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Kebede F, Kebede T, Negese B, Abera A, Fentaw G, Kasaw A. Incidence and predictors of severe acute malnutrition mortality in children aged 6-59 months admitted at Pawe general hospital, Northwest Ethiopia. PLoS One 2022; 17:e0263236. [PMID: 35213569 PMCID: PMC8880861 DOI: 10.1371/journal.pone.0263236] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 01/15/2022] [Indexed: 11/19/2022] Open
Abstract
Background Severe acute malnutrition (SAM) is defined as a weight-for-height < -3z scores of the median WHO growth standards, or visible severe wasting or the presence of nutritional edema. SAM related mortality rates in under-five children are well documented in Ethiopia but data on their predictors are limited. We aimed to document factors associated with SAM related mortality to inform better inpatient management. Methods A facility-based retrospective cohort study was conducted among children admitted due to SAM at Pawe General Hospital, Northwest Ethiopia, from the 1st of January 2015 to the 31st of December 2019. Data from the records of SAM children were extracted using a standardized checklist. Epi-Data version 3.2 was used for data entry, and Stata version 14 was used for analysis. Bi-variable and multivariable Cox regression analyses were conducted to identify predictors of mortality. Variables with P<0.05 were considered significant predictors of mortality. Results Five-hundred sixty-eight SAM cases were identified of mean age was 27.4 (SD± 16.5) months. The crude death rate was 91/568 (16.02%) and the mean time to death was determined as 13 (±8) days. Independent risk factors for death were: (i) vomiting AHR = 5.1 (1.35–21.1, p = 0.026), (ii) diarrhea AHR = 2.79 (1.46–5.4, p = 0.002), (iii) needing nasogastric therapy AHR = 3.22 (1.65–6.26, p = 0.001), (iv) anemia AHR = 1.89 (1.15–3.2, p = 0.012), and (v) being readmitted with SAM AHR = 1.7 (1.12–2.8, p = 0.037). Conclusion SAM mortality was high in under-five children in our setting. The identified risk factors should inform treatment and prevention strategies. Improved community health education should focus on healthy nutrition and seeking early treatment. Inpatient mortality may be reduced by stricter adherence to treatment guidelines and recognizing early the key risk factors for death.
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Affiliation(s)
- Fassikaw Kebede
- Department of Epidemiology and Biostatics, College of Health Science, Woldia University, Woldia, Ethiopia
- * E-mail:
| | - Tsehay Kebede
- Faculty of Social Science, Department of Geography & Environment study, Bahir Dare University, Bahir Dar, Ethiopia
| | - Belete Negese
- Department of Nursing & Midwifery, College of Medicine & Health Science, Debre Birhan University, Debre Birhan, Ethiopia
| | - Atitegeb Abera
- Department of Epidemiology and Biostatics, College of Health Science, Woldia University, Woldia, Ethiopia
| | - Getahun Fentaw
- Department of Nutrition, School of Public Health, College of Health Science, Woldia University, Woldia, Ethiopia
| | - Ayalew Kasaw
- Department of Nursing and Midwifery, Gambela College of Health Science Southern Ethiopia, Gambela, Ethiopia
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Lambebo A, Temiru D, Belachew T. Frequency of relapse for severe acute malnutrition and associated factors among under five children admitted to health facilities in Hadiya Zone, South Ethiopia. PLoS One 2021; 16:e0249232. [PMID: 33765081 PMCID: PMC7993841 DOI: 10.1371/journal.pone.0249232] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Severe acute malnutrition is a common cause of morbidity and mortality among under five children in Ethiopia. A child may experience more than one episode of SAM depending on the improvement of the underlying factors. However, there is no study that determined the frequency of relapse of SAM cases after discharge in Ethiopia. OBJECTIVE To identify the frequency of relapse and associated factors among children discharged after undergoing treatment for SAM in Hadiya Zone, South, Ethiopia. METHODS An institution based retrospective cohort study was done among children admitted to health posts for treatment of SAM from 2014/2015-2019/2020 under-five children's after discharge in health post for severe acute malnutrition in the last five years in Hadiya zone, SNNPR, Ethiopia. Both first admission data and relapse data were abstracted from the records of the SAM children from Aguste 1-30 /2020 Using a data collection format. Data were coded and edited manually, then doubly entered into Epi-Data statistical software version 3.1 and then exported to SPSS for windows version 26. After checking all the assumptions finally Negative binomial regression for poison has been used. All tests were two sided and P values <0.05 were used to declare statistical significance. RESULTS In the last five year there were the proportion of relapsed cases were 9.6%, 95% CI: (7.7%, 11.7%) On multivariable negative binomial regression model, after adjusting for background variables relapse of severe acute undernutrition was significantly associated with having edema during admission with (IRR = 2.21, 95% CI:1.303-3.732), being in the age group of 6-11 months (IRR = 4.74,95% CI:1.79-12.53), discharge MUAC for the first admission (P = 0.001, IRR = 0.37, 95% CI:0.270-0.50) increase the risk of incidence rate ratio(IRR) relapse case of severe acute under nutrition. CONCLUSION Frequency of SAM relapse was positively associated with age, having edema during admission, while it was negatively associated with discharge MUAC. The results imply the need for reviewing the discharge criteria taking into account the recovery of MUAC as a marker for lean tissue accretion, especially in edematous children and those in the younger age.
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Affiliation(s)
- Abera Lambebo
- Department of Public Health, Institute of Medical and Health Science, Collage of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
| | - Deselegn Temiru
- Department of Nutrition and Dietetics, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Tefera Belachew
- Department of Nutrition and Dietetics, Faculty of Public Health, Jimma University, Jimma, Ethiopia
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Abate BB, Tilahun BD, Kassie AM, Kassaw MW. Treatment outcome of Severe Acute Malnutrition and associated factors among under-five children in outpatient therapeutics unit in Gubalafto Wereda, North Wollo Zone, Ethiopia, 2019. PLoS One 2020; 15:e0238231. [PMID: 32881883 PMCID: PMC7470268 DOI: 10.1371/journal.pone.0238231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 08/12/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In Ethiopia, uncomplicated severe acute malnutrition is managed through the outpatient therapeutic program at health posts level. This brings the services for the management of Severe Acute Malnutrition closer to the community by making services available at decentralized treatment points within the primary health care settings. So far, evidence of the treatment outcome of the program is limited. OBJECTIVE The main aim of this study was to determine the magnitude of treatment outcomes of severe acute malnutrition and associated factors among under-five children at outpatient therapeutic feeding units in Gubalafto Wereda, Ethiopia, 2019. METHODS This was a retrospective cohort study conducted on 600 children who had been managed for Severe Acute Malnutrition (SAM) under Outpatient Therapeutic Program (OTP) in Gubalafto Wereda from April to May/2019. The children were selected using systematic random sampling from 9 health posts. The structured, pre-tested, and adapted questionnaire was used to collect the data. The data was entered by using EPI-data Version 4.2 and exported to SPSS version 24.0 for analysis. Bivariate and Multivariate regression was also carried out to determine the association between dependent and independent variables. RESULTS A total of 600 records of children with a diagnosis of severe acute malnutrition were reviewed. Of these cases of malnutrition, the recovery rate was found to be 65%. The death rate, default rate, and medical transfer were 2.0, 16.0, and 17.0 respectively. Immunized children had 6.85 times higher odds of recovery than children who were not immunized (AOR = 6.85 at 95% CI (3.68-12.76)). The likelihood of recovery was 3.78 times higher among children with new admission than those with re-admission (AOR = 3.78at 95% CI ((1.77-8.07))). Likewise, children provided with amoxicillin were 3.38 times recovered than their counterparts (AOR = 3.38 at 95% CI ((1.61-7.08))). SAM treatment in OTP is beneficial because of its local access for most severe cases since children reach early before developing complications as a result fatalities will be reduced. CONCLUSIONS The recovery rate and medical transfer were lower than the sphere standard. Presence of cough, presence of diarrhea admission category, provision of amoxicillin, and immunization status were factors identified as significantly associated with treatment outcome of severe acute malnutrition. The impact on increasing the recovery rates of children treated using the OTP service indicates the potential benefits of increasing the capacity of such services across a target region on child mortality/recovery. Timely intervention is another benefit of a more local service like OTP. Building capacity of OTP service providers and regular monitoring of service provision based on the management protocol was recommended.
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Affiliation(s)
- Biruk Beletew Abate
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Amhara Regional State, Ethiopia
- * E-mail:
| | - Befkad Deresse Tilahun
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Amhara Regional State, Ethiopia
| | - Ayelign Mengesha Kassie
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Amhara Regional State, Ethiopia
| | - Mesfin Wudu Kassaw
- Department of Nursing, College of Health Sciences, Woldia University, Woldia, Amhara Regional State, Ethiopia
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Chase RP, Kerac M, Grant A, Manary M, Briend A, Opondo C, Bailey J. Acute malnutrition recovery energy requirements based on mid-upper arm circumference: Secondary analysis of feeding program data from 5 countries, Combined Protocol for Acute Malnutrition Study (ComPAS) Stage 1. PLoS One 2020; 15:e0230452. [PMID: 32492023 PMCID: PMC7269364 DOI: 10.1371/journal.pone.0230452] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/01/2020] [Indexed: 01/31/2023] Open
Abstract
Background Severe and moderate acute malnutrition (SAM and MAM) are currently treated with different food products in separate treatment programs. The development of a unified and simplified treatment protocol using a single food product aims to increase treatment program efficiency and effectiveness. This study, the first stage of the ComPAS trial, sought to assess rate of growth and energy requirements among children recovering from acute malnutrition in order to design a simplified, MUAC-based dosage protocol. Methods We obtained secondary data from patient cards of children aged 6–59 months recovering from SAM in outpatient therapeutic feeding programs (TFPs) and from MAM in supplementary feeding programs (SFPs) in five countries in Africa and Asia. We used local polynomial smoothing to assess changes in MUAC and proportional weight gain between clinic visits and assessed their normalized differences for a non-zero linear trend. We estimated energy needs to meet or exceed the growth observed in 95% of visits. Results This analysis used data from 5518 patients representing 33942 visits. Growth trends in MUAC and proportional weight gain were not significantly different, each lower at higher MUAC values: MUAC growth averaged 2mm/week at lower MUACs (100 to <110mm) and 1mm/week at higher MUACs (120mm to <125mm); and proportional weight gain declined from 3.9g/kg/day to 2.4g/kg/day across the same MUAC values. In 95% of visits by children with a MUAC 100mm to <125mm who were successfully treated, energy needs could be met or exceeded with 1,000 kilocalories a day. Conclusion Two 92g sachets of Ready-to-Use Therapeutic Food (RUTF) (1,000kcal total) is proposed to meet the estimated total energy requirements of children with a MUAC 100mm to <115mm, and one 92g sachet of RUTF (500kcal) is proposed to meet half the energy requirements of children with a MUAC of 115 to <125mm. A simplified, combined protocol may enable a more holistic continuum of care, potentially contributing to increased coverage for children suffering from acute malnutrition.
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Affiliation(s)
- Rachel P. Chase
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Marko Kerac
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Angeline Grant
- Action Against Hunger-USA, New York, New York, United States of America
| | - Mark Manary
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, United States of America
| | - André Briend
- University of Tampere, University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
| | - Jeanette Bailey
- Department of Population Health & Centre for Maternal, Adolescent and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, England, United Kingdom
- International Rescue Committee, New York, New York, United States of America
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Schwinger C, Golden MH, Grellety E, Roberfroid D, Guesdon B. Severe acute malnutrition and mortality in children in the community: Comparison of indicators in a multi-country pooled analysis. PLoS One 2019; 14:e0219745. [PMID: 31386678 PMCID: PMC6684062 DOI: 10.1371/journal.pone.0219745] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 07/02/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES This study aims to describe the mortality risk of children in the community who had severe acute malnutrition (SAM) defined by either a mid-upper arm circumference (MUAC) <115mm, a low weight-for-height Z-score (WHZ) <-3 or both criteria. METHODS We pooled individual-level data from children aged 6-59 months enrolled in 3 community-based studies in the Democratic Republic of the Congo (DRC), Senegal and Nepal. We estimate the mortality hazard using Cox proportional hazard models in groups defined by either anthropometric indicator. RESULTS In total, we had 49,001 time points provided by 15,060 children available for analysis, summing to a total of 143,512 person-months. We found an increasing death rate with a deteriorating nutritional status for all anthropometrical indicators. Children identified as SAM only by a low MUAC (<115mm) and those identified only by a low WHZ (Z-score <-3) had a similar mortality hazard which was about 4 times higher than those without an anthropometric deficit. Having both a low MUAC and a low WHZ was associated with an 8 times higher hazard of dying compared to children within the normal range. The 2 indicators identified a different set of children; the proportion of children identified by both indicators independently ranged from 7% in the DRC cohort, to 35% and 37% in the Senegal and the Nepal cohort respectively. CONCLUSION In the light of an increasing popularity of using MUAC as the sole indicator to identify SAM children, we show that children who have a low WHZ, but a MUAC above the cut-off would be omitted from diagnosis and treatment despite having a similar risk of death.
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Affiliation(s)
- Catherine Schwinger
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | - Michael H. Golden
- Department of Medicine and Therapeutics, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Emmanuel Grellety
- Research Center Health Policy and Systems - International Health, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
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Kulkarni B, Mamidi RS. Nutrition rehabilitation of children with severe acute malnutrition: Revisiting studies undertaken by the National Institute of Nutrition. Indian J Med Res 2019; 150:139-152. [PMID: 31670269 PMCID: PMC6829782 DOI: 10.4103/ijmr.ijmr_1905_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 11/04/2022] Open
Abstract
Severe acute malnutrition (SAM) in children under five years is an important public health problem due to associated high mortality and long-term health consequences. Research on the dietary causes of SAM, especially the role and relative importance of dietary protein, in the aetiology of oedematous malnutrition, has led to considerable debates and controversies. The present article revisits some of the debates in this field, where the researchers at the National Institute of Nutrition (NIN), Hyderabad, India, with their pioneering work, have contributed to the global literature on the various facets of the disease. Highlighting the importance of energy as a bigger problem than protein malnutrition is a noteworthy contribution of NIN's research. It is, however, important to examine the protein quality of the diets in light of the new information on the lysine requirements. The article argues that the currently dominating hypothesis of free radical theory requires a critical review of the supporting evidence. Over the past few decades, the research has focused on low-cost diets using locally available foods. The article also argues that solutions based on local foods, being acceptable and sustainable, need to be strengthened for their effective delivery through the existing nutrition programmes. Recent evidence shows that the use of ready-to-use therapeutic foods (RUTF) with high micronutrient density may be linked with higher mortality possibly due to the high iron content, which could be counterproductive. There are several unaddressed concerns regarding the potential long-term impact of consumption of RUTF in children with SAM. More evidence and a cautious approach are, therefore, needed before implementing these solutions.
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Affiliation(s)
- Bharati Kulkarni
- Division of Maternal & Child Nutrition, ICMR-National Institute of Nutrition, Hyderabad, India
| | - Raja Sriswan Mamidi
- Division of Clinical Epidemiology, ICMR-National Institute of Nutrition, Hyderabad, India
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Altmann M, Altare C, van der Spek N, Barbiche JC, Dodos J, Bechir M, Ait Aissa M, Kolsteren P. Effectiveness of a Household Water, Sanitation and Hygiene Package on an Outpatient Program for Severe Acute Malnutrition: A Pragmatic Cluster-Randomized Controlled Trial in Chad. Am J Trop Med Hyg 2018; 98:1005-1012. [PMID: 29488461 PMCID: PMC5928824 DOI: 10.4269/ajtmh.17-0699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/10/2018] [Indexed: 11/25/2022] Open
Abstract
Water, sanitation and hygiene (WASH) interventions have a small but measurable benefit on stunting, but not on wasting. Our objective was to assess the effectiveness of a household WASH package on the performance of an Outpatient Therapeutic feeding Program (OTP) for severe acute malnutrition (SAM). We conducted a cluster-randomized controlled trial embedded in a routine OTP. The study population included 20 health centers (clusters) from Mao and Mondo districts in Chad. Both arms received the OTP. The intervention arm received an additional household WASH package (chlorine, soap, water storage container, and promotion on its use). The primary objective measures were the relapse rates to SAM at 2 and 6 months post-recovery. The secondary objectives included the recovery rate from SAM, the time-to-recovery, the weight gain, and the diarrhea longitudinal prevalence in OTP. The study lasted from April 2015 to May 2016. Among the 1,603 recruited children, 845 were in the intervention arm and 758 in the control arm. No differences in the relapse rates were noticed at 2 (-0.4%; P = 0.911) and 6 (-1.0%; P = 0.532) months. The intervention decreased the time-to-recovery (-4.4 days; P = 0.038), improved the recovery rate (10.5%; P = 0.034), and the absolute weight gain (3.0 g/d; P = 0.014). No statistical differences were noticed for the diarrhea longitudinal prevalence (-1.7%; P = 0.223) and the weight gain velocity (0.4 g/kg/d; P = 0.086). Our results showed that adding a household WASH package did not decrease post-recovery relapse rates but increased the recovery rate among children admitted in OTP. We recommend further robust trials in other settings to confirm our results.
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Affiliation(s)
| | | | | | | | | | - Mahamat Bechir
- Alliance Sahélienne de Recherches Appliquées pour le Développement Durable, Quartier Klemat, N’Djamena, Chad
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Farràs M, Chandwe K, Mayneris-Perxachs J, Amadi B, Louis-Auguste J, Besa E, Zyambo K, Guerrant R, Kelly P, Swann JR. Characterizing the metabolic phenotype of intestinal villus blunting in Zambian children with severe acute malnutrition and persistent diarrhea. PLoS One 2018; 13:e0192092. [PMID: 29499047 PMCID: PMC5834158 DOI: 10.1371/journal.pone.0192092] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 01/16/2018] [Indexed: 02/07/2023] Open
Abstract
Background Environmental enteric dysfunction (EED) is widespread throughout the tropics and in children is associated with stunting and other adverse health outcomes. One of the hallmarks of EED is villus damage. In children with severe acute malnutrition (SAM) the severity of enteropathy is greater and short term mortality is high, but the metabolic consequences of enteropathy are unknown. Here, we characterize the urinary metabolic alterations associated with villus health, classic enteropathy biomarkers and anthropometric measurements in severely malnourished children in Zambia. Methods/Principal findings We analysed 20 hospitalised children with acute malnutrition aged 6 to 23 months in Zambia. Small intestinal biopsies were assessed histologically (n = 15), anthropometric and gut function measurements were collected and the metabolic phenotypes were characterized by 1H nuclear magnetic resonance (NMR) spectroscopy. Endoscopy could not be performed on community controls children. Growth parameters were inversely correlated with enteropathy biomarkers (p = 0.011) and parameters of villus health were inversely correlated with translocation and permeability biomarkers (p = 0.000 and p = 0.015). Shorter villus height was associated with reduced abundance of metabolites related to gut microbial metabolism, energy and muscle metabolism (p = 0.034). Villus blunting was also related to increased sucrose excretion (p = 0.013). Conclusions/Significance Intestinal villus blunting is associated with several metabolic perturbations in hospitalized children with severe undernutrition. Such alterations include altered muscle metabolism, reinforcing the link between EED and growth faltering, and a disruption in the biochemical exchange between the gut microbiota and host. These findings extend our understanding on the downstream consequences of villus blunting and provide novel non-invasive biomarkers of enteropathy dysfunction. The major limitations of this study are the lack of comparative control group and gut microbiota characterization.
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Affiliation(s)
- Marta Farràs
- Computational and Systems Medicine Group, Division of Surgery and Cancer, Imperial College, London, United Kingdom
- CIBER de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Barcelona, Spain
- * E-mail: (JRS); (MF)
| | - Kanta Chandwe
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Jordi Mayneris-Perxachs
- Computational and Systems Medicine Group, Division of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - John Louis-Auguste
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Ellen Besa
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Richard Guerrant
- University of Virginia, Charlottesville, VA, United States of America
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Jonathan Richard Swann
- Computational and Systems Medicine Group, Division of Surgery and Cancer, Imperial College, London, United Kingdom
- * E-mail: (JRS); (MF)
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Sheppard A, Ngo S, Li X, Boyne M, Thompson D, Pleasants A, Gluckman P, Forrester T. Molecular Evidence for Differential Long-term Outcomes of Early Life Severe Acute Malnutrition. EBioMedicine 2017; 18:274-280. [PMID: 28330812 PMCID: PMC5405153 DOI: 10.1016/j.ebiom.2017.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/14/2017] [Accepted: 03/01/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) in infants may present as one of two distinct syndromic forms: non-edematous (marasmus), with severe wasting and no nutritional edema; or edematous (kwashiorkor) with moderately severe wasting. These differences may be related to developmental changes prior to the exposure to SAM and phenotypic changes appear to persist into adulthood with differences between the two groups. We examined whether the different response to SAM and subsequent trajectories may be explained by developmentally-induced epigenetic differences. METHODS We extracted genomic DNA from muscle biopsies obtained from adult survivors of kwashiorkor (n=21) or marasmus (n=23) and compared epigenetic profiles (CpG methylation) between the two groups using the Infinium® 450K BeadChip array. FINDINGS We found significant differences in methylation of CpG sites from 63 genes in skeletal muscle DNA. Gene ontology studies showed significant differential methylation of genes in immune, body composition, metabolic, musculoskeletal growth, neuronal function and cardiovascular pathways, pathways compatible with the differences in the pathophysiology of adult survivors of SAM. INTERPRETATION These findings suggest persistent developmental influences on adult physiology in survivors of SAM. Since children who develop marasmus have lower birth weights and after rehabilitation have different intermediary metabolism, these studies provide further support for persistent developmentally-induced phenomena mediated by epigenetic processes affecting both the infant response to acute malnutrition and later life consequences. FUNDING Supported by a Grant from the Bill and Melinda Gates Foundation (Global Health OPP1066846), Grand Challenge "Discover New Ways to Achieve Healthy Growth." EVIDENCE BEFORE THIS STUDY Previous research has shown that infants who develop either kwashiorkor or marasmus in response to SAM differ in birth weight and subsequently have different metabolic patterns in both infancy and adulthood. ADDED VALUE OF THIS STUDY This study demonstrates epigenetic differences in the skeletal muscle of adult survivors of marasmus versus kwashiorkor and these differences are in genes that may underlie the longer-term consequences. IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE These data are compatible with the different clinical responses to SAM arising from developmentally-induced epigenetic changes laid down largely before birth and provide evidence for the predictive adaptive response model operating in human development.
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Affiliation(s)
- Allan Sheppard
- The Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Sherry Ngo
- The Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Xiaoling Li
- The Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Michael Boyne
- Tropical Medicine Research Institute, The University of the West Indies, Mona, Kingston 7, Jamaica
| | - Debbie Thompson
- Tropical Medicine Research Institute, The University of the West Indies, Mona, Kingston 7, Jamaica
| | - Anthony Pleasants
- The Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Peter Gluckman
- The Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Terrence Forrester
- The Liggins Institute, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand; UWI Solutions for Developing Countries, The University of the West Indies, Mona, Kingston 7, Jamaica.
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Isanaka S, Guesdon B, Labar AS, Hanson K, Langendorf C, Grais RF. Comparison of Clinical Characteristics and Treatment Outcomes of Children Selected for Treatment of Severe Acute Malnutrition Using Mid Upper Arm Circumference and/or Weight-for-Height Z-Score. PLoS One 2015; 10:e0137606. [PMID: 26376281 PMCID: PMC4574398 DOI: 10.1371/journal.pone.0137606] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/20/2015] [Indexed: 11/18/2022] Open
Abstract
Objectives Debate for a greater role of mid-upper arm circumference (MUAC) measures in nutritional programming continues, but a shift from therapeutic feeding programs admitting children using MUAC and/or weight-for-height Z (WHZ) to a new model admitting children using MUAC only remains complicated by limited information regarding the clinical profile and response to treatment of children selected by MUAC vs. WHZ. To broaden our understanding of how children identified for therapeutic feeding by MUAC and/or WHZ may differ, we aimed to investigate differences between children identified for therapeutic feeding by MUAC and/or WHZ in terms of demographic, anthropometric, clinical, and laboratory and treatment response characteristics. Methods Using secondary data from a randomized trial in rural Niger among children with uncomplicated severe acute malnutrition, we compared children that would be admitted to a therapeutic feeding program that used a single anthropometric criterion of MUAC< 115 mm vs. children that are admitted under current admission criteria (WHZ< -3 and/or MUAC< 115 mm) but would be excluded from a program that used a single MUAC< 115 mm admission criterion. We assessed differences between groups using multivariate regression, employing linear regression for continuous outcomes and log-binomial regression for dichotomous outcomes. Results We found no difference in terms of clinical and laboratory characteristics and discharge outcomes evaluated between children that would be included in a MUAC< 115 mm therapeutic feeding program vs. children that are currently eligible for therapeutic feeding but would be excluded from a MUAC-only program. Conclusions A single anthropometric admission criterion of MUAC < 115 mm did not differentiate well between children in terms of clinical or laboratory measures or program outcomes in this context. If nutritional programming is to use a single MUAC-based criterion for admission to treatment, further research and program experience can help to identify the most appropriate criterion in a broad range of contexts to target children in most urgent need of treatment.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, United States of America
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States of America
- * E-mail:
| | | | - Amy S. Labar
- Department of Research, Epicentre, Paris, France
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