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Montana AV, Mildon A, Daniel AI, Pitino MA, Baxter JAB, Beggs MR, Unger SL, O'Connor DL, Walton K. Is Maternal Body Weight or Composition Associated with Onset of Lactogenesis II, Human Milk Production, or Infant Consumption of Mother's Own Milk? A Systematic Review and Meta-Analysis. Adv Nutr 2024; 15:100228. [PMID: 38609047 DOI: 10.1016/j.advnut.2024.100228] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 04/14/2024] Open
Abstract
Maternal adiposity impacts lactation performance, but the pathways are unclear. We conducted a systematic review to understand whether maternal adiposity (body mass index [BMI] or percentage fat mass) is associated with onset of lactogenesis II (copious milk; hours), human milk production (expressed volume/24 h), and infant consumption of mother's own milk (volume/24 h). We used random-effects standard meta-analyses to compare the relative risk (RR) of delayed lactogenesis II (>72 h) between mothers classified as underweight (BMI <18.5 kg/m2), healthy weight (BMI, 18.5-24.9 kg/m2), and overweight/obese (BMI ≥25 kg/m2) and random-effects meta-regressions to examine associations with hours to lactogenesis II and infant milk consumption. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. We included 122 articles. Mothers with underweight (RR: 0.64; 95% CI: 0.49, 0.83; I2 = 39.48%; 8 articles/data points) or healthy weight status (RR: 0.67; 95% CI: 0.57, 0.79; I2 = 70.91%; 15 articles/data points) were less likely to experience delayed lactogenesis II than mothers with overweight/obesity. We found no association between maternal BMI and time to onset of lactogenesis II (β: 1.45 h; 95% CI: -3.19, 6.09 h; P = 0.52, I2 = 0.00%; 8 articles, 17 data points). Due to limited data, we narratively reviewed articles examining BMI or percentage fat mass and milk production (n = 6); half reported an inverse association and half no association. We found no association between maternal BMI (β: 6.23 mL; 95% CI: -11.26, 23.72 mL; P = 0.48, I2 = 47.23%; 58 articles, 75 data points) or percentage fat mass (β: 7.82 mL; 95% CI: -1.66, 17.29 mL; P = 0.10, I2 = 28.55%; 30 articles, 41 data points) and infant milk consumption. The certainty of evidence for all outcomes was very low. In conclusion, mothers with overweight/obesity may be at risk of delayed lactogenesis II. The available data do not support an association with infant milk consumption, but the included studies do not adequately represent mothers with obesity. This study was registered in PROSPERO as 285344.
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Affiliation(s)
- Amanda V Montana
- Translational Medicine, The Hospital for Sick Children, Toronto ON, Canada; Department of Nutritional Sciences, University of Toronto, Toronto ON, Canada
| | - Alison Mildon
- Department of Nutritional Sciences, University of Toronto, Toronto ON, Canada
| | | | - Michael A Pitino
- Translational Medicine, The Hospital for Sick Children, Toronto ON, Canada; Department of Nutritional Sciences, University of Toronto, Toronto ON, Canada
| | - Jo-Anna B Baxter
- Department of Nutritional Sciences, University of Toronto, Toronto ON, Canada
| | - Megan R Beggs
- Translational Medicine, The Hospital for Sick Children, Toronto ON, Canada; Department of Nutritional Sciences, University of Toronto, Toronto ON, Canada
| | - Sharon L Unger
- Department of Nutritional Sciences, University of Toronto, Toronto ON, Canada; Paediatrics, Mount Sinai Hospital, Toronto ON, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto ON, Canada
| | - Deborah L O'Connor
- Translational Medicine, The Hospital for Sick Children, Toronto ON, Canada; Department of Nutritional Sciences, University of Toronto, Toronto ON, Canada; Paediatrics, Mount Sinai Hospital, Toronto ON, Canada
| | - Kathryn Walton
- Translational Medicine, The Hospital for Sick Children, Toronto ON, Canada; Department of Family Relations & Applied Nutrition, University of Guelph, Guelph, ON, Canada.
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Vresk L, Flanagan M, Daniel AI, Potani I, Bourdon C, Spiegel-Feld C, Thind MK, Farooqui A, Ling C, Miraglia E, Hu G, Wen B, Zlotkin S, James P, McGrath M, Bandsma RHJ. Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations. Nutr Rev 2024:nuad165. [PMID: 38350491 DOI: 10.1093/nutrit/nuad165] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).
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Affiliation(s)
- Laura Vresk
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mary Flanagan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allison I Daniel
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isabel Potani
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Celine Bourdon
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carolyn Spiegel-Feld
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mehakpreet K Thind
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amber Farooqui
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Catriona Ling
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emiliano Miraglia
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Guanlan Hu
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bijun Wen
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stanley Zlotkin
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Philip James
- Emergency Nutrition Network, Oxford, United Kingdom
| | | | - Robert H J Bandsma
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Daniel AI, Jemutai J. Identification of risk factors for inpatient mortality in infants and children with severe wasting and/or nutritional oedema-what next? Eur J Clin Nutr 2024; 78:163-164. [PMID: 37957237 DOI: 10.1038/s41430-023-01366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/02/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
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Brockway MM, Daniel AI, Reyes SM, Granger M, McDermid JM, Chan D, Refvik R, Sidhu KK, Musse S, Patel PP, Monnin C, Lotoski L, Geddes D, Jehan F, Kolsteren P, Allen LH, Hampel D, Eriksen KG, Rodriguez N, Azad MB. Human Milk Macronutrients and Child Growth and Body Composition in the First Two Years: A Systematic Review. Adv Nutr 2024; 15:100149. [PMID: 37981047 PMCID: PMC10831902 DOI: 10.1016/j.advnut.2023.100149] [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: 02/17/2023] [Revised: 10/16/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023] Open
Abstract
Among exclusively breastfed infants, human milk (HM) provides complete nutrition in the first mo of life and remains an important energy source as long as breastfeeding continues. Consisting of digestible carbohydrates, proteins, and amino acids, as well as fats and fatty acids, macronutrients in human milk have been well studied; however, many aspects related to their relationship to growth in early life are still not well understood. We systematically searched Medline, EMBASE, the Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born healthy infants. From 9992 abstracts screened, 57 articles reporting observations from 5979 dyads were included and categorized based on their reporting of HM macronutrients and infant growth. There was substantial heterogeneity in anthropometric outcome measurement, milk collection timelines, and HM sampling strategies; thus, meta-analysis was not possible. In general, digestible carbohydrates were positively associated with infant weight outcomes. Protein was positively associated with infant length, but no associations were reported for infant weight. Finally, HM fat was not consistently associated with any infant growth metrics, though various associations were reported in single studies. Fatty acid intakes were generally positively associated with head circumference, except for docosahexaenoic acid. Our synthesis of the literature was limited by differences in milk collection strategies, heterogeneity in anthropometric outcomes and analytical methodologies, and by insufficient reporting of results. Moving forward, HM researchers should accurately record and account for breastfeeding exclusivity, use consistent sampling protocols that account for the temporal variation in HM macronutrients, and use reliable, sensitive, and accurate techniques for HM macronutrient analysis.
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Affiliation(s)
- Meredith Merilee Brockway
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Canada; Department of Pediatrics and Child Health, University of Manitoba, Canada; Faculty of Nursing, University of Calgary, Canada
| | - Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Canada; Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Sarah M Reyes
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Canada
| | - Matthew Granger
- Department of Food and Human Nutritional Sciences, University of Manitoba, Canada
| | | | - Deborah Chan
- Department of Pediatrics and Child Health, University of Manitoba, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Canada
| | - Rebecca Refvik
- Department of Food and Human Nutritional Sciences, University of Manitoba, Canada
| | - Karanbir K Sidhu
- Department of Food and Human Nutritional Sciences, University of Manitoba, Canada
| | - Suad Musse
- Department of Food and Human Nutritional Sciences, University of Manitoba, Canada
| | - Pooja P Patel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, USA
| | - Caroline Monnin
- Neil John Maclean Health Sciences Library, University of Manitoba, Canada
| | - Larisa Lotoski
- Department of Pediatrics and Child Health, University of Manitoba, Canada
| | - Donna Geddes
- School of Molecular Sciences, The University of Western Australia, Australia
| | - Fyezah Jehan
- Department of Pediatrics, Aga Khan University, Pakistan
| | - Patrick Kolsteren
- Department of Food Safety and Food Quality, Ghent University, Belgium
| | - Lindsay H Allen
- Western Human Nutrition Research Center, Agriculture Research Service, United States Department of Agriculture, USA; Department of Nutrition, University of California, Davis, USA
| | - Daniela Hampel
- Western Human Nutrition Research Center, Agriculture Research Service, United States Department of Agriculture, USA; Department of Nutrition, University of California, Davis, USA
| | - Kamilla G Eriksen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
| | - Natalie Rodriguez
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Canada; Department of Pediatrics and Child Health, University of Manitoba, Canada
| | - Meghan B Azad
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Canada; Department of Pediatrics and Child Health, University of Manitoba, Canada.
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Brockway MM, Daniel AI, Reyes SM, Gauglitz JM, Granger M, McDermid JM, Chan D, Refvik R, Sidhu KK, Musse S, Patel PP, Monnin C, Lotoski L, Geddes DT, Jehan F, Kolsteren P, Bode L, Eriksen KG, Allen LH, Hampel D, Rodriguez N, Azad MB. Human Milk Bioactive Components and Child Growth and Body Composition in the First 2 Years: A Systematic Review. Adv Nutr 2024; 15:100127. [PMID: 37802214 PMCID: PMC10831900 DOI: 10.1016/j.advnut.2023.09.015] [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: 02/17/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 10/08/2023] Open
Abstract
Human milk (HM) contains macronutrients, micronutrients, and a multitude of other bioactive factors, which can have a long-term impact on infant growth and development. We systematically searched MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born infants. From 9992 abstracts screened, 141 articles were included and categorized based on their reporting of HM micronutrients, macronutrients, or bioactive components. Bioactives including hormones, HM oligosaccharides (HMOs), and immunomodulatory components are reported here, based on 75 articles from 69 unique studies reporting observations from 9980 dyads. Research designs, milk collection strategies, sampling times, geographic and socioeconomic settings, reporting practices, and outcomes varied considerably. Meta-analyses were not possible because data collection times and reporting were inconsistent among the studies included. Few measured infant HM intake, adjusted for confounders, precisely captured breastfeeding exclusivity, or adequately described HM collection protocols. Only 5 studies (6%) had high overall quality scores. Hormones were the most extensively examined bioactive with 46 articles (n = 6773 dyads), compared with 13 (n = 2640 dyads) for HMOs and 12 (n = 1422 dyads) for immunomodulatory components. Two studies conducted untargeted metabolomics. Leptin and adiponectin demonstrated inverse associations with infant growth, although several studies found no associations. No consistent associations were found between individual HMOs and infant growth outcomes. Among immunomodulatory components in HM, IL-6 demonstrated inverse relationships with infant growth. Current research on HM bioactives is largely inconclusive and is insufficient to address the complex composition of HM. Future research should ideally capture HM intake, use biologically relevant anthropometrics, and integrate components across categories, embracing a systems biology approach to better understand how HM components work independently and synergistically to influence infant growth.
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Affiliation(s)
- Meredith Merilee Brockway
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada; Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Allison I Daniel
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Sarah M Reyes
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | | | - Matthew Granger
- Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada
| | | | - Deborah Chan
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
| | - Rebecca Refvik
- Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Karanbir K Sidhu
- Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Suad Musse
- Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Pooja P Patel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, Unites States
| | - Caroline Monnin
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, MB, Canada
| | - Larisa Lotoski
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Donna T Geddes
- School of Molecular Sciences, The University of Western Australia, Perth, WA, Australia
| | - Fyezah Jehan
- Department of Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan
| | - Patrick Kolsteren
- Department of Food Safety and Food Quality, Ghent University, Ghent, Belgium
| | - Lars Bode
- Department of Pediatrics, Mother-Milk-Infant Center of Research Excellence (MOMI CORE), University of California, San Diego (UC San Diego), San Diego, CA, United States
| | - Kamilla G Eriksen
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Lindsay H Allen
- Department of Nutrition, University of California, Davis, CA, United States; Western Human Nutrition Research Center, Agriculture Research Service, United States Department of Agriculture, Washington, DC, Unites States
| | - Daniela Hampel
- Department of Nutrition, University of California, Davis, CA, United States; Western Human Nutrition Research Center, Agriculture Research Service, United States Department of Agriculture, Washington, DC, Unites States
| | - Natalie Rodriguez
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Meghan B Azad
- Manitoba Interdisciplinary Lactation Centre (MILC), Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada; Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada.
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Potani I, Daniel AI, Briend A, Courtney-Martin G, Berkley JA, Voskuijl W, Vresk L, Bourdon C, Kathumba S, Mbale E, Bandsma RHJ. A protocol for a proof-of-concept randomized control trial testing increased protein quantity and quality in ready-to-use therapeutic food in improving linear growth among 6-23-month-old children with severe wasting in Malawi. PLoS One 2023; 18:e0287680. [PMID: 37619218 PMCID: PMC10449476 DOI: 10.1371/journal.pone.0287680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/07/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Ready-to-use therapeutic foods (RUTFs) have successfully promoted recovery from severe wasting and increased treatment coverage. However, RUTFs do not sufficiently improve linear growth, leaving many survivors of severe wasting at risk of persistent stunting, which is associated with high mortality risk, poor child development and non-communicable diseases in adulthood. High protein quantity and quality can stimulate linear growth. AIM The trial aims to assess whether higher-protein-RUTF leads to higher concentrations of markers of linear growth compared to standard RUTF among 6-23 months old children with severe wasting. METHODS We designed a higher protein quantity and quality RUTF for a proof-of-concept (PoC) double-blind randomized controlled trial. OUTCOMES The primary outcome is a change in insulin-like growth factor-1 (IGF-1), a hormone positively associated with linear growth after four weeks of treatment. Secondary outcomes include changes in ponderal and linear growth and in body composition from baseline to eight weeks later; plasma amino acid profile at four weeks; acceptability and safety. IMPLICATIONS These findings will help in informing the potential impact of increased protein in RUTF on linear growth when treating severe wasting towards conducting a larger clinical trial. TRIAL REGISTRATION The trial has been registered on clinicaltrial.gov (NCT05737472).
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Affiliation(s)
- Isabel Potani
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Allison I. Daniel
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Independent Nutrition Consultant, Toronto, Canada
| | - André Briend
- Centre for Child Health Research, University of Tampere School of Medicine, Tampere, Finland
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Glenda Courtney-Martin
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - James A. Berkley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Clinical Research Department, Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Wieger Voskuijl
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Amsterdam Universtair Medische Centra, University of Amsterdam, Amsterdam Centre for Global Child Health, Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Laura Vresk
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Celine Bourdon
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Sylvester Kathumba
- Department of Nutrition and Human Immunodeficiency Virus, Ministry of Health, Lilongwe, Malawi
| | - Emmie Mbale
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Robert H. J. Bandsma
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Daniel AI, Shama S, Ismail S, Bourdon C, Kiss A, Mwangome M, Bandsma RH, O'Connor DL. Corrigendum to "Maternal BMI is positively associated with human milk fat: a systematic review and meta-regression analysis" American Journal of Clinical Nutrition 2021 113:1009-1022. Am J Clin Nutr 2023; 118:342. [PMID: 37178713 PMCID: PMC10447478 DOI: 10.1016/j.ajcnut.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Affiliation(s)
- Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada; Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sara Shama
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Ismail
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada; The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Martha Mwangome
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya; Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya
| | - Robert H Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada; Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya; Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Deborah L O'Connor
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Walton K, Daniel AI, Mahood Q, Vaz S, Law N, Unger SL, O'Connor DL. Eating Behaviors, Caregiver Feeding Interactions, and Dietary Patterns of Children Born Preterm: A Systematic Review and Meta-Analysis. Adv Nutr 2022; 13:875-912. [PMID: 35157009 PMCID: PMC9156386 DOI: 10.1093/advances/nmac017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/26/2022] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Infants born preterm (<37 weeks of gestation) often experience feeding problems during hospitalization. Whether difficulties persist or have long-term sequelae on childhood eating is unclear. We aimed to describe the oromotor eating skills (e.g., chewing/swallowing), eating behaviors (e.g., food neophobia), food parenting practices (e.g., pressure to eat), and dietary patterns of preterm children during late infancy (6-12 mo) and early childhood (>12 mo-7 y) and to determine whether these differed from those of term-born peers. We identified 67 articles (57 unique studies) for inclusion. We used random-effects meta-analysis of proportions to examine the prevalence of oromotor eating skill and eating behavior challenges among preterm children, standard meta-analysis for comparisons with term-born peers, and the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of evidence. Forty-three percent (95% CI: 24%, 62%) of infants and 25% (95% CI: 17%, 33%) of children born preterm experienced oromotor eating difficulties and 16% (95% CI: 4%, 27%) and 20% (95% CI: 11%, 28%), respectively, exhibited challenging eating behaviors. During late infancy and early childhood, oromotor eating difficulties (OR: 2.86; 95% CI: 1.71, 4.77; I2 = 67.8%) and challenging eating behaviors (OR: 1.52; 95% CI: 1.11, 2.10; I2 = 0.0%) were more common in those born preterm than in those born term: however, the certainty of evidence was very low. Owing to the low number and heterogeneity of studies, we narratively reviewed literature on food parenting and dietary patterns. Mothers of preterm infants appeared to have heightened anxiety while feeding and utilized coercive food parenting practices; their infants reportedly received less human milk, started solid foods earlier, and had poorer diet quality than term-born peers. In conclusion, meta-analyses show preterm children experience frequent oromotor eating difficulties and challenging eating behaviors throughout the early years. Given preterm birth increases risk of later obesity and diet-related chronic disease, research examining the effects of caregiver-child interactions on subsequent diet is warranted. This review was registered at www.crd.york.ac.uk/prospero/ as CRD42020176063.
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Affiliation(s)
- Kathryn Walton
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allison I Daniel
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Quenby Mahood
- Hospital Library & Archives, Learning Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Simone Vaz
- Department of Pediatrics, William Osler Health System, Brampton, Ontario, Canada
| | - Nicole Law
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sharon L Unger
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada,Paediatrics, Sinai Health, Toronto, Ontario, Canada,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Potani I, Spiegel-Feld C, Brixi G, Bendabenda J, Siegfried N, Bandsma RHJ, Briend A, Daniel AI. Ready-to-Use Therapeutic Food (RUTF) Containing Low or No Dairy Compared to Standard RUTF for Children with Severe Acute Malnutrition: A Systematic Review and Meta-Analysis. Adv Nutr 2021; 12:1930-1943. [PMID: 33838044 PMCID: PMC8483958 DOI: 10.1093/advances/nmab027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/19/2021] [Accepted: 02/24/2021] [Indexed: 01/15/2023] Open
Abstract
Ready-to-use therapeutic food (RUTF) containing less dairy may be a lower-cost treatment option for severe acute malnutrition (SAM). The objective was to understand the effectiveness of RUTF containing alternative sources of protein (nondairy), or <50% of protein from dairy products, compared with standard RUTF in children with SAM. The Cochrane Library, MEDLINE, Embase, CINAHL, and Web of Science were searched using terms relating to RUTF. Studies were eligible if they included children with SAM and evaluated RUTF with <50% of protein from dairy products compared with standard RUTF. Meta-analysis and meta-regression were completed to assess the effectiveness of intervention RUTF on a range of child outcomes. The quality of the evidence across outcomes was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A total of 5868 studies were identified, of which 8 articles of 6 studies met the inclusion criteria evaluating 7 different intervention RUTF recipes. Nondairy or lower-dairy RUTF showed less weight gain (standardized mean difference: -0.20; 95% CI: -0.26, -0.15; P < 0.001), lower recovery (relative risk ratio: 0.93; 95% CI: 0.87, 1.00; P = 0.046), and lower weight-for-age z scores (WAZ) near program discharge (mean difference: -0.10; 95% CI: -0.20, 0.0; P = 0.047). Mortality, time to recovery, default (consecutive absences from outpatient therapeutic feeding program visits), nonresponse, and other anthropometric measures did not differ between groups. The certainty of evidence was high for weight gain and ranged from very low to moderate for other outcomes. RUTF with lower protein from dairy or dairy-free RUTF may not be as effective as standard RUTF for treatment of children with SAM based on weight gain, recovery, and WAZ evaluated using meta-analysis, although further research is required to explore the potential of alternative formulations. This review was registered at https://www.crd.york.ac.uk/prospero/ as CRD42020160762.
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Affiliation(s)
- Isabel Potani
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Carolyn Spiegel-Feld
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Jaden Bendabenda
- Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
| | - Nandi Siegfried
- Independent Clinical Epidemiologist, Cape Town, South Africa
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - André Briend
- Center for Child Health Research, University of Tampere School of Medicine, Tampere, Finland
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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10
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Daniel AI, Bwanali M, Ohuma EO, Bourdon C, Gladstone M, Potani I, Mbale E, Voskuijl W, van den Heuvel M, Bandsma RHJ. Pathways between caregiver body mass index, the home environment, child nutritional status, and development in children with severe acute malnutrition in Malawi. PLoS One 2021; 16:e0255967. [PMID: 34424919 PMCID: PMC8382172 DOI: 10.1371/journal.pone.0255967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/12/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022] Open
Abstract
Children with severe acute malnutrition (SAM) remain vulnerable after treatment at nutritional rehabilitation units (NRUs). The objective was to assess the concurrent pathways in a hypothesized model between caregiver body mass index (BMI), the home environment, and child nutritional status, and development (gross motor, fine motor, language, and social domains) in children with SAM following discharge from inpatient treatment. Structural equation modelling (SEM) was performed with data from a cluster-randomized controlled trial at the Moyo Nutritional Rehabilitation and Research Unit in Blantyre, Malawi. This approach was undertaken to explore simultaneous relationships between caregiver BMI, the home environment (Home Observation for Measurement of the Environment Inventory scores), child nutritional status (anthropometric indicators including weight-for-age z-scores [WAZ]), and child development (Malawi Developmental Assessment Tool (MDAT) z-scores as a latent variable) in children with SAM. These data were collected at participants' homes six months after discharge from NRU treatment. This analysis included 85 children aged 6-59 months with SAM and their caregivers recruited to the trial at the NRU and followed up successfully six months after discharge. The model with WAZ as the nutritional indicator fit the data according to model fit indices (χ2 = 28.92, p = 0.42). Caregiver BMI was predictive of better home environment scores (β = 0.23, p = 0.03) and child WAZ (β = 0.30, p = 0.005). The home environment scores were positively correlated with MDAT z-scores (β = 0.32, p = 0.001). Child nutritional status based on WAZ was also correlated with MDAT z-scores (β = 0.37, p<0.001). This study demonstrates that caregiver BMI could ultimately relate to child development in children with SAM, through its links to the home environment and child nutritional status.
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Affiliation(s)
- Allison I. Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mike Bwanali
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Eric O. Ohuma
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Melissa Gladstone
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Isabel Potani
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Emmie Mbale
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Meta van den Heuvel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert H. J. Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
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11
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Daniel AI, Bwanali M, Tenthani JC, Gladstone M, Voskuijl W, Potani I, Ziwoya F, Chidzalo K, Mbale E, Heath A, Bourdon C, Njirammadzi J, van den Heuvel M, Bandsma RHJ. A Mixed-Methods Cluster-Randomized Controlled Trial of a Hospital-Based Psychosocial Stimulation and Counseling Program for Caregivers and Children with Severe Acute Malnutrition. Curr Dev Nutr 2021; 5:nzab100. [PMID: 34447897 PMCID: PMC8382273 DOI: 10.1093/cdn/nzab100] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/17/2021] [Accepted: 07/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Children with severe acute malnutrition (SAM) who require nutritional rehabilitation unit (NRU) treatment often have poor developmental and nutritional outcomes following discharge. The Kusamala Program is a 4-d hospital-based counseling program for caregivers of children with SAM that integrates nutrition, water, sanitation, and hygiene and psychosocial stimulation, aimed at improving these outcomes. OBJECTIVES The aim was to evaluate the effects of the Kusamala Program on child development and nutritional status in children with SAM 6 mo after NRU discharge. The other aim was to qualitatively understand perceptions and experiences of caregivers who participated in the intervention. METHODS A cluster-randomized controlled trial was conducted with caregivers and their children 6-59 mo of age with SAM admitted to the Moyo NRU in Blantyre, Malawi. The primary outcome of the trial was child development according to Malawi Developmental Assessment Tool (MDAT) composite z-scores of gross motor, fine motor, language, and social domains. A qualitative component with focus group discussions and in-depth interviews was also completed with a subset of caregivers who participated in the trial. RESULTS Sixty-eight caregivers and children were enrolled to clusters by week and randomly assigned to the comparison arm and 104 to the intervention arm. There were no differences in child development, with mean MDAT composite z-scores in the comparison arm of -1.2 (95% CI: -2.1, -0.22) and in the intervention arm of -1.1 (95% CI: -1.9, -0.40) (P = 0.93). The qualitative evaluation with 20 caregivers indicated that the 3 modules of the Kusamala Program were appropriate and that they applied many of the lessons learned at home as much as possible. CONCLUSIONS The Kusamala Program did not result in improved developmental or nutritional outcomes, yet it was viewed positively by caregivers according to qualitative results. Future research should evaluate more intensive interventions for caregivers and children with SAM. This trial was registered at www.clinicaltrials.gov as NCT03072433.
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Affiliation(s)
- Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mike Bwanali
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | | | - Melissa Gladstone
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Department of Pediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Isabel Potani
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Frank Ziwoya
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Kate Chidzalo
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Emmie Mbale
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Department of Pediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Anna Heath
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
| | - Jenala Njirammadzi
- Department of Pediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Meta van den Heuvel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Blantyre, Malawi
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
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12
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Daniel AI, Shama S, Ismail S, Bourdon C, Kiss A, Mwangome M, Bandsma RHJ, O'Connor DL. Maternal BMI is positively associated with human milk fat: a systematic review and meta-regression analysis. Am J Clin Nutr 2021; 113:1009-1022. [PMID: 33675341 PMCID: PMC8023843 DOI: 10.1093/ajcn/nqaa410] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 12/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Lack of robust estimates of human-milk nutrient composition and influential maternal factors, such as body composition, are barriers to informing nutrition policies and programs. OBJECTIVE The objective was to understand the relation between maternal BMI and human-milk energy, fat, and/or total protein. METHODS Four electronic databases (MEDLINE, Embase, CINAHL, and Web of Science) were searched. Outcomes assessed were human-milk energy (kcal/L), fat (g/L), and total protein (g/L) from mothers 1 to 6 mo postpartum. Studies with data on maternal BMI or weight and height that quantified human-milk energy, fat, or protein between 1 and 6 mo postpartum were eligible. Random-effects meta-regression weighted by the inverse of the study-level SE was completed for each of the 3 outcomes. The certainty of evidence for each outcome was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. RESULTS A total of 11,373 titles and abstracts were identified, and after full-text screening, 69 articles of 66 studies were included. Meta-regression results showed a positive association between maternal BMI and human-milk fat (β: 0.56 g/L; 95% CI: 0.034, 1.1; P = 0.04; I2 = 93.7%, n = 63 datapoints). There was no significant association between maternal BMI and human-milk energy (β: 3.9 kcal/L; 95% CI: -1.6, 9.5; P = 0.16, I2 = 93.3%, n = 40 datapoints) or total protein (β: 0.13 g/L; 95% CI: -0.16, 0.41; P = 0.37, I2 = 99.1%, n = 40 datapoints). The certainty of evidence for human-milk energy was low and the certainty of evidence for fat and total protein was very low. CONCLUSIONS Meta-regression analysis of available literature suggested an association between maternal BMI and human-milk fat between 1 and 6 mo postpartum. Future studies are needed to confirm the relation between maternal BMI; variation in human-milk energy, fat, and protein content; and the implications for child growth and development. This review is registered with International Prospective Register of Systematic Reviews (PROSPERO 2018 CRD42018098808) at https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sara Shama
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Ismail
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Martha Mwangome
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Deborah L O'Connor
- Translational Medicine Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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13
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Chimera B, Potani I, Daniel AI, Chatenga H. Clinical nutrition care challenges in low-resource settings during the COVID-19 pandemic: A focus on Malawi. J Glob Health 2020; 10:020363. [PMID: 33110558 PMCID: PMC7565745 DOI: 10.7189/jogh.10.020363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Bernadette Chimera
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Isabel Potani
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi
| | - Allison I Daniel
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Humphrey Chatenga
- Nutrition Group, North West University South Africa, Potchefstroom, South Africa
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Ledger E, Harawa PP, Daniel AI, Candler T, Prentice AM, Bandsma RHJ. Dysglycemia in Children with Severe Acute Malnutrition: A Systematic Review and Meta-Analysis. Adv Nutr 2020; 12:959-968. [PMID: 33179024 PMCID: PMC8166557 DOI: 10.1093/advances/nmaa138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/05/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023] Open
Abstract
Dysglycemia is a common complication of severe acute malnutrition (SAM) in children. Its prevalence and impact on short- and long-term outcomes are not well described. This systematic review was undertaken to review the available evidence on dysglycemia (either hypo- or hyperglycemia) in hospitalized children with SAM. The 2 primary objectives of this systematic review were to understand the prevalence of hypoglycemia and hyperglycemia in children with SAM. A secondary objective was to understand the relation between dysglycemia and clinical outcomes like mortality in children with SAM. MEDLINE was searched with terms related to children, SAM, and dysglycemia. A meta-analysis of proportions was completed to determine the hypoglycemia prevalence and a standard meta-analysis was done to determine the relation between hypoglycemia and mortality. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A total of 2148 articles were identified in the database search of which 16 met the inclusion criteria for the systematic review based on screening done by multiple reviewers. The overall prevalence of hypoglycemia in SAM across studies based on the meta-analysis of proportions was 9% (95% CI: 7%, 12%; I2 = 92%). Meta-analysis results showed that hypoglycemia was associated with a higher chance of mortality during hospitalization in children with SAM (OR: 4.29; 95% CI: 3.04, 6.05; I2 = 0%). According to the GRADE evaluation, the certainty of the evidence for the prevalence of hypoglycemia was low and for hyperglycemia was very low. For the relation between hypoglycemia and mortality, the certainty of the evidence was moderate. A meta-analysis was not carried out for the prevalence of hyperglycemia due to the wide range of definitions used for across studies, but the prevalence ranged from 2% to 38% in the literature. This systematic review highlights the need for further work in this area to include serial glucose measurements to understand the clinical importance of dysglycemia during hospitalization in children with SAM.
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Affiliation(s)
| | - Philliness Prisca Harawa
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi,Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Toby Candler
- Medical Research Council The Gambia at the London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Andrew M Prentice
- Medical Research Council The Gambia at the London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Robert H J Bandsma
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi,Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada,The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
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15
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Daniel AI, Chidzalo K, Potani I, Voskuijl W, Gladstone M, van den Heuvel M, Bwanali M, Mbale E, Bandsma RHJ. A quantitative cross-sectional survey of psychosocial stimulation and counselling interventions at nutritional rehabilitation units in Southern Malawi. Malawi Med J 2020; 31:238-243. [PMID: 32128033 PMCID: PMC7036430 DOI: 10.4314/mmj.v31i4.4] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Inpatient treatment at nutritional rehabilitation units (NRUs) is needed for children who have severe acute malnutrition (SAM) and acute illness, loss of appetite, or severe oedema. World Health Organization guidelines state that nutritional counselling should be done with primary caregivers at NRUs. These recommendations also include psychosocial stimulation interventions to improve developmental outcomes in children with SAM. However, there is limited information about the delivery of these types of interventions for caregivers and children in NRU settings. The primary objective of this research was therefore to obtain data about NRU resources, activities, and protocols relevant to psychosocial stimulation and counselling interventions during inpatient treatment of children with SAM. Methods A cross-sectional survey was administered by interview at all 16 NRUs in seven districts in Southern Malawi. Participants were health workers, nurses, and nutritionists employed at the respective NRUs. Results The response rate was 100% across NRUs. Half of participants said that psychosocial stimulation interventions are conducted at their respective NRUs, yet none of the NRUs have protocols for delivery of these interventions. Furthermore, 7/16 (44%) NRUs have no resources for psychosocial stimulation including play materials. Thirteen of 16 (81%) participants said that they feel this type of intervention is very important and 3/16 (19%) participants said that this somewhat important for children with SAM. All NRUs provide counselling to caregivers about breastfeeding and nutrition; 15/16 (94%) also give counselling about water, sanitation and hygiene. Conclusions Ultimately, results from this survey highlighted that there is a need to invest in comprehensive interventions to improve developmental and nutritional outcomes in these vulnerable children requiring admission to NRUs.
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Affiliation(s)
- Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Translational Medicine Program.,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kate Chidzalo
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi
| | - Isabel Potani
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi.,Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Melissa Gladstone
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Meta van den Heuvel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Mike Bwanali
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi
| | - Emmie Mbale
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Translational Medicine Program.,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,The Childhood Acute Illness & Nutrition Network (CHAIN), Blantyre, Malawi.,Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
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16
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Daniel AI, Kvissberg MEA, Senga E, Versloot CJ, Harawa PP, Voskuijl W, Wishart D, Mandal R, Bandsma R, Bourdon C. Urinary Organic Acids Increase After Clinical Stabilization of Hospitalized Children With Severe Acute Malnutrition. Food Nutr Bull 2019; 40:532-543. [PMID: 31303023 DOI: 10.1177/0379572119853930] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite a reduction of child mortality in low-income countries, acutely ill undernourished children still have an elevated risk of death. Those at highest risk are children with severe acute malnutrition (SAM) who often show metabolic dysregulation that remains poorly understood. OBJECTIVE We performed a pilot study to examine changes in urinary organic acids during nutritional rehabilitation of children with SAM, and to identify metabolites associated with the presence of edema or with mortality. METHODS This study included 76 children aged between 6 and 60 months, hospitalized for SAM at the Moyo Nutritional Rehabilitation and Research Unit in Blantyre, Malawi. Urine was collected at admission and 3 days after clinical stabilization and metabolomics were performed using gas chromatography-mass spectrometry. Metabolite concentrations were evaluated with both uni- and multivariate approaches. RESULTS Most metabolites increased 3 days after clinical stabilization, and total urinary concentration changed from 1.2 mM (interquartile range [IQR], 0.78-1.7) at admission to 3.8 mM (IQR, 2.1-6.6) after stabilization (P < .0001). In particular, 6 metabolites showed increases: 3-hydroxybutyric, 4-hydroxyhippuric, p-hydroxyphenylacetic, oxoglutaric, succinic, and lactic acids. Urinary creatinine was low at both time points, but levels did increase from 0.63 mM (IQR, 0.2-1.2) to 2.6 mM (IQR,1.6-4.4; P < .0001). No differences in urinary profiles were found between children who died versus those who survived, nor between children with severe wasting or edematous SAM. CONCLUSIONS Total urinary metabolites and creatinine increase after stabilization and may reflect partial recovery of overall metabolism linked to refeeding. The use of urinary metabolites for risk assessment should be furthered explored. TRIAL REGISTRATION TranSAM study (ISRCTN13916953).
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Affiliation(s)
- Allison I Daniel
- Hospital for Sick Children, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Allison I. Daniel and Matilda E. Arvidsson Kvissberg are co-first authors
| | - Matilda E Arvidsson Kvissberg
- Hospital for Sick Children, Toronto, Canada.,University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Allison I. Daniel and Matilda E. Arvidsson Kvissberg are co-first authors
| | - Edward Senga
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Christian J Versloot
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Wieger Voskuijl
- College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness and Nutrition Network, Narobi, Kenya.,Academic Medical Centre, University of Amsterdam, The Netherlands
| | | | | | - Robert Bandsma
- Hospital for Sick Children, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness and Nutrition Network, Narobi, Kenya
| | - Céline Bourdon
- Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness and Nutrition Network, Narobi, Kenya
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17
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Ware SG, Daniel AI, Bandawe C, Mulaheya YP, Nkunika S, Nkhoma D, Kokota D, Stewart RC, Voskuijl W. Perceptions and experiences of caregivers of severely malnourished children receiving inpatient care in Malawi: An exploratory study. Malawi Med J 2019; 30:167-173. [PMID: 30627351 PMCID: PMC6307046 DOI: 10.4314/mmj.v30i3.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Severe acute malnutrition (SAM) affects approximately 18 million children under the age of five and is associated with more than 500 thousand deaths per year. Existing research has indicated that a high number of caregivers of children admitted for inpatient treatment of SAM experience psychological distress, depressive symptoms, and suicidality. However, no published studies in Malawi have been undertaken to qualitatively explore caregivers' perceptions and experiences regarding their children's malnutrition and inpatient treatment. Aim To explore caregivers' perceptions and experiences surrounding childhood acute malnutrition and the experience of inpatient care in Malawi. Methods Interviews were conducted utilising a semi-structured topic guide and were coded using thematic analysis. Results Caregivers (N=30) gave informed consent to participate in interviews. Caregiver understanding and perceptions of their children's illness varied. Some caregivers identified a physical cause, with a minority identifying lack of dietary protein. Other narratives were around characteristics of the infant, other circumstantial events and religious and spiritual influences. One-third of caregivers described their own health difficulties and marital and relationship stressors. Challenges such as poverty, lack of access to food, poor food variability and competing demands for caregiver time were explained. Both positive and negative experiences of family and community support and hospital-based care were reported. Conclusion The themes identified contribute to a greater contextual understanding of the multifactorial and integrated approaches required to address malnutrition. This study indicates that healthcare providers need to take a multi-faceted view of malnutrition and be aware of the many factors that may influence healthcare experience and response to treatment. Acknowledging pluralistic belief systems may improve engagement with care. This demands a broader appreciation of perceptions and experiences of malnutrition, hospital-based care, sources of support and stressors within the caregiver, family and community environment as well as consideration of social determinants such as poverty and how these influences present within a clinical context.
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Affiliation(s)
- Selena Gleadow Ware
- Global Mental Health Academic Network, University of Edinburgh; Department of Mental Health, College of Medicine, University of Malawi
| | - Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto Ontario, Canada; Department of Nutritional Sciences, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Chiwoza Bandawe
- Department of Mental Health, College of Medicine, University of Malawi
| | | | | | | | - Demoubly Kokota
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi
| | - Robert C Stewart
- Division of Psychiatry, University of Edinburgh; Department of Mental Health, College of Medicine, University of Malawi
| | - Wieger Voskuijl
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi; Global Child Health Group, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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18
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Daniel AI, Chatenga H, Chimera B, Mbale E, Chisala M, Borgstein E, Langton J, Gonzalez C, Bandsma RHJ, Vresk L. The introduction of a paediatric nutrition support program led by a clinical dietitian at a low-resource hospital setting in Malawi. Glob Health Action 2019; 12:1656452. [PMID: 31512960 PMCID: PMC6746265 DOI: 10.1080/16549716.2019.1656452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/08/2019] [Indexed: 11/25/2022] Open
Abstract
In low- and middle-income countries, nutrition support strategies are often suboptimal or non-existent in hospital settings. This is further compounded by high rates of malnutrition in these countries. The first four dietitians graduated in Malawi in 2017 providing a new opportunity to build capacity to introduce nutrition support in an acute care setting. A paediatric nutrition support program was implemented at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi including the hiring of a local dietitian. This capacity building paper explains the development and introduction of the nutrition support program including a description of perceptions of health professionals at QECH working alongside the dietitian. In the first four months of the program at QECH, the dietitian provided nutrition support to 183 different patients across paediatric wards. Nutritional interventions predominantly included infant formula and breastmilk fortification, provision of therapeutic feeds orally or via nasogastric tubes, increased dietary protein intake for children identified to be at high risk, and nutritional counselling to caregivers. More complex nutritional interventions were also given such as the insertion of gastrostomy tubes to deliver nutrition directly to the stomach. Following the introduction of the program, qualitative interviews were done with health professionals at QECH including nurses (n = 5) and physicians (n = 11). All participants emphasized the importance and impact of the nutrition support program in enhancing the care of hospitalized children, therefore improving outcomes such as tolerability of clinical interventions, decreased duration of stay, and reduced risk of hospital readmission. In conclusion, there is a need for nutrition support provided by a dietitian for different paediatric patients which was corroborated by positive feedback from health professionals at QECH. Integration of dietitians into the healthcare system by respective Ministries of Health will require advocacy around the potential for nutrition support to strengthen the quality of care of vulnerable children. A Chichewa abstract for this paper is available in a supplementary file.
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Affiliation(s)
- Allison I. Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Humphrey Chatenga
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bernadette Chimera
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Emmie Mbale
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Mphatso Chisala
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Eric Borgstein
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Department of Surgery, College of Medicine, Blantyre, Malawi
| | - Josephine Langton
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Carmen Gonzalez
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Robert H. J. Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Laura Vresk
- Department of Clinical Dietetics, Hospital for Sick Children, Toronto, Ontario, Canada
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19
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Daniel AI, van den Heuvel M, Gladstone M, Bwanali M, Voskuijl W, Bourdon C, Potani I, Fernandes S, Njirammadzi J, Bandsma RHJ. A mixed methods feasibility study of the Kusamala Program at a nutritional rehabilitation unit in Malawi. Pilot Feasibility Stud 2018; 4:151. [PMID: 30258650 PMCID: PMC6151933 DOI: 10.1186/s40814-018-0347-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/17/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Children admitted to nutritional rehabilitation units (NRUs) for inpatient treatment of severe acute malnutrition (SAM) are at high risk of poor developmental and nutritional outcomes. The Kusamala Program is an interactive hospital-based counseling program for primary caregivers of children with SAM that integrates three modules: nutrition and feeding; water, sanitation, and hygiene (WASH); and psychosocial stimulation. This mixed methods feasibility study aimed to evaluate the implementation of the Kusamala Program in an NRU setting and developmental outcomes in children with SAM 6 months after inpatient treatment. METHODS An internal pilot trial including the first 30 children and their primary caregivers enrolled to a cluster-randomized controlled trial of the Kusamala Program was performed. Barriers and enablers were identified in a qualitative study with a focus group discussion (FGD) and in-depth interviews (IDIs) with 12 hospital staff members, including five NRU nurses who deliver the Kusamala Program. RESULTS Results demonstrated high participant engagement (100%) and adherence (87%) of primary caregivers to the Kusamala Program. Potential barriers to implementation identified through the qualitative study were caregivers' perceived value of the program, prioritization of other ward activities, and shortages of staff. On the other hand, enablers to implementation were engaging other staff members, motivation and work ethic, and refresher training. CONCLUSIONS This mixed methods study demonstrates the feasibility of implementing the Kusamala Program in a real NRU setting. The full cluster-randomized controlled trial will be completed to evaluate the effectiveness of the Kusamala Program. TRIAL REGISTRATION ClinicalTrials.gov, NCT03072433. Registered on 7 March 2017-retrospectively registered.
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Affiliation(s)
- Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario Canada
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Meta van den Heuvel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario Canada
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
| | - Melissa Gladstone
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Mike Bwanali
- Moyo Nutritional Rehabilitation and Research Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Wieger Voskuijl
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Celine Bourdon
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario Canada
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Isabel Potani
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Sara Fernandes
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jenala Njirammadzi
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario Canada
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
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20
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Daniel AI, Bandsma RH, Lytvyn L, Voskuijl WP, Potani I, van den Heuvel M. Psychosocial stimulation interventions for children with severe acute malnutrition: a systematic review. J Glob Health 2018; 7:010405. [PMID: 28567278 PMCID: PMC5441448 DOI: 10.7189/jogh.07.010405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background The WHO Guidelines for the inpatient treatment of severely malnourished children include a recommendation to provide sensory stimulation or play therapy for children with severe acute malnutrition (SAM). This systematic review was performed to synthesize evidence around this recommendation. Specifically, the objective was to answer the question: “In children with severe acute malnutrition, does psychosocial stimulation improve child developmental, nutritional, or other outcomes?” Methods A review protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO 2016: CRD42016036403). MEDLINE, Embase, CINAHL, and PsycINFO were searched with terms related to SAM and psychosocial stimulation. Studies were selected if they applied a stimulation intervention in children with SAM and child developmental and nutritional outcomes were assessed. Findings were presented within a narrative synthesis and a summary of findings table. Quality of the evidence was evaluated using the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Findings Only two studies, both non–randomized controlled trials, met the selection criteria for this review. One was conducted in Jamaica (1975) with a follow–up period of 14 years; the other was done in Bangladesh (2002) with a six–month follow–up. At the individual study level, each of the included studies demonstrated significant differences in child development outcomes between intervention and control groups. Only the study conducted in Bangladesh demonstrated a clinically significant increase in weight–for–age z–scores in the intervention group compared to the control group. Conclusions The evidence supporting the recommendation of psychosocial stimulation for children with SAM is not only sparse, but also of very low quality across important outcomes. High–quality trials are needed to determine the effects of psychosocial stimulation interventions on outcomes in children with SAM.
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Affiliation(s)
- Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada.,Department of Nutritional Sciences, University of Toronto Faculty of Medicine, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Robert H Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada.,Department of Nutritional Sciences, University of Toronto Faculty of Medicine, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
| | - Lyubov Lytvyn
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
| | - Wieger P Voskuijl
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Isabel Potani
- Nutritional Rehabilitation Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Meta van den Heuvel
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto Faculty of Medicine, Toronto, Canada
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21
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Daniel AI, van den Heuvel M, Voskuijl WP, Gladstone M, Bwanali M, Potani I, Bourdon C, Njirammadzi J, Bandsma RHJ. The Kusamala Program for primary caregivers of children 6-59 months of age hospitalized with severe acute malnutrition in Malawi: study protocol for a cluster-randomized controlled trial. Trials 2017; 18:550. [PMID: 29149905 PMCID: PMC5693531 DOI: 10.1186/s13063-017-2299-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 10/27/2017] [Indexed: 11/16/2022] Open
Abstract
Background Severe acute malnutrition (SAM) is associated with high mortality rates and impairments in growth and development in children that do survive. There are complex nutritional, health, and behavioural risk factors involving severely malnourished children and their primary caregivers, requiring integrated intervention approaches. Methods A cluster-randomized controlled trial at the Queen Elizabeth Central Hospital in Blantyre, Malawi will be conducted to evaluate the effectiveness of a 4-day hospital-based intervention programme directed at primary caregivers. This programme, titled the Kusamala Program, aims to improve developmental and nutritional outcomes in children with SAM. Up to six primary caregivers and their children will be enrolled to groups each week, which will be randomly allocated to intervention or comparison arms. The intervention package consists of interactive counselling on three modules: 1) nutrition and feeding; 2) water, sanitation, and hygiene (WASH); and 3) psychosocial stimulation. Data collection will be performed at enrolment, at discharge from hospital, and at 6 months following discharge. The primary outcome is child development assessed with the Malawi Developmental Assessment Tool (MDAT), a validated measure of gross and fine motor, language, and social development. Discussion This intervention programme is unique because it utilizes primary caregivers’ time spent in-hospital while children receive treatment for SAM. The programme has the potential to be effective in addressing multiple aspects of child, nutrition and development. Trial registration ClinicalTrials.gov, NCT03072433. Registered on 7 March 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2299-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Allison I Daniel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada. .,Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada. .,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Meta van den Heuvel
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wieger P Voskuijl
- Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Melissa Gladstone
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Mike Bwanali
- Moyo Nutritional Rehabilitation and Research Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Isabel Potani
- Moyo Nutritional Rehabilitation and Research Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Celine Bourdon
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Jenala Njirammadzi
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.,Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
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