Community Management Of Acute Malnutrition Research Articles

Caregiver use of MUAC tapes in South Sudan: a three-group prospective comparison.

Nutrition program modifications occurred globally in response to the COVID-19 pandemic. Within community management of acute malnutrition (CMAM), community screenings for acute malnutrition were replaced by caregivers monitoring child mid-upper arm circumference (MUAC), but questions remain about different MUAC tapes' performance and acceptability for caregiver use. The study was conducted in Central Equatoria and Warrap States, South Sudan, between March 2022 and January 2023. A three-group prospective non-randomized design was used to compare the performance of three MUAC tapes (UNICEF 2009, UNICEF 2020, and GOAL MAMI) used by caregivers. The primary outcome was the false negative rate (i.e., the proportion of children not identified as wasted by the caregiver but classified as wasted by enumerators). Caregivers with children aged 5-53 months were assigned to and trained on the use of 1 of the 3 tapes and followed for 8 months, including three monitoring visits and baseline/endline surveys. Of the 2,893 enrolled children, 2,401 (83.0%) completed baseline, endline, and two or more monitoring visits. Only 3.7% of children were identified as wasted by caregivers and 3.8% by study team measurement. Cumulative measurement agreement between caregivers and enumerators was similar by tape. False negative and false positive rates were both <0.5% overall and similar among the tapes. There were differences in training needs and durability between the tapes, but all three were acceptable and performed equally well. Caregiver measurement of child MUAC is feasible in South Sudan. The three MUAC tapes were acceptable, and caregivers could measure accurately with minimal support. All tapes performed similarly and are appropriate for use in Family MUAC programs in South Sudan. There were indications that the UNICEF 2020 tape may be less durable; the GOAL MAMI tape has the added benefit of being suitable for assessments of infants <6 months of age.

Risk factors for food contamination among children discharged from community management of acute malnutritionprogrammes in South Sudan: A cross-sectional study and hazard analysis critical control pointapproach.

Children under-5 years of age are particularly vulnerable to severe acute malnutrition (SAM), and the risk factors associated with relapse to SAM are poorly understood. Possible causes are asymptomatic or symptomatic infection with enteric pathogens, with contaminated food as a critical transmission route. This cross-sectional study comprised a household survey with samples of child food (n = 382) and structured observations of food preparation (n = 197) among children aged 6-59 months that were discharged from treatment in community management of acute malnutrition (CMAM) programmes in South Sudan. We quantified Escherichia coli and total coliforms (TCs), measured in colony forming units per g of food (CFU/g), as indicators of microbial contamination of child food. A modified hazard analysis critical control point (HACCP) approach was utilised to determine critical control points (CCPs) followed by multivariate logistic regression analysis to understand the risk factors associated with contamination. Over 40% (n = 164) of samples were contaminated with E. coli (43% >0 E. coli CFU/g, 95%CI 38%-48%), and 90% (n = 343) had >10 TCs (CFU/g) (>10 TC CFU/g, 95%CI 87%-93%). Risk factors associated (p < 0.05) with child food contamination included if the child fed themselves (9.05 RR, 95% CI [3.18, 31.16]) and exposure to animals (2.63 RR, 95% CI [1.33, 5.34]). This study highlights the risk factors and potential control strategies that can support interventions that reduce food contamination exposure in young children and help further protect those that are highly vulnerable to recurrent exposure to enteric pathogens.

Impact of COVID-19 program adaptations on costs and cost-effectiveness of community management of acute malnutrition program in South Sudan.

We assessed the impact of the COVID-19 pandemic and the protocol adaptations on cost and cost-effectiveness of community management of acute malnutrition (CMAM) program in South Sudan. Retrospective program expenditure-based analysis of non-governmental organisation (NGO) CMAM programs for COVID-19 period (April 2020-December 2021) in respect to pre-COVID period (January 2019-March 2020). Study was conducted as part of a bigger evaluation study in South Sudan. International and national NGOs operating CMAM programs under the nutrition cluster participated in the study. The average cost per child recovered from the programme declined by 20 % during COVID from $133 (range: $34-1174) pre-COVID to $107 (range: $20-333) during COVID. The cost per child recovered was negatively correlated with programme size (pre-COVID r-squared = 0·58; during COIVD r-squared = 0·50). Programmes with higher enrollment were cheaper compared with those with low enrolment. Salaries, ready to use food and community activities accounted for over two-thirds of the cost per recovery during both pre-COVID (69 %) and COVID (79 %) periods. While cost per child recovered decreased during COVID period, it did not negatively impact on the programme outcome. Enrolment increased by an average of 19·8 % and recovery rate by 4·6 % during COVID period. Costs reduced with no apparent negative implication on recovery rates after implementing the COVID CMAM protocol adaptations with a strong negative correlation between cost and programme size. This suggests that investing in capacity, screening and referral at existing CMAM sites to enable expansion of caseload maybe a preferable strategy to increasing the number of CMAM sites in South Sudan.

A Prospective Comparison of Standard and Modified Acute Malnutrition Treatment Protocols during COVID-19 in South Sudan

A non-randomized prospective cohort study was conducted in 2022 to compare recovery rate and length of stay (LoS) for acutely malnourished children treated under South Sudan’s standard Community Management of Acute Malnutrition (CMAM) protocol and a COVID-modified protocol. Children aged 6–59 months received acute malnutrition (AM) treatment under the standard or modified protocol (mid-upper-arm circumference-only entry/exit criteria and simplified dosing). Primary (recovery rate and LoS) were compared for outpatient therapeutic (OTP) and therapeutic supplementary feeding programs (TSFP) using descriptive statistics and mixed-effects models. Children admitted to OTP under both protocols were similar in age and sex; children admitted to TSFP were significantly older under the modified protocol than the standard protocol. Shorter LoS and higher recovery rates were observed under the modified protocol for both OTP (recovery: 93.3% vs. 87.2%; LoS: 38.3 vs. 42.8 days) and TSFP (recovery: 79.8% vs. 72.7%; LoS: 54.0 vs. 61.9 days). After adjusting for site and child characteristics, neither differences in adjusted odds of recovery [OTP: 2.63; TSFP 1.80] nor LoS [OTP −10.0; TSFP −7.8] remained significant. Modified protocols for AM performed well. Adjusted models indicate similar treatment outcomes to the standard protocol. Adopting simplified protocols could be beneficial post-pandemic; however, recovery and relapse will need to be monitored.

Outcome Evaluation of Community Management of Severe Acute Malnutrition in Some Selected Outpatient Therapeutic Programme Centres of Katsina State, Nigeria

Severe acute malnutrition remains a major public health problem, especially in developing countries. In this study, a retrospective and on-site assessment of the effectiveness of the community management of acute malnutrition (CMAM) program in four (4) Outpatient Therapeutic Programme (OTP) centres of Katsina and Daura Local Government Areas of Katsina State was carried out from January 2021 to December 2021. Assessment of CMAM performance indicators, anthropometric indices, oedema, the biochemical and haematological status of children with severe acute malnutrition (SAM) and a follow-up assessment of probable relapse 8 weeks after discharge was carried out. The result indicated that both the treatment (87.90% and 94.44% at Katsina and Daura OTPs respectively) and geographical coverage (20.00% at both Katsina and Daura OTPs) in the present study were higher than the values for the retrospective study. Outcome measures of CMAM in the Katsina OTPs showed a cure rate of 95.0% and 97.3% in the retrospective and current studies, respectively. While in Daura OTPs, the cure rates were 86.8% and 93.52% respectively for the retrospective and the present study. Result for the growth performance and recovery indices have shown higher percentages in normal range values for mid upper arm circumference, weight for height and Oedema among the SAM children at the point of discharge over the values at the admission. In fact, all the children that presented with oedema in both OTPs at admission did not have oedema at the point of discharge. In addition, there was a significant improvement in biochemical and hematologic indices in SAM children at discharge compared to the values at admission ​​(p &lt; 0.05). Findings of the study have indicated a good performance of CMAM program in OTP centers of Katsina and Daura Local Government Areas of Katsina State as prescribed by the SPHERE standard.

Influence of a quality improvement intervention on rehabilitation outcomes of children (6–24 months) with acute malnutrition: a retrospective study in rural Angola

BackgroundDefaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate.MethodsRetrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6–24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate.ResultsThe intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil.ConclusionsThe present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.

Acceptability of alternative ready-to-use therapeutic foods in acute malnutrition management—a systematic review

“Commercial” Ready-To-Use Therapeutic Foods (RUTFs) are used in acute malnutrition management, but they are not always appropriate being expensive and unfamiliar. Much research has tried to develop alternative RUTF formulations and this work systematically reviewed eight articles discussing the approaches used to assess the children’s sensory satisfaction, families’ acceptance, and the cultural appropriateness of 13 alternative RUTFs. Different approaches were used by the authors and much research to standardise methodologies and findings is urgent to ensure that food products are culturally appropriate, acceptable and appreciated, with the final aim of completing the development process of alternative RUTFs. This work proposed some indications to follow in alternative RUTF acceptability evaluation processing. Moreover, community engagement and education resulted key aspects in alternative RUTF acceptance. An innovative, multi-disciplinary, multi-stakeholder approach could develop alternative “fit-for-the-purpose” RUTFs to help food-insecure communities acquire sufficient, safe, nutritious food in long-term Community Management of Acute Malnutrition.

Key Challenges to Optimal Therapeutic Coverage and Maternal Utilization of CMAM Program in Rural Southern Pakistan: A Qualitative Exploratory Study.

Severe Acute Malnutrition (SAM) is a serious public health problem in many low- and middle-income countries (LMICs). Therapeutic programs are often considered the most effective solution to this problem. However, multiple social and structural factors challenge the social inclusion, sustainability, and effectiveness of such programs. In this article, we aim to explore how poor and remote households face structural inequities and social exclusion in accessing nutrition-specific programs in Pakistan. The study specifically highlights significant reasons for the low coverage of the Community Management of Acute Malnutrition (CMAM) program in one of the most marginalized districts of south Punjab. Qualitative data are collected using in-depth interviews and FGDs with mothers and health and nutrition officials. The study reveals that mothers’ access to the program is restricted by multiple structural, logistical, social, and behavioral causes. At the district level, certain populations are served, while illiterate, and poor mothers with lower cultural capital from rural and remote areas are neglected. The lack of funding for nutrition causes the deprioritization of nutrition by the health bureaucracy. The subsequent work burden on Lady Health Workers (LHWs) and the lack of proper training of field staff impact the screening of SAM cases. Moreover, medical corruption in the distribution of therapeutic food, long distances, traveling or staying difficulties, the lack of social capital, and the stigmatization of mothers are other prominent difficulties. The study concludes that nutrition governance in Pakistan must address these critical challenges so that optimal therapeutic coverage can be achieved.

Nutrition status and morbidity of Ethiopian children after recovery from severe acute malnutrition: Prospective matched cohort study.

After recovery, children with severe acute malnutrition (SAM) remain vulnerable to sub-optimal growth and malnutrition relapse. Although there is an increased interest in understanding these problems, data are scarce, and contextual factors can cause variability. We prospectively followed a cohort of Ethiopian children (215 post-SAM cases and 215 non-wasted controls), monthly for one year. The post-SAM cases were: age 6-59 months at admission into the community management of acute malnutrition (CMAM) program and being successfully discharged from CMAM (MUAC>11.0cm, weight gain of 20%, absence of oedema and clinically stable for two consecutive weeks). The controls were apparently healthy children from same village who had no history of an episode of AM and were matched 1:1 to a post-SAM child by age and sex. The primary outcomes were: cumulative incidence of acute malnutrition; growth trajectory; cumulative incidence of reported common morbidities, and cumulative proportion and incidence of deaths. The burden of common morbidities was higher among post-SAM than controls; post-SAM children had more frequent illness episodes (Incidence Rate Ratio of any illness 1.39, 95% CI: 1.14, 1.71; p<0.001). The prevalence of SAM was consistently higher among post-SAM cases than the control group, having a 14 times higher risk of developing SAM (Incidence Rate Ratio: 14.1; 95% CI: 3.5, 122.5; p<0.001). The divergence in weight and growth trajectory remained the same during the study period. Our results advocate for the design of post-discharge interventions that aim to prevent the reoccurrence of acute malnutrition, reduce morbidity and promote catch-up growth. Research is needed to define the appropriate package of post-discharge interventions.

Concomitant health benefits package design and research prioritisation: development of a new approach and an application to Malawi

Health benefits packages (HBPs) are increasingly used in many countries to guide spending priorities on the path towards universal health coverage. Their design is, however, informed by an uncertain evidence...

Impact of a CMAM Intervention on Demand for Other Primary Health Care Services in Katsina State, Nigeria

Malnutrition in both acute and chronic forms is a global issue responsible for as much as 50% of infant mortality worldwide. Acute malnutrition exists as both moderate and severe forms depending on factors such as access to nutritious meals and maternal care practices. Moderate Acute Malnutrition (MAM) can be easily treated and has lesser mortality impacts compared to Severe Acute Malnutrition (SAM). Community Management of Acute Malnutrition (CMAM) is a community-based approach to addressing SAM and MAM. In this study, the impact of a donor funded CMAM intervention delivered through primary healthcare (PHC) facilities in Katsina state, Nigeria is measured. Prior to this study, there was low utilization of these facilities due to the several factors such as transportation and communication problems, traditional conservatism, poor quality of services, and low literacy rates. A randomised sampling method was used to select and compare 5 CMAM and 5 non-CMAM facilities across the state. A test for significance for two independent groups (CMAM supported and non-CMAM supported sites) was also conducted for different categories of admissions such as antenatal care (ANC), outpatient department (OPD) and routine immunization (RI). From the result, it is concluded that the CMAM intervention increased the rate of patient access and use of PHCs within the state. The test of significance also shows significant differences between the admissions for OPD, ANC, and RI when compared to non-CMAM sites.

A cross-sectional study of prevalence and risk factors for stunting among under-fives attending acute malnutrition treatment programmes in north-western Nigeria: Should these programmes be adapted to also manage stunting?

BackgroundStunting and severe wasting can co-occur in under-fives, predisposing them to increased risks for morbidity and mortality. The Community Management of Acute Malnutrition (CMAM) programme, which provides outpatient malnutrition care for severely wasted children, has been successful at managing severe wasting, but there are limited data on stunting among entrants into these programmes.MethodsWe performed secondary analysis of data collected from attendees of two CMAM centres in north-western Nigeria. Using WHO reference standards, we determined the prevalence of concurrent stunting (height/length-for-age <-2 SD) among severely wasted children (weight-for-height z-scores <-3 SD). We identified individual and household-level risk factors for concurrent stunting using multivariable logistic regression analysis.ResultsOur cohort comprised 472 severely wasted children and the majority (82.8%) were stunted. Age groups of 12–23 mo (adjusted OR [AOR]=2.38, 95% CI 1.26 to 4.48) and 24–35 mo (AOR=7.81, 95% CI 1.99 to 30.67), male gender (AOR=2.51, 95% CI 1.43 to 4.39) and attending the rural malnutrition clinic (AOR=3.08, 95% CI 1.64 to 5.79) were associated with a significantly increased probability of stunting.ConclusionsStunting prevalence is high among severely wasted children attending CMAM programmes in north-western Nigeria. Policymakers need to adapt these treatment programmes to also cater for stunting, taking into account practical programmatic realities such as available expertise and scarce resource allocation.

Community-Based Management of Acute Malnutrition in Infants Under 6 Months of Age

Abstract Objectives To examine the outcomes of acutely malnourished infants under 6 months (u6m) who could not be hospitalized or exclusively breastfed and were instead treated under the community management of acute malnutrition (CMAM) model using ready to use therapeutic food (RUTF) or a supplemental food. Methods The study was a retrospective chart review of 323 infants u6m with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) seen across 20 CMAM clinics in rural southern Malawi who could not be admitted to inpatient care, which is the established standard of care for acute malnutrition in infants u6m. Infants with SAM were given 175 kcal/kg/day of RUTF and those with MAM were given 75 kcal/kg/day RUTF or supplemental food, based on availability. Nutritional counseling was provided to the caregivers of all participants, and mothers were counseled about improved breastfeeding practices. Infants were reassessed every two weeks. Outcomes included successful nutritional recovery (achieving WHZ of ≥−2 without edema), failure to achieve recovery after 12 weeks, hospitalization, death, and loss to follow up. Demographic information was also collected. Continuous variables were compared using Student's t test. Categorical variables were compared using Fisher's exact test. Results 130 infants u6m with SAM and 193 with MAM were treated using the same CMAM model used in 6–59 month-old children. About 90% of children in both groups were breastfeeding. Mean duration of therapy was 31.5 days for SAM and 20.8 days for MAM. Recovery rates were high in both groups (SAM 75%; MAM 81%). Recovery rates and other outcomes were similar to older children who were being treated contemporaneously at the same sites in the context of randomized clinical trials. Conclusions When inpatient care is not possible, therapeutic and supplementary foods provided to infants u6m with acute malnutrition is a viable treatment option. Making this option available has the potential to massively scale up the number of infants treated, with acceptable recovery rates, and at a relatively low cost to the health care system. Funding Sources None.

Program and Caseload Implications of Adopting the Global MUAC Criteria for Community Management of Acute Malnutrition in Children Under 5 Years Old in Ethiopia

Abstract Objectives Ethiopia has been hesitant to shift to the global MUAC-based definitions for acute malnutrition given the two to four times potential increase in caseload suggested by several cross-sectional surveys. Thus, the objective of this study was to provide specific evidence on the caseload implications for Ethiopia of aligning with the WHO recommended criteria. Methods A cluster-randomized control study was conducted in four districts of Amhara and Oromia regions of Ethiopia in a total of 36 health posts (HPs). Districts and HPs were selected based on previous high case report. In each district, an equal numbers of HPs were randomly assigned to use either the global MUAC criteria of &amp;lt;11.5 cm for severe acute malnutrition (SAM) and the moderate acute malnutrition (MAM) criteria of ≥11.5cm to &amp;lt;12.5 cm (intervention) or the current Ethiopian criteria of &amp;lt;11 cm for SAM and ≥11 cm to &amp;lt;12 cm for MAM (control). All 6–59 mo children were screened regularly for 16 wks. Malnourished children were admitted to the study according to the criteria assigned to their HP. Results A total of 349 SAM and 986 MAM new cases were admitted during the 16 wk recruitment. Of the new SAM cases, 225 were in intervention and 124 were in control HPs. The ratio of SAM in intervention compared to control HPs was 1.78 (1.14–2.42, 95%CI), which indicates an increase in admissions of 78% (P = 0.019). The mean (±SD) monthly SAM admissions per HPs were 1.71 (0.53) in control and 2.97 (3.31) in intervention (P = 0.191). For MAM, 592 cases were in intervention and 394 were in control for a ratio of 1.50 (1.11–1.89). The global MUAC criteria increased caseload by 50% (P = 0.015) compared to control. The mean monthly new MAM admissions per HPs were 5.47 (4.02) in control and 8.22 (3.28) in intervention (P = 0.045). The mean number of children served during biweekly combined sessions for SAM and MAM was 19.67 (9.28) in intervention and 13.08 (8.28) in control (P = 0.026). For sessions restricted to SAM, a mean of 4.26 (4.11) was served in intervention and 1.92 (1.88) in control (P = 0.028). Conclusions The increases in cases and workload resulting from shifting from Ethiopia's current national SAM and MAM admission and discharge criteria to the WHO criteria are likely to be on a smaller scale than is usually claimed based on various cross-sectional surveys. Most HPs were not overwhelmed due to the shift. Funding Sources Bill and Melinda Gates Foundation.

Community-Based Management of Acute Malnutrition: An Effective Intervention for Under-Nutrition

Globally, Acute Malnutrition (AM) causes more than 50% of childhood mortality among children under five years of age. Before embracing the use of ready-to-use therapeutic foods, the management of AM was restricted to hospitals bases. However, the current availability of Ready to Use Therapeutic Food (RUTF) has enabled undernourished children to be treated in their communities. RUTF has proved to be highly effective in treating severely malnourished children and allows households to facilitate food intake without supervision from health care professionals. Recent evidence shows that Community Management of Acute Malnutrition (CMAM) is a cost-effective method in management and prevention of malnutrition with high impact on population health, especially in reducing childhood mortality attributed to severe acute malnutrition (SAM). The unique components and principles of CMAM enable early detection and treatment of AM, with high coverage rates. Despite the proven effectiveness of CMAM programs, CMAM still draws insufficient attention for global implementation, and thus the need to integrate CMAM as well as health education and promotion programs into national health systems.

Risk Factors Of Stunting Among Children Under 5 Years Of Age In The Eastern And Western Provinces Of Rwanda: Analysis Of Rwanda Demographic And Health Survey 2014/2015.

BackgroundStunting is one of the most public health burdens in Rwanda. Most deaths due to stunting are associated with inappropriate feeding practices that occur in the first 5 years of life. This study aimed at determining the risk factors for stunting in children under 5 years of age in the Eastern and Western provinces of Rwanda.MethodCross-sectional study using secondary data from Rwanda Demographic Health Survey 2014/2015.ResultsStunting was highly prevalent in eastern province compared to Western province. It was also highly prevalent in rural area in both provinces. Results indicated a significant association between maternal education and stunting (n{x^2}n=6.868; p=0.001), maternal age group (n{x^2}n=15.44; p=0.017), maternal occupation (n{x^2}n=30.012; p=0.000), wealth index (n{x^2}n=14.327; p=0.006), sex of child (n{x^2}n=2.91; p=0.008) and giving child fortified food (n{x^2}n=4.256; p=0.039). Results indicated that antenatal care visits were significantly associated with stunting (n{x^2}n=6.653; p=0.01). Sharing a toilet was significantly associated with stunting (n{x^2}n=25.88; p=0.000). Multiple logistic regression indicated that the gender of child [OR=1.08; 95% CI (1.057–1.093), p=0.008], household wealth index [OR=0.386; 95% CI (0.357–0.414)] and breastfeeding [OR=0.02; 95% CI (0.004–0.036), p=0.013] were the risk factors of stunting in eastern and western provinces.ConclusionImmediate and appropriate interventions targeted at community management of acute malnutrition and stunting are needed to manage the associated morbidity and mortality. Strengthening the health system for improving child health through prioritizing maternal and child by addressing poverty and increase food access is mostly needed. These tactics yield more sustainable improvement in child nutrition within Eastern and Western provinces.

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.

Risk Factors for Stunting Among Children Under Five Years of Age in the Eastern and Western Provinces of Rwanda: Analysis of Rwanda Demographic and Health Survey 2014/2015

Background: Stunting remains one of the most common predictors of morbidity and mortality throughout low- and middle- income counties. Most deaths due to stunting are associated with inappropriate feeding practices that occur in the first five years of life. This study aimed to compare the risk factors for stunting in children under five years of age in the Eastern and Western provinces of Rwanda. Method: A cross-sectional study using secondary data from the Rwanda Demographic Health Survey (RDHS) 2014/2015. Results: Results indicated a significant association between maternal education and stunting (x^2=6.868; p=0.001), maternal age group (x^2=15.44; p=0.017), maternal occupation (x^2=30.012; p=0.000), wealth index (x^2=14.327; p=0.006), sex of child (x^2=2.91; p=0.008) and giving child fortified food (x^2=4.256; p=0.039). Sharing a toilet was found to be significant at (x^2=25.88; p=0.000). The multivariate analysis indicated the associated risk factors for stunting included sex (OR=1.08; p=0.008; 95% CI: 1.057-1.093 for males compared to females under five years), wealth index (OR=0.386(95% CI: 0.357-0.414) for the richest compared to the poorest) and breastfeeding (OR=0.02; p=0.013; 95%CI: 0.004-0.036) for breastfed compared to non-breastfed children). Discussion: Maternal occupation and education, child's sex, family size, giving the child food in the three first days, type of cooking, access to electricity, residence, anemia level, diarrhea in 2 weeks before survey, marital status, wealth index, breastfeeding, who the child lives with and giving fortified food to the child were the associated risk factors of stunting. Sharing toilet facilities, sex of child, and religion were the risk determinants of stunting in the Eastern and Western Provinces of Rwanda. Conclusion: Immediate and appropriate interventions targeted at community management of acute malnutrition and stunting are needed to manage the associated morbidity and mortality. Funding: In this research, we don't have any funding from anywhere else or anyone else .It is only research interest on researchers themselves. Declaration of Interest: In this study, there is no competing interest. It is only scientific interest of research to evaluate the stunting in these provinces in Rwanda Ethical Approval: We used second data from Rwanda Demographic Health survey conducted 2014/2015. We did not meet with participants. Here, data collection had been approved by Rwanda National Ethics Committee before data collection.

Nutritional and morbidity outcomes of children managed for severe acute malnutrition in Jigawa State, Nigeria

Introduction: The community-based approach to the management of severe acute malnutrition (SAM) is a cost effective and scientifically sound method of mitigating the soaring burden of under-five malnutrition in resource constrained countries. However, since the adoption of this novel intervention in Nigeria, local studies that have evaluated its overall effectiveness are sparse. Methodology: This longitudinal observational study was designed to assess at discharge, the nutritional status, as well as the nutritional related co-morbidities of 494 children enrolled into the Community Management of Acute Malnutrition (CMAM) programme. It is part of an impact evaluation study. The parameters evaluated at enrolment and at discharge included the anthropometry, presence of common morbidities and immunization status. Data were captured electronically with the aid of CSPro software. The study was carried out across 10 randomly selected CMAM clinics in Jigawa state, North West Nigeria. Result: Out of the 494 malnourished children recruited, 410 were discharged, the remaining were reported as absconded or died, with an average duration of stay of 7.3±1.6 weeks in the clinics, and a discharge cure rate of 63.4%. There was improvement in the mean weight (6.0kg at enrolment vs 7.3kg at discharge, p=0.000), mean occipito-frontal circumference (44.1cm at enrolment vs 45.3cm at discharge, p=0.000) and Weight-for-Height z score (-2.65 at enrolment vs 0.75 at discharge, p=0.000 ). A significant discordance in the nutritional outcome at discharge, as assessed independently by Mid Upper Arm Circumference (MUAC) and Weight-for-Height z score (WHZ), was documented; 9% and 28% still had SAM at discharge based on MUAC and WHZ respectively (p=0.000). The burden of nutritional related morbidities (diarrhoea dysentery, refusal to eat) reduced significantly at discharge (p=0.000) while immunization coverage increased by 7%. Conclusion: The CMAM programme in Jigawa, Nigeria has undoubtedly yielded positive outcomes. However, proactive measures should be taken to achieve the Sphere standards recommended minimum discharge cure rate. This may be achieved by ensuring that health care workers continually adhere to the guiding principles of CMAM. There is also a need for introduction of HIV and tuberculosis screening as non-responders maybe infected by any of these diseases.

Community management of acute malnutrition (CMAM) programme in Pakistan effectively treats children with uncomplicated severe wasting.

Severe wasting is the most widespread form of severe acute malnutrition, affecting an estimated 17 million children globally. This analysis assesses the effectiveness of Pakistan's community management of acute malnutrition (CMAM) programme. We conducted a retrospective case series analysis of 32,458 children aged 6–59 months who were admitted to the programme with a mid‐upper arm circumference (MUAC) < 115 mm (January 1–December 31, 2014). We found that at admission, 59.6% of the children were girls and 87.4% were in the age group 6–23 months old. While in the programme, 120 children (0.4%) died, 3,456 (10.6%) defaulted, and 28,882 (89.0%) were discharged after a mean length of stay of 69.3 ± 25.7 days. Children's mean weight gain while in the programme was 3.2 ± 2.7 g/kg body weight/day. At discharge, 28,499 children (98.7% of discharged) had recovered (MUAC ≥ 125 mm). The odds of death were significantly higher among children with weight‐for‐height (WHZ) < −3 and/or height‐for‐age (HAZ) < −2 at admission. The odds of recovery on the basis of MUAC ≥125 mm were higher among children with HAZ ≥ −2 at admission. The odds of recovery on the basis of WHZ ≥ −2 were significantly higher among children with WHZ ≥ −3 and/or HAZ < −2 at admission. Pakistan's CMAM programme is effective in achieving good survival and recovery rates. Population‐level impact could be increased by giving priority to children 6–23 months old and children with multiple anthropometric failure and by scaling up CMAM in the provinces and areas where the risk, prevalence, and/or burden of severe acute malnutrition is highest.