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Kangas ST, Ouédraogo CT, Tounkara M, Ouoluoguem B, Coulibaly IN, Haidara A, Diarra NH, Diassana K, Tausanovitch Z, Ritz C, Wells JC, Briend A, Myatt M, Radin E, Bailey J. Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm randomized controlled trial. Trials 2024; 25:30. [PMID: 38191436 PMCID: PMC10773065 DOI: 10.1186/s13063-023-07890-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/18/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol. METHODS This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ. DISCUSSION This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.
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Affiliation(s)
| | | | - Moctar Tounkara
- Department of Education and Research in Public Health and Specialties, Faculty of Medicine and Dentistry, University of Sciences, Technics and Technologies of Bamako, Bamako, Mali
| | | | | | | | | | | | | | - Christian Ritz
- National Institute of Public Health, Copenhagen, Denmark
| | - Jonathan C Wells
- Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - André Briend
- Department of International Health, University of Tampere School of Medicine, Tampere, Finland
- Department of Nutrition, Exercise and Sports, Faculty of Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mark Myatt
- Brixton Health, Brixton, UK
- Emergency Nutrition Network, Kidlington, Oxforshire, UK
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Grant-Beurmann S, Jumare J, Ndembi N, Matthew O, Shutt A, Omoigberale A, Martin OA, Fraser CM, Charurat M. Dynamics of the infant gut microbiota in the first 18 months of life: the impact of maternal HIV infection and breastfeeding. Microbiome 2022; 10:61. [PMID: 35414043 PMCID: PMC9004197 DOI: 10.1186/s40168-022-01230-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Access to antiretroviral therapy (ART) during pregnancy and breastfeeding for mothers with HIV has resulted in fewer children acquiring HIV peri- and postnatally, resulting in an increase in the number of children who are exposed to the virus but are not infected (HEU). HEU infants have an increased likelihood of childhood infections and adverse growth outcomes, as well as increased mortality compared to their HIV-unexposed (HUU) peers. We explored potential differences in the gut microbiota in a cohort of 272 Nigerian infants born to HIV-positive and negative mothers in this study during the first 18 months of life. RESULTS The taxonomic composition of the maternal vaginal and gut microbiota showed no significant differences based on HIV status, and the composition of the infant gut microbiota at birth was similar between HUU and HEU. Longitudinal taxonomic composition of the infant gut microbiota and weight-for-age z-scores (WAZ) differed depending on access to breast milk. HEU infants displayed overall lower WAZ than HUU infants at all time points. We observed a significantly lower relative abundance of Bifidobacterium in HEU infants at 6 months postpartum. Breast milk composition also differed by time point and HIV infection status. The antiretroviral therapy drugs, lamivudine and nevirapine, as well as kynurenine, were significantly more abundant in the breast milk of mothers with HIV. Levels of tiglyl carnitine (C5) were significantly lower in the breast milk of mothers without HIV. ART drugs in the breast milk of mothers with HIV were associated with a lower relative abundance of Bifidobacterium longum. CONCLUSIONS Maternal HIV infection was associated with adverse growth outcomes of HEU infants in this study, and these differences persist from birth through at least 18 months, which is a critical window for the development of the immune and central nervous systems. We observed that the relative abundance of Bifidobacterium spp. was significantly lower in the gut microbiota of all HEU infants over the first 6 months postpartum, even if HEU infants were receiving breast milk. Breastfeeding was of benefit in our HEU infant cohort in the first weeks postpartum; however, ART drug metabolites in breast milk were associated with a lower abundance of Bifidobacterium. Video abstract.
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Affiliation(s)
- Silvia Grant-Beurmann
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jibreel Jumare
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Ashley Shutt
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Olivia A Martin
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claire M Fraser
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Man Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Hurst DM, Oster ME, Smith S, Clabby ML. Is Clinic Visit Frequency Associated with Weight Gain During the Interstage Period? A Report from the Joint Council on Congenital Heart Disease National Pediatric Cardiology Quality Improvement Collaborative (JCCHD-NPCQIC). Pediatr Cardiol 2015; 36:1382-5. [PMID: 25916314 DOI: 10.1007/s00246-015-1169-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 04/02/2015] [Indexed: 11/30/2022]
Abstract
Growth problems are prevalent among infants with congenital heart disease. We sought to determine whether frequency of outpatient clinic visits correlated with weight gain in patients with hypoplastic left heart syndrome or variant during the interstage period between discharge from stage I palliation and presentation for stage II palliation (SIIP). Using prospectively collected data from the JCCHD NPC-QIC database from June 2008 to July 2013, we performed a retrospective cohort study assessing the association of days between clinic visits (DBV) with the change in weight-for-age z-score (WAZ) during the interstage period. Eligible subjects were those who survived to a SIIP performed at <270 days of age and had at least two outpatient clinic visits. There were 561 patients from 49 centers who fulfilled inclusion criteria. The average interstage change in WAZ was +0.22. The mean number of DBV was 16.1 days, and the average number of clinic visits was six. There was no correlation of change in WAZ with either DBV (r = 0.02, P = 0.62) or the number of visits (r = 0.03, P = 0.44). Subjects within this cohort are seen about every 2 weeks averaged over the interstage period. There is no correlation between interstage visit frequency and change in WAZ in this patient population. Further research is needed to describe differences in visit frequency as the patient progresses through the interstage period and to elucidate whether patient factors such as growth velocity are influencing visit frequency. The optimal visit frequency remains unknown.
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Affiliation(s)
- David M Hurst
- Sibley Heart Center Cardiology at Children's Healthcare of Atlanta, Atlanta, GA, USA.,Emory University School of Medicine Atlanta, Atlanta, GA, USA
| | - Matthew E Oster
- Sibley Heart Center Cardiology at Children's Healthcare of Atlanta, Atlanta, GA, USA.,Emory University School of Medicine Atlanta, Atlanta, GA, USA.,Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sherry Smith
- Sibley Heart Center Cardiology at Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Martha L Clabby
- Sibley Heart Center Cardiology at Children's Healthcare of Atlanta, Atlanta, GA, USA. .,Emory University School of Medicine Atlanta, Atlanta, GA, USA. .,, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.
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Ubesie AC, Kocoshis SA, Mezoff AG, Henderson CJ, Helmrath MA, Cole CR. Multiple micronutrient deficiencies among patients with intestinal failure during and after transition to enteral nutrition. J Pediatr 2013; 163:1692-6. [PMID: 23978355 PMCID: PMC3842410 DOI: 10.1016/j.jpeds.2013.07.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/20/2013] [Accepted: 07/09/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the prevalence of deficiencies of specific micronutrients (iron, zinc, magnesium, phosphorus, selenium, copper, folate, and vitamins A, D, E, and B12) in children with intestinal failure (IF), and to identify risk factors associated with developing these deficiencies. STUDY DESIGN This study was a retrospective review of prospectively collected data from 178 children with IF managed by the Intestinal Care Center of Cincinnati Children's Hospital Medical Center between August 1, 2007, and July 31, 2012. Transition to full enteral nutrition (FEN) was defined as the period during which the patient received between 20% and 100% of estimated required nutrition enterally. FEN was defined as the patient's ability to tolerate 100% estimated required nutrition enterally for >2 weeks. RESULTS Necrotizing enterocolitis was the most common cause of IF (27.5%). Iron was the most common micronutrient deficiency identified both during (83.9%) and after (61%) successful transition to FEN, with a significant reduction in the percentage of patients with iron deficiency between these 2 periods (P = .003). Predictors of micronutrient deficiency after successful transition to FEN included birth weight (P = .03), weight percentile (P = .02), height percentile (P = .04), and duration of parenteral nutrition (PN) (P = .013). After multivariate adjustments, only duration of PN remained statistically significant (P = .03). CONCLUSION Micronutrient deficiencies persist in patients with IF during and after transition to FEN. These data support the need for routine monitoring and supplementation of these patients, especially those on prolonged PN.
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Affiliation(s)
- Agozie C Ubesie
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria.
| | - Samuel A Kocoshis
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam G Mezoff
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carol J Henderson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael A Helmrath
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Conrad R Cole
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Roth DE, Perumal N, Al Mahmud A, Baqui AH. Maternal vitamin D3 supplementation during the third trimester of pregnancy: effects on infant growth in a longitudinal follow-up study in Bangladesh. J Pediatr 2013; 163:1605-1611.e3. [PMID: 23998516 DOI: 10.1016/j.jpeds.2013.07.030] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 06/14/2013] [Accepted: 07/19/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To estimate the effects of prenatal vitamin D supplementation on infant growth in Dhaka, Bangladesh. STUDY DESIGN Longitudinal follow-up of infants born at term or late preterm (≥34 weeks) to participants in a randomized double-blind trial of maternal third-trimester vitamin D3 (35 000 IU/wk; vitamin D ) vs placebo. Anthropometry was performed at birth, 1, 2, 4, 6, 9, and 12 months of age. The primary analysis (n = 145 overall; n = 134 at 1 year) was a comparison of mean length-for-age z-score (LAZ) based on World Health Organization standards. RESULTS LAZ was similar between groups at birth, but 0.44 (95% CI, 0.06-0.82) higher in vitamin D vs placebo at 1 year, corresponding to a sex-adjusted increase of 1.1 cm (95% CI, 0.06-2.0). Mean change in LAZ from birth to 1 month was significantly greater in vitamin D (0.53 per month) vs placebo (0.19 per month; P = .004); but there was no significant divergence thereafter. In longitudinal (repeated-measures) analysis, average LAZ during infancy was 0.41 higher in vitamin D vs placebo (95% CI, 0.11-0.71, P = .01). Stunting was less common in vitamin D (17% of infants were ever stunted) vs placebo (31%; P = .049). Other anthropometric indices were similar between groups. CONCLUSIONS Maternal vitamin D3 supplementation (35 000 IU/wk) during the third trimester of pregnancy enhanced early postnatal linear growth in a cohort of infants in Bangladesh.
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Affiliation(s)
- Daniel E Roth
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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