalent (27.5%; 95% CI 25.6-29.5). In 2016, clinical malaria incidence was 675 per 1000 person-years (95% CI 613-744) in Burkina Faso, and 1245 per 1000 person-years (95% CI 1152-1347) in Mali. There was some evidence that severe stunting was associated with lower incidence of malaria in Mali (RR 0.81; 95% CI 0.64-1.02; p = 0.08), but this association was not seen in Burkina Faso. Being moderately underweight tended to be associated with higher incidence of clinical malaria in Burkina Faso (RR 1.27; 95% CI 0.98-1.64; p = 0.07), while this was the case in Mali for moderate wasting (RR 1.27; 95% CI 0.98-1.64; p = 0.07). However, these associations were not observed in severely affected children, nor consistent between countries. MUAC-for-age was not associated with malaria risk.

CONCLUSIONS

Both malnutrition and malaria were common in the study areas, high despite high coverage of seasonal malaria chemoprevention and long-lasting insecticidal nets. However, no strong or consistent evidence was found for an association between any of the nutritional indicators and the subsequent incidence of clinical malaria.

Factors associated with stunting and wasting in children under 2 years in Bangladesh

Child undernutrition has been a major concern for Bangladesh as it is amongst the highest stunting and wasting prevalent countries in the world. The objective of our study was to explore the socioeconomic determinants of stunting and wasting in children under two years. This study explored nationally representative sample of 7,230 children ranging in age from 0 to <24 months using two separate binary logistic regression models to determine the risk factors associated with child stunting and wasting. Our study estimated approximately 33 percent children to be stunted and 11 percent to be wasted. Our analysis found that, 12 to <24 months old children's height-for-age-z-score and weight-for-height-z-score deteriorated in comparison to those of below 6 months. Female children had significantly lower odds of stunting and wasting compared with male children. Study revealed that children from wealthier families were at lower risk of being stunted and wasted compared to children from poorer households. Parental education was determined as a significant predictor of stunting. Children who lived in Sylhet division were 1.26 times more likely to be stunted than the children of Dhaka division [OR = 1.26; 95% CI: 1.02-1.55]. Our study revealed age, gender, geographic distribution, and household's position in wealth index as common determinants of child stunting and wasting in Bangladesh. While parental education was significant predictor for child stunting, type of toilet facility was found as statistically significant determinant of child wasting in children of less than two years age.

The double burden of chronic malnutrition and overweight and obesity in Ecuadorian mothers and children, 1986-2012

BACKGROUND:

The simultaneous presence of undernutrition and over-nutrition represents a paradox in global public health and is of increasing concern in Ecuador, where chronic malnutrition and overweight and obesity occur in the context of demographic and epidemiologic transitions. Two overlapping trends are present in Ecuador; while levels of stunting have decreased slowly in the past three decades, increasing proportions of children <5 years and women of reproductive age suffer from overweight and obesity.

AIM:

To analyze stunting and overweight and obesity in children <5 and their mothers aged from 15 to 49 years in the context of demographic and household characteristics between 1986 and 2012.

METHODS:

This study compares data from nationally-representative surveys conducted in Ecuador in 1986, 2004, and 2012, each of which collected information on children <5 and mothers aged 15-49 years.

RESULTS:

The prevalence of chronic malnutrition in children <5 decreased at different rates among Ecuadorians who differ in terms of residence, socioeconomic status, and mothers' level of education, while overweight and obesity increased dramatically in the same period.

CONCLUSION:

Chronic malnutrition in children <5 and overweight in children <5 and mothers 15-49 years represent a double burden of malnutrition in Ecuador. The phenomena differ in their effects, and, while the prevalence of stunting is declining in Ecuador as it is in many parts of the world, the problem of overweight and obesity has emerged in dramatic fashion, and currently represents an extraordinary challenge to public health.

Piecing together the stunting puzzle: a framework for attributable factors of child stunting

Reducing the burden of stunting in childhood is critical to improving health in low- and middle-income settings. However, because many aetiologies underlie linear growth failure, stunting has proved difficult to prevent and reverse. Understanding the contributions these aetiologies make to the burden of stunting can help the development of targeted, effective interventions. To begin to frame these causes, a qualitative and a quantitative framework of the primary drivers of stunting in low-resource settings were developed. Population attributable fractions (PAF) were estimated to inform the quantitative framework. According to these estimates, infectious diseases were responsible for large attributable fractions in all settings, and a combination of dietary indicators also comprised a large fraction in Africa. However, the PAF calculation was found to have several limitations, including a requirement for a binary outcome and sensitivity to confounding, which necessitate broad interpretation of the results. More robust tools to model complex causality are needed in order to understand the causal aetiology of stunting.

Determinants of childhood stunting in the Democratic Republic of Congo: further analysis of Demographic and Health Survey 2013-14

BACKGROUND

Prevalence of child stunting in the Democratic Republic of Congo (DRC) is among the highest in the world. There is a need to systematically investigate how stunting operates at different levels of determination and identify major factors contributing to the development of stunting. The aim of this study was to look for key determinants of stunting in the DRC.

METHODS

This study used data from the DRC Demographic Health Survey 2013-14 which included anthropometric measurement for 9030 under 5 year children. Height-for-Age Z score was calculated and classified according to the WHO guideline. The association between stunting and bio-demographic characteristics was assessed using logistic regression.

RESULTS

Prevalence of stunting was much higher in boys than girls. There was a significant rural urban gap in the prevalence of stunting with rural areas having a larger proportion of children living with stunting than urban. Male children, older than 6 months, preceding birth interval less than 24 months, being from lower wealth quintiles had the highest odds of stunting. Several provinces had in particular high odds of stunting. Early initiation of breastfeeding, mother's age more than 20 years at the time of delivery had lower odds of stunting. The taller the mother the less likely the child was to be stunted. Similarly, mother's BMI, access to safe water, access to hygienic toilet, mother's education were found negatively correlated with child stunting in the bivariate logistic regression, but they lost statistical significance in multivariate analysis together with numbers of children in the family and place of residence.

CONCLUSIONS

Child stunting is widespread in the DRC and increasing prevalence is worrisome. This study has identified modifiable factors determining high prevalence of stunting in the DRC. Policy implementation should in particular target provinces with high prevalence of stunting and address modifiable determinants such as reducing socioeconomic disparity. Nutrition promotion intervention, including early initiation of breastfeeding should be an immediate priority.

Stunting correlates with high salivary and serum antibody levels after 13-valent pneumococcal conjugate vaccination of Venezuelan Amerindian children

OBJECTIVE

To determine the impact of pre-vaccination nutritional status on vaccine responses in Venezuelan Warao Amerindian children vaccinated with the 13-valent pneumococcal conjugate vaccine (PCV13) and to investigate whether saliva can be used as read-out for these vaccine responses.

METHODS

A cross-sectional cohort of 504 Venezuelan Warao children aged 6 weeks - 59 months residing in nine geographically isolated Warao communities were vaccinated with a primary series of PCV13 according to Centers for Disease Control and Prevention (CDC)-recommended age-related schedules. Post-vaccination antibody concentrations in serum and saliva of 411 children were measured by multiplex immunoassay. The influence of malnutrition present upon vaccination on post-vaccination antibody levels was assessed by univariate and multivariable generalized estimating equations linear regression analysis.

RESULTS

In both stunted (38%) and non-stunted (62%) children, salivary antibody concentrations correlated well with serum levels for all serotypes with coefficients varying from 0.61 for serotype 3-0.80 for serotypes 5, 6A and 23F (all p < 0.01). Surprisingly, higher serum and salivary antibody levels were observed with increasing levels of stunting in children for all serotypes. This was statistically significant for 5/13 and 11/13 serotype-specific serum and saliva IgG concentrations respectively.

CONCLUSION

Stunted Amerindian children showed generally higher antibody concentrations than well-nourished children following PCV13 vaccination, indicating that chronic malnutrition influences vaccine response. Saliva samples might be useful to monitor serotype-specific antibody levels induced by PCV vaccination. This would greatly facilitate studies of vaccine efficacy in rural settings, since participant resistance generally hampers blood drawing.

Immunogenicity of poliovirus vaccines in chronically malnourished infants: a randomized controlled trial in Pakistan

Reaching high population immunity against polioviruses (PV) is essential to achieving global polio eradication. Efficacy of oral poliovirus vaccine (OPV) varies and is lower among children living in tropical areas with impoverished environments. Malnutrition found as a risk factor for lower serological protection against PV. We compared whether inactivated polio vaccine (IPV) can be used to rapidly close the immunity gap among chronically malnourished (stunted) infants in Pakistan who will not be eligible for the 14 week IPV dose in routine EPI schedule. A phase 3, multicenter 4-arm randomized controlled trial conducted at five Primary Health Care (PHC) centers in Karachi, Pakistan. Infants, 9–12 months were stratified by length for age Z score into chronically malnourished and normally nourished. Infants were randomized to receive one dose of either bivalent OPV (bOPV) alone or bOPV + IPV. Baseline seroprevalence of PV antibodies and serum immune response to study vaccine dose were assessed by neutralization assay. Vaccine PV shedding in stool was evaluated 7 days after a bOPV challenge dose. Sera and stool were analyzed from 852/928 (92%) enrolled children. At baseline, the seroprevalence was 85.6% (n = 386), 73.6% (n = 332), and 70.7% (n = 319) in malnourished children against PV types 1, 2 and 3 respectively; and 94.1% (n = 448), 87.0% (n = 441) and 83.6% (n = 397) in the normally nourished group (p < 0.05). Children had previously received 9–10 doses of bOPV (80%) or tOPV (20%). One dose of IPV + bOPV given to malnourished children increased their serological protection (PV1, n = 201, 97.6%; PV2, n = 198, 96.1% and PV3, n = 189, 91.7%) to parity with normally nourished children who had not received IPV (p = <0.001). Seroconversion and boosting for all three serotypes was significantly more frequent in children who received IPV + bOPV than in those with bOPV only (p < 0.001) in both strata. Shedding of polioviruses in stool did not differ between study groups and ranged from 2.4% (n = 5) to 7.1% (n = 15). In malnourished children the shedding was reduced after bOPV + IPV compared to bOPV only.

Chronically malnourished infants were more likely to be unprotected against polioviruses than normal infants. bOPV + IPV helped close the immunity gap better than bOPV alone.