Acute Malnutrition In Children Research Articles

Impact on child acute malnutrition of integrating small-quantity lipid-based nutrient supplements into community-level screening for acute malnutrition: A cluster-randomized controlled trial in Mali.

BackgroundCommunity-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence.Methods and findingsA two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6–23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers’ participation and supplement children’s diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design.ConclusionsIncorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated.Trial registrationClinicalTrials.gov NCT02323815.

Impact on child acute malnutrition of integrating a preventive nutrition package into facility-based screening for acute malnutrition during well-baby consultation: A cluster-randomized controlled trial in Burkina Faso.

BackgroundCommunity management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM’s effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children <2 years of age is conducted during well-baby consultations (consultation du nourrisson sain [CNS]) at health centers. We hypothesized that the integration of a preventive package including age-appropriate behavior change communication (BCC) on nutrition, health, and hygiene practices and a monthly supply of small-quantity lipid-based nutrient supplements (SQ-LNSs) to the monthly screening would increase AM screening and treatment coverage and decrease the incidence and prevalence of AM.Methods and findingsWe used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0–17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was α = 0.016 after adjustment for multiple testing. Children’s average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10–26, P < 0.001; longitudinal study: +23 pp, 95% CI 17–29, P < 0.001). There were no impacts on either AM treatment coverage (cross-sectional study: +8.0 pp, 95% CI 0.09–16, P = 0.047; longitudinal study: +7.7 pp, 95% CI −1.2 to 17, P = 0.090), AM incidence (longitudinal study: incidence rate ratio = 0.98, 95% CI 0.75–1.3, P = 0.88), or AM prevalence (cross-sectional study: −0.46 pp, 95% CI −4.4 to 3.5, P = 0.82). A study limitation is the referral of AM cases (for ethical reasons) by study enumerators as part of the monthly measurement in the longitudinal study that may have attenuated the detectable impact on AM treatment coverage.ConclusionsAdding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery.Trial registrationClinicalTrials.gov NCT02245152.

Venezuelan Migration and the Border Health Crisis in Colombia and Brazil

Executive Summary Venezuela’s economic crisis has triggered mass migration; more than 3.4 million Venezuelans have fled to other countries in the region and beyond. An assessment mission to Cúcuta, in the Colombian border state of North Santander, was undertaken from July 26 to August 1, 2018, and to Bôa Vista and Pacaraima, in the state of Roraima, Brazil, between August 24 and 28, 2018. Interviews were conducted with key informants, including health providers and organizations engaged in the humanitarian response. Secondary analysis of gray literature and data shared by key informants was also undertaken. Surveillance data demonstrate increases in infectious diseases, as well as adverse maternal and neonatal health outcomes, among Venezuelans in North Santander and Roraima. Summary of Findings for North Santander Reportable public health surveillance events among Venezuelans increased from 182 in 2015 to 865 in the first half of 2018. In 2018, the most common reported events included gender-based and intrafamiliar violence (17 percent), malaria (15 percent), and acute malnutrition in children &lt;5 years (9 percent). There were 14 measles cases reported between January and June 2018 (compared to none in the previous years), the majority associated with migration from Venezuela. Thirty-six cases of maternal morbidity and two cases of maternal mortality among Venezuelans were observed in the first half of 2018 (compared to three cases of maternal morbidity and no maternal deaths in 2015). Low-birth-weight Venezuelan births rose from three in 2015 to 34 in 2017. Between January 2017 and June 2018, emergency medical attention was provided to 19,108 Venezuelans in government health facilities. Summary of Findings for Roraima In 2018, there were 355 cases of measles in Roraima (compared to none in previous years) — all cases had the genotype lineage originating in the 2017 Venezuelan measles outbreak. Children younger than one year old (812.1/100,000) had the highest measles incident rate in Roraima, followed by children 1–4 years old (245.7/100,000). Malaria cases among Venezuelans increased 3.5-fold from 2015 to 2018 (1,260 vs. 4,402 cases). As of August 2018, 171 HIV-infected Venezuelans were receiving HIV care at the Coronel Motta Clinic in Bôa Vista, Roraima. In 2018, 1,603 Venezuelan women gave birth at the Hospital Materno-Infantil in Bôa Vista, and by mid-2018, 10,040 Venezuelans had received outpatient care and 666 had been hospitalized at the Hospital General Roraima. In Colombia, primary healthcare is not available to Venezuelans, and provision of emergency care is perceived as unsustainable given current funding mechanisms. In Brazil, primary care is available to Venezuelans, but the healthcare system is under severe strain to meet the increased demand for care and is facing unprecedented shortages in medications and supplies. There is an urgent need to expand the humanitarian health response in Colombia and Brazil, both to ensure health among Venezuelans and to protect public health in border areas.

Predictive Model for the Risk of Severe Acute Malnutrition in Children.

Background The nutritional status is the best indicator of the well-being of the child. Inadequate feeding practices are the main factors that affect physical growth and mental development. The aim of this study was to develop a predictive score of severe acute malnutrition (SAM) in children under 5 years of age. Methods It was a case-control study. The case group (n = 263) consisted of children aged 6 to 59 months admitted to hospital for SAM that was defined by a z-score weight/height < −3 SD or presence of edema of malnutrition. We performed a univariate and multivariate analysis. Discrimination score was assessed using the ROC curve and the calibration of the score by Hosmer–Lemeshow test. Results Low birth weight, history of recurrent or chronic diarrhea, daily meal's number less than 3, age of breastfeeding's cessation less than 6 months, age of introduction of complementary diets less than 6 months, maternal age below 25 years, parity less than 5, family history of malnutrition, and number of children under 5 over 2 were predictive factors of SAM. Presence of these nine criteria affects a certain number of points; a score <6 points defines children at low risk of SAM, a score between 6 and 8 points defines a moderate risk of SAM, and a score >8 points presents a high risk of SAM. The area under ROC curve of this score was 0.9685, its sensitivity was 93.5%, and its specificity was 93.1%. Conclusion We propose a simple and efficient prediction model for the risk of occurrence of SAM in children under 5 years of age in developing countries. This predictive model of SAM would be a useful and simple clinical tool to identify people at risk, limit high rates of malnutrition, and reduce disease and child mortality registered in developing countries.

The whole is more than the sum of the parts: establishing an enabling health system environment for reducing acute child malnutrition in a rural South African district.

There is a gap in understanding of how national commitments to child nutrition are translated into sub-national implementation. This article is a mixed methods case study of a rural South African health district which achieved accelerated declines in morbidity and mortality from severe acute malnutrition (SAM) in young children, following a district health system strengthening (HSS) initiative centred on real-time death reporting, analysis and response. Drawing on routine audit data, the declining trends in under-five admissions and in-hospital mortality for SAM over a 5-year period are presented, comparing the district with two others in the same province. Adapting Gillespie et al.’s typology of ‘enabling environments’ for Maternal and Child Nutrition, and based on 41 in-depth interviews and a follow-up workshop, the article then presents an analysis of how an enabling local health system environment for maternal-child health was established, creating the conditions for achievement of the SAM outcomes. Embedded in supportive policy and processes at national and provincial levels, the district HSS interventions and the manner in which they were implemented produced three kinds of system-level change: knowledge and use of evidence by providers and managers (‘ways of thinking’), leadership, participation and coordination (‘ways of governing’) and inputs and capacity (‘ways of resourcing’). These processes mainstreamed responsibility, deepened accountability and triggered new service delivery and organizational practices and mindsets. The article concludes that it is possible to foster enabling district environments for the prevention and management of acute malnutrition, emphasizing the multilevel and simultaneous nature of system actions, where action on system ‘software’ complements the ‘hardware’ of HSS interventions, and where the whole is more than the sum of the parts.

The Prevalence of Acute and Chronic Malnutrition Among Children Under Five in a Rural Haitian Town: A Population-Based Survey (P11-103-19)

ObjectivesBoth chronic and acute malnutrition in children under 5 remain a persistent problem in low and low-middle income countries. Haiti faces the highest burden of childhood malnutrition in the Western Hemisphere. We attempted to describe the prevalence of malnutrition in children in a farming community in Haiti and record characteristics of the those experiencing the disease. MethodsA household survey was conducted within the town of Fontaine in the Nord department of Haiti on all children under the age of 5. A total of 535 children were assessed. Anthropometric data was taken on the children and household information was assessed via a population-based survey. ResultsOf the children assessed, 28% (149/535) were either chronically or acutely malnourished. Of the children who were malnourished: 36.4% (43/118) had 3 or more bouts of diarrhea in the past 3 months and only 5.3% (7/132) had stopped breastfeeding before 1 year of age. On average, the mothers of these children had completed 6.2 years of formal schooling. A slight majority of mothers, 54.7% (81/148), either “never” or “rarely” were concerned their child was malnourished. Of the households with malnourished children 88.4% (130/147) had reported running out of food in the last month. When asked what caused children in Fontaine to be malnourished, mothers of malnourished children cited a lack of food, 56.2% (82/146), and a lack of access to employment, 25.3% (37/146), most frequently. ConclusionsMalnutrition commonly affects children in Fontaine. Efficacious prevention interventions could possibly include decreasing food insecurity, or increasing girls’ education level. Funding SourcesNone.

Examining Response to Treatment of Severe Acute Malnutrition in Children 6–59 Months Old in Afghanistan, Chad, Mali, and Niger (P12-002-19)

ObjectivesIdentify the most significant factors affecting the trajectory of recovery from severe acute malnutrition (SAM), as measured by average daily weight gain in each child 6–59 months of age who were diagnosed and treated for SAM and treated, adjusting for covariates including: breastfeeding status, number of children in household, illness, and distance to health center.Hypothesis 1a:Children 6–59 months enrolled in SAM treatment have slower times to recovery and slower weight gain if they are admitted for treatment at a lower anthropometric cut-off admission (weight for height z-score < –4) than children admitted for treatment at a higher anthropometric cut-off (weight for height z-score ≥ –4).Hypothesis 1b: Older children (24–59 months) recover more quickly than younger children (6–23 months) controlling for ration size. MethodsA retrospective panel data analysis on children 6–59 months enrolled in standard outpatient treatment for severe acute malnutrition (SAM) between 2014 and 2016 was conducted. The study period was between September-December 2018. Children were exhaustively sampled. Children with edema, children with implausible z-scores for W/H (<–5 and >5) and H/A (<–6 and >6), children who were referred for inpatient therapeutic feeding to a stabilization center, and children from the same household, except in the case of twins, were eliminated from the analysis. There was one database per country. A total of 1384 children between 6–59 months were included in the analysis. ResultsThe most significant factors affecting the proportional weight gain include age at enrollment (P = 0.001, 95%CI = –0.00—0.00) and Weight for height z-score (WHZ) (P = 0.00, 95%CI = 0.04—0.05) in each child 6–59 months of age who were diagnosed with SAM and treated, adjusting for covariates including: breastfeeding status, number of children in household, illness, and distance to health center. Sex of child did not significantly affect proportional weight gain (P = 0.404, 95%CI = –0.012–0.005). ConclusionsThe existing protocol to treat severe acute malnutrition should be modified to treat younger children and children who are admitted with a lower weight for height z-score due to different vulnerabilities. Funding SourcesThe research was conducted as part of a dissertation at The Friedman School of Nutrition Science and Policy at Tufts University. Data were obtained from World Vision.

Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age.

Ready-to-use therapeutic food (RUTF) for home-based nutritional rehabilitation of severe acute malnutrition in children from six months to five years of age.

Refeeding syndrome during management of severe acute malnutrition in children: Biological aspects

A global optimizer has been developed, capable of computing the optimal configuration in a probe for spatially resolved reflectance spectroscopy (SRS). The main objective is to minimize the number of detection fibers, while maintaining an accurate estimation of both absorption and scattering profiles. Multiple fibers are necessary to robustify the estimation of optical properties against noise, which is typically present in the measured signals and influences the accuracy of the inverse estimation. The optimizer is based on a robust metamodel-based inverse estimation of the absorption coefficient and a reduced scattering coefficient from the acquired SRS signals. A genetic algorithm is used to evaluate the effect of the fiber placement on the performance of the inverse estimator to find the bulk optical properties of raw milk. The algorithm to find the optimal fiber placement was repeatedly executed for cases with a different number of detection fibers, ranging from 3 to 30. Afterwards, the optimal designs for each considered number of fibers were compared based on their performance in separating the absorption and scattering properties, and the significance of the differences was tested. A sensor configuration with 13 detection fibers was found to be the combination with the lowest number of fibers which provided an estimation performance which was not significantly worse than the one obtained with the best design (30 detection fibers). This design resulted in the root mean squared error of prediction (RMSEP) of 1.411 cm−1 (R2 = 0.965) for the estimation of the bulk absorption coefficient values, and 0.382 cm−1 (R2 = 0.996) for the reduced scattering coefficient values.

Prevalence of Severe Acute Malnutrition in Children Admitted to the Emergency Paediatric Unit at a Tertiary Centre in North Central Nigeria

Background: Malnutrition is of major public health concern worldwide. The prevalence of severe acute malnutrition/wasting is increasing nationally and globally. The aim of this study is to determine the prevalence of Severe Acute Malnutrition (SAM) at Dalhatu Araf Specialist Hospital, Lafia Nasarawa State. Methods: This was a cross-sectional prospective study. All children admitted between the months of June to October 2016 had their anthropometry taken. All children 6 months to 60 months with SAM based on the WHZ score were identified and a pre-designed proforma was administered to obtain information from the parents of children with SAM. Results: SAM was present in 44.4% of all admitted children. No child above the age of 36 months had SAM and 84.8% of all SAM patients were less than 24 months old. Most mothers (72.9%) of the children with SAM were unemployed and (55.9%) had no formal education. Only 18.6% of these mothers practiced exclusive breastfeeding and as many as 62.7% of the children with SAM had been introduced to complementary feeds before 6 months of age. Conclusion: This is the first time a very high prevalence of SAM has been reported in Nasarawa State. The absence of exclusive breastfeeding, early commencement of complementary feeds and lower educational status were prevalent among mothers of children with SAM.

Validating the MUAC (Mid-upper arm circumference) Cut-off for Detection of Severe Acute Malnutrition in Children Aged 6–59 Months in Rural Maharashtra

To review the Mid-upper arm circumference (MUAC) cut-off currently being used to identify Severe Acute Malnutrition (SAM) as currently defined using Weight-for-Height. Cross-sectional study conducted in 24 villages of a Primary Health Centre in Wardha district of Maharashtra among 2650 children between the ages of 6 to 59 months. For identifying SAM, sensitivity of MUAC was 23.5% and specificity was 99.7% for cut-off <11.5 cm. Using Youden index, best Mid-upper arm circumference cut-off point to identify SAM was <13 cm with sensitivity of 74.5% and specificity of 92.7%. Using Receiver operating characteristics curve, best MUAC cut-off point was 12.8 cm with 74.5% sensitivity and 92.7% specificity. Area under curve was 0.88 (95%CI: 0.85-0.91). The current MUAC cut-off of <11.5 cm for detecting SAM needs to be increased to ensure that children, who need referral for management of malnutrition, are not missed.

Time-to-recovery from severe acute malnutrition in children 6\u201359\u2009months of age enrolled in the outpatient treatment program in Shebedino, Southern Ethiopia: a prospective cohort study

BackgroundIn Ethiopia uncomplicated severe acute malnutrition (SAM) is managed at health posts level through the outpatient therapeutic program (OTP). Yet, evidence on the treatment success rate of the program is scarce. This study determines the treatment outcomes and predictors of time-to-recovery among children 6–59 months of age with SAM managed at the health posts level in Shebedino district, Southern Ethiopia.MethodsThis was a prospective cohort study that enrolled 216 children with SAM identified through a campaign conducted in May 2015 and treated over eight weeks at 25 health posts of the district. The average time-to-recovery was estimated using Kaplan-Meier survival curve and the independent predictors of the recovery were determined using multivariable Cox-proportional hazard model. The outputs of the analyses are presented via adjusted hazard ratio with 95% confidence intervals (AHR, CI).ResultsAt the end of the eight weeks of treatment 79.6% (95% CI: 74.2–85.0%) of cases recovered from SAM with a weight gain rate of 5.4 g/kg/day. The median time-to-recover was 36 days. The analysis indicated, maternal illiteracy (0.54, 0.38–0.78), severe household food insecurity (0.47, 0.28–0.79), walking for more than 1 h to receive the treatment (0.69, 0.50–0.96), diarrhoea co-morbidity (0.63, 0.42–0.91) and practicing sharing of ready to use therapeutic food (RUTF) (0.53, 0.32–0.88) were associated with slower propensity of recovery from SAM. Children who were enrolled with marasmus diagnosis showed lower recovery than children with kwashiorkor (0.30, 0.18–0.51).ConclusionThe median time-to-recover was 36 days. Discouraging sharing of RUTF, appropriate management of diarrhoea in SAM cases and improving access to OTP sites can help to improve the treatment outcome for SAM.

Interleukine 6 and C-reactive protein predict growth impairment and acute malnutrition in children and adolescents with chronic kidney disease.

Objective: secondary malnutrition and systemic inflammation may impair growth and body composition in children and adolescents with chronic kidney disease (CKD). This association has been scantily studied, particularly in pre-dialytic stages. Our aim was to correlate growth and nutritional status indicators with the serum concentration of interleukine 6 (IL-6) and ultrasensitive C-reactive protein (CRP) in children with CKD. Methods: this was a prospective cross-sectional study in 29 children and adolescents aged 3-16 years with CKD, stages 3 or 4, in two third-level general hospitals. The outcome variables were height for age, body mass index, arm anthropometric indicators, plus lean mass/fat percentage by bioelectrical impedance. The independent variables were IL-6 and CRP. This study was reviewed and approved by the Health Research and Ethics Committees of both hospitals. Results: height for age, body mass index, subscapular skinfold, arm fat area, and lean mass had a significant negative correlation with IL-6. The height-for-age z-score had a negative correlation with CRP. IL-6 explained 15% to 35% of the variance in height for age and nutritional status indicators. CRP predicted 22% of height for age. One fifth of the patients had acute malnutrition, and one third were stunted. Muscle was the most affected compartment. Conclusion: IL-6 and CRP in children and adolescents with CKD in the pre-dialytic stage predicted one fifth and one third of the variance in acute and chronic malnutrition indicators. The frequency of acute malnutrition and impaired growth was clinically significant. Muscular mass deficit was a central component of malnutrition.

Path to severe acute malnutrition in children below 2 years of age: Findings of qualitative research in Uttar Pradesh, North India

IntroductionMalnutrition in infancy contributes to high mortality and morbidity. In India, government has established nutrition rehabilitation centres for managing children with severe acute malnutrition. The study was conducted with aim to understand how community perceived malnutrition and how child's size at birth, infant and young child feeding related behaviours and child's illness were associated with decline in the child's growth or health. MethodsQualitative research employing focused ethnographic methodologies was used. From February–December 2016, cases studies and in-depth interviews were conducted with 12 mothers of malnourished children <24 months of age (cases), purposively recruited from nutrition rehabilitation centre of 3 districts in Uttar Pradesh, North India. Twenty-four mothers of gender and age matched well-nourished controls from village of cases were also interviewed. Focus group discussion was done with community health workers from villages of cases. Data were coded and after analysis and data triangulation, emerging concepts were grouped into core themes linked with malnutrition. ResultsGrounded on experience of participants, emerging themes were that importance of exclusive breastfeeding was neither understood nor emphasized, there was no concept of complementary feeding, family food lacked diversity, malnutrition was not recognised as a health hazard, and there was lack of autonomy of females in reproductive and general health issues. ConclusionGiven these paths to malnutrition in infancy, there is an urgent need to create community awareness about malnutrition as a disease as well as about optimal breastfeeding and complementary feeding practices in infancy by using innovative behaviour change communication strategies.

The Human Microbiome and Child Growth - First 1000 Days and Beyond.

The assembly of microbial communities within the gastrointestinal tract during early life plays a critical role in immune, endocrine, metabolic, and other host developmental pathways. Environmental insults during this period, such as food insecurity and infections, can disrupt this optimal microbial succession, which may contribute to lifelong and intergenerational deficits in growth and development. Here, we review the human microbiome in the first 1000 days - referring to the period from conception to 2 years of age - and using a developmental model, we examine the role of early microbial succession in growth and development. We propose that an 'undernourished' microbiome is intergenerational, thereby perpetuating growth impairments into successive generations. We also identify and discuss the intertwining host-microbe-environment interactions occurring prenatally and during early infancy, which may impair the trajectories of healthy growth and development, and explore their potential as novel microbial targets for intervention.

Use of Mid-Upper Arm Circumference by Novel Community Platforms to Detect, Diagnose, and Treat Severe Acute Malnutrition in Children: A Systematic Review.

A stubborn persistence of child severe acute malnutrition (SAM) and continued gaps in program coverage have made identifying methods for expanding detection, diagnosis, and treatment of SAM an urgent public health need. There is growing consensus that making mid-upper arm circumference (MUAC) use more widely accessible among caregivers and community health workers (CHWs) is an important next step in further decentralizing SAM care and increasing program coverage, including the ability of CHWs to treat uncomplicated SAM in community settings. We conducted a systematic review to summarize published and operational evidence published since 2000 describing the use of MUAC for detection and diagnosis of SAM in children aged 6-59 months by caregivers and CHWs, and of management of uncomplicated SAM by CHWs, all outside of formal health care settings. We screened 1,072 records, selected 43 records for full-text screening, and identified 22 studies that met our eligibility criteria. We extracted data on a number of items, including study design, strengths, and weaknesses; intervention and control; and key findings and operational lessons. We then synthesized the qualitative findings to inform our conclusions. The issue of treating children classified as SAM based on low weight-for-height, rather than MUAC, at household level, is not addressed in this review. We found evidence that caregivers are able to use MUAC to detect SAM in their children with minimal risk and many potential benefits to early case detection and coverage. We also found evidence that CHWs are able to correctly use MUAC for SAM detection and diagnosis and to provide a high quality of care in the treatment of uncomplicated SAM when training, supervision, and motivation are adequate. However, the number of published research studies was small, their geographic scope was narrow, and most described intensive, small-scale interventions; thus, findings are not currently generalizable to public-sector health care systems. Scaling up the use of MUAC by caregivers and CHWs to detect SAM in household and community settings is a promising step toward improving the coverage of SAM detection, diagnosis, and treatment. Further research on scalability, applicability across a wider range of contexts, coverage impact, and cost is needed. The primary use of MUAC for SAM detection should also be explored where appropriate.

Perceptions and experiences of caregivers of severely malnourished children receiving inpatient care in Malawi: An exploratory study.

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. To explore caregivers' perceptions and experiences surrounding childhood acute malnutrition and the experience of inpatient care in Malawi. Interviews were conducted utilising a semi-structured topic guide and were coded using thematic analysis. 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. 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.

Amino-acid-enriched cereals ready-to-use therapeutic foods (RUTF) are as effective as milk-based RUTF in recovering essential amino acid during the treatment of severe acute malnutrition in children: An individually randomized control trial in Malawi.

BackgroundReady-to-use therapeutic food (RUTF) is used to treat children suffering from severe acute malnutrition (SAM). Standard RUTF uses milk as the primary protein source, which makes the product expensive, and given the high worldwide SAM burden, having a less expensive effective alternative is a public health priority.ObjectiveThe objective of this study was to evaluate whether newly developed amino acid-enriched milk-free RUTF (FSMS-RUTF) or amino acid-enriched low-milk RUTF (MSMS-RUTF) treatment could replenish plasma amino acids to levels comparable to those following standard peanut-milk RUTF (PM-RUTF) treatment and to improve understanding of the effects of treatment on anthropometric measurements. A secondary analysis was performed to test the noninferiority hypothesis of plasma essential amino acid (EAA) levels.MethodsPlasma EAA levels were measured in a nonblinded, 3-arm, parallel-group simple randomized controlled trial conducted in Malawi to examine the efficacy of FSMS-RUTF, MSMS-RUTF and PM-RUTF in the treatment of SAM in 2 groups of children aged 6–23 and 24–59 months (mo). Sample size calculations were performed based on the previous our study. A noninferiority margin was set at -25% of the PM-RUTF arm at discharge.ResultsThe relative values of the differences (95% CI) in plasma EAA levels between PM-RUTF treatment and FSMS-RUTF and MSMS-RUTF treatments at discharge were -7.9% (-18.6, 2.8) and 9.8% (0.2, 19.5), respectively, in children aged 6–23 mo, while in those aged 24–59 mo, the difference values were 17.8% (1.6, 34.1) and 13.6% (-2.8, 29.9), respectively.ConclusionAt discharge, the plasma EAA concentrations in 6-59-mo-old SAM children treated with FSMS-RUTF and MSMS-RUTF were not less than those of children treated with PM-RUTF. These findings indicate that treatment with either of the 3 RUTFs was associated with adequate protein synthesis and that all the formulations provided sufficient functional metabolites of plasma amino acids to support nutritional recovery from SAM.

Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis

BackgroundArua district, in Uganda, hosts some of the largest refugee camps in the country. The estimated prevalence of moderate and severe acute malnutrition in children is higher than the national estimates (10.4 and 5.6% respectively, compared to 3.6 and 1.3%). This study aimed at assessing the quality of care provided to children with acute malnutrition at out-patient level in such a setting.MethodsSix facilities with the highest number of children with malnutrition were selected. The main tool used was the National Nutrition Service Delivery Assessment Tool, assessing 10 key areas of service delivery and assigned a score as either poor, fair, good or excellent. Health outcomes, quality of case management and data quality were assessed from the health management information system and from the official nutrition registers.ResultsAll facilities except two scored either poor or fair under all the 10 assessment areas. Overall, 33/60 (55%) areas scored as poor, 25/60 (41%) as fair, 2/60 (3.3%) as good, and none as excellent. Main gaps identified included: lack of trained staff; disorganised patient flow; poor case management; stock out of essential supplies including ready-to-use therapeutic foods; weak community linkage. A sample coverage of 45.4% (1020/2248) of total children admitted in the district during the 2016 financial year were included. The overall mean cure rate was 52.9% while the default rate was 38.3%. There was great heterogeneity across health facilities in health outcomes, quality of case management, and data quality.ConclusionThis study suggests that quality of care provided to children with malnutrition at health center level is substandard with unacceptable low cure rates. It is essential to identify effective approaches to enhance adherence to national guidelines, provision of essential nutritional commodities, regular monitoring of services and better linkage with the community through village health teams.

Identification of Acute Malnutrition in Children in Cambodia Requires Both Mid Upper Arm Circumference and Weight-For-Height to Offset Gender Bias of Each Indicator.

Malnutrition remains a serious health problem in Cambodia with over 10% of children less than five years of age suffering from acute malnutrition. In addition to the presence of nutritional edema, two indicators are recommended by the World Health Organization for the diagnosis of acute malnutrition: weight-for-height Z-scores (WHZ; with acute malnutrition defined as WHZ < −2 Z-score) and mid-upper arm circumference (MUAC, with acute malnutrition defined as MUAC < 12.5 cm). Earlier, we showed that WHZ and MUAC identified different subgroups of children with acute malnutrition. To explore factors associated with both indicators of acute malnutrition, we analyzed baseline data from a longitudinal study in three provinces in Cambodia: Phnom Penh (capital, urban environment), Kratie (rural province), and Ratanakiri (hilly, rural province). Data was available for 4381 children below 30 months of age. Malnutrition rates were higher in the two rural provinces than in the capital. Although both MUAC and WHZ showed gender bias, with MUAC identifying more girls, and WHZ identifying more boys with acute malnutrition, the gender effect was strongest for MUAC. The gender bias of MUAC diminished with older age, but remained significant up to 30 months of age. Only using both MUAC and WHZ as indicators resulted in gender neutral identification of acute malnutrition. WHZ alone always identified more children with acute malnutrition than MUAC alone. In Phnom Penh, MUAC alone identified only 11% with acute malnutrition in addition to WHZ. To conclude, both MUAC and WHZ showed gender bias in this cohort of Cambodian children. In Cambodia, implementation of a MUAC-only or a WHZ-only program for the identification of acute malnutrition would be unethical as it will lead to many children remaining undiagnosed.