Management Of Severe Acute Malnutrition Research Articles

A narrative review of efficacy of antibiotics in treatment of children with severe acute malnutrition in community based out-patient treatment.

The World Health Organisation (WHO) updated guidelines on the management of severe acute malnutrition in infants and children (2013) recommends antibiotic treatment of uncomplicated severe acute malnutrition (SAM) in the community setting. As community-based treatment is gaining ground, this evidence review looks at the emerging data to improve the decision-making process. The databases of Pubmed, Google Scholar, Cochrane Database of Systematic Review were searched for experimental and observational studies in the English literature for the period of 2011-2021. The search identified seven studies: two interventional and five observational. Six of these studies showed significant improvement in recovery rates using weight for height Z-score-2. Emerging evidence supports the continuation of antibiotic treatment for uncomplicated SAM in out-patient settings, as recommended in the WHO guideline of 2013.

Ready to use therapeutic food (RUTF) for outpatient-based nutritional rehabilitation of severe acute malnutrition in children aged 6-59 months.

Background:Severe acute malnutrition (SAM) affects nearly 20 million preschool-age children. Malnutrition is a risk factor in approximately one third of deaths in children who are under 5 years of age worldwide. In-hospital rehabilitation of children with SAM is not always desirable or practical , and home-based care can offer a better solution. Ready-to-use therapeutic food (RUTF) is a widely used option for home-based rehabilitation in children without medical complications and with good appetite. Aim of the Study: To assess the effectiveness of standard RUTF (plumpy nut) in outpatient management of SAM in children aged 6-59 months without medical complications and with good appetite. Type of the study:Cohort, prospective interventional study.Patients & Methods: A cohort prospective interventional study was carried out among children ages 6-59 months with SAM who were referred to nutritional rehabilitation ward in two hospitals in Baghdad , a Central Teaching Hospital for Pediatrics in Al-kurkh district and Fatima Al-Zahraa hospital for Obstetrics & Pediatrics in Al- Russafa district in an attempt to evaluate the acceptability and effectiveness of standard RUTF in outpatient management .

Evaluating the coverage and quality of nutrition programs via a bottom-up approach: A secondary analysis of real-time data from an end-user monitoring system in Ethiopia.

Over the last two decades, great efforts and investments have been made in Ethiopia to ensure that all children have equal access to nutrition services in health facilities. While quality health systems are a prerequisite for quality nutrition services, little attention has been given to the evaluation of the supply and delivery services. The purpose of the study was to evaluate the coverage and quality of the nutrition-specific interventions delivered through the health system. Using an end-user monitoring (EUM) system, we monitored the delivery of nutrition-specific interventions in 500 districts,having 2514 health facilities distributed throughout Ethiopia. Data were collected through third-party monitors between August 2020 and 2021. Roughly 90% of health facilities were performing severe acute malnutrition management in line with the national guideline/protocol, and 2/3 of the assessed facilities were delivering iron and folic acid, vitamin A supplementationand deworming. A third of the messages on AMIYCN were retained by beneficiaries. Warehouse conditions were good in 64.3% of the facilities, but only 22% had good recording practices and about half had problems related to the quality and availability of nutrition supplies. Most beneficiaries were satisfied with the nutrition supplies and service delivered at the health facility level. This study also suggests the relevance of an EUM system to assess the quality of nutrition service delivery and its related supply management, as well as to improve the implementation of nutrition interventions as a decision-making tool.

Time to recovery and its predictors among children aged 6\u201359\u2009months with severe acute malnutrition admitted to outpatient therapeutic program in Southwest Ethiopia: retrospective cohort study

BackgroundOutpatient therapeutic program (OTP) brings the services for the management of Severe Acute Malnutrition (SAM) closer to the community by making services available at decentralized treatment points within the primary health care setting. Despite the available interventions to tackle nutritional problems, there is scarce information on time to recovery and its predictors. Therefore, the aim of this study was to estimate time to recovery and identify its predictors among children aged 6–59 month with SAM admitted to OTP in Bench Sheko zone Southwest Ethiopia.MethodsA retrospective cohort study was conducted on 588 children who had been managed for SAM under OTP, from September 01, 2018, to August 30, 2019, in 4 public health centers in Bench Sheko zone. A total of 1301 children’s card were eligible from them 588 children’s cards were selected by simple random sampling methods. Data was entered into EPI- data version 4.4.2 and exported to SPSS version 20 for analysis. Kaplan Meir estimate median time to recovery and survival curve was used to compare the time to recovery using a log-rank test among different characteristics. Cox Proportional Hazard Model was used to identify significant predictors of time to recovery. Association was summarized by using adjusted hazard ratio (AHR) and statistical significance was declared at 95% CI, and P-value < 0.05.ResultRecovery rate was 54.4% with the median recovery time 49 days with an Interquartile range of 21 days. The independent predictors of nutritional recovery time were: newly admitted (AHR = 1.52, 95% CI: 1.17, 2.98),had no diarrhea (AHR = 1.9, 95% CI: 1.52, 2.42), had no cough (AHR = 1.4, 95% CI: 1.13, 1.74) had no blood stool (AHR = 1.55, 95% CI: 1.14, 2.10) had no malaria (AHR = 1.75, 95% CI: 1.32, 2.32), and took deworming (AHR = 1.4, 95% CI: 1.01–1.61).Conclusion and recommendationIn the current study recovery rate and the median time of recovery is by far below the standard. Cough, diarrhea, malaria, deworming and admission status were independently associated with recovery time. Health professionals should give attention for early detection and management of co-morbidities. Minster of health should give refreshment community based management of acute malnutrition training for health workers to follow the national guideline strictly.

Risk of community- and hospital-acquired bacteremia and profile of antibiotic resistance in children hospitalized with severe acute malnutrition in Niger

ObjectiveTo estimate the prevalence and antibiotic resistance profile of community- and hospital-acquired bacteremia among hospitalized children with severe acute malnutrition in Niger. MethodsA descriptive, longitudinal study was conducted in an intensive nutritional rehabilitation center in Madarounfa, Niger. Children aged 6 to 59 months admitted for inpatient treatment of complicated severe acute malnutrition (n=2187) had blood specimens drawn at admission to assess prevalence of community-acquired bacteremia. Subsequent specimens were drawn per physician discretion to assess incidence of hospital-acquired bacteremia. Antibiotic susceptibility testing was performed on positive blood cultures. ResultsThe prevalence of community-acquired bacteremia at admission was at least 9.1% (95% confidence interval [CI]: 8.1, 10.4%), with non-typhoid Salmonella identified in over half (57.8%) of cases. The cumulative incidence of hospital-acquired bacteremia was estimated at 1.2% (95% CI: 0.8, 1.7%), among which the most common organisms were Klebsiella pneumoniae (19.4%), Acinetobacter baumannii (16.1%), Enterococcus faecalis (12.9%), and Escherichia coli (12.9%). In community-acquired bacteremia, 58% cases were resistant to amoxicillin-clavulanate; 100% of hospital-acquired bacteremia cases were resistant to amoxicillin and amoxicillin-clavulanate. Mortality risk was elevated among children with hospital-acquired bacteremia (risk ratio [RR] = 9.32) and community-acquired bacteremia (RR = 2.67). ConclusionBacteremia was a significant contributor to mortality. Antibiotic resistance poses a challenge to effective clinical management of severe acute malnutrition.

Scaling Up Improved Inpatient Treatment of Severe Malnutrition: Key Factors and Experiences From South Africa, Bolivia, Malawi, and Ghana.

Severe acute malnutrition (SAM) can have high mortality, especially in very ill children treated in the hospital. Many medical and nursing schools do not adequately, if at all, teach how to manage children with SAM. There is a dearth of experienced practitioners and trainers to serve as exemplars of good practice or participate in capacity development. We consider 4 country studies of scaling up implementation of WHO guidelines for improving the inpatient management of SAM within under-resourced public sector health services in South Africa, Bolivia, Malawi, and Ghana. Drawing on implementation reports, qualitative and quantitative data from our research, prospective and retrospective data collection, self-reflection, and our shared experiences, we review our capacity-building approaches for improving quality of care, implementation effectiveness, and lessons learned. These country studies provide important evidence that improved inpatient management of SAM is scalable in routine health services and scalability is achievable within different contexts and health systems. Effectiveness in reducing inpatient SAM deaths appears to be retained at scale.The country studies show evidence of impact on mortality early in the implementation and scaling-up process. However, it took many years to build workforce capacity, establish monitoring and mentoring procedures, and institutionalize the guidelines within health systems. Key features for success included collaborations to build capacity and undertake operational research and advocacy for guideline adoption; specialist teams to mentor and build confidence and competency through supportive supervision; and political commitment and administrative policies for sustainability. For frontline staff to be confident in their ability to deliver appropriate care competently, an enabling environment and supportive policies and processes are needed at all levels of the health system.

Effectiveness of a monthly schedule of follow-up for the treatment of uncomplicated severe acute malnutrition in Sokoto, Nigeria: A cluster randomized crossover trial.

BackgroundCommunity-based management of severe acute malnutrition (SAM) involves weekly or biweekly outpatient clinic visits for clinical surveillance and distribution of therapeutic foods. Distance to outpatient clinics and high opportunity costs for caregivers can represent major barriers to access. Reducing the frequency of outpatient visits while providing training to caregivers to recognize clinical danger signs at home between outpatient visits may increase acceptability, coverage, and public health impact of SAM treatment. We investigated the effectiveness of monthly clinic visits compared to the standard weekly follow-up in the outpatient treatment of uncomplicated SAM in northwestern Nigeria.Methods and findingsWe conducted a cluster randomized crossover trial to test the noninferiority of nutritional recovery in children with uncomplicated SAM receiving monthly follow-up compared to the standard weekly schedule. From January 2018 to November 2019, 3,945 children aged 6 to 59 months were enrolled at 10 health centers (5 assigned to monthly follow-up and 5 assigned to weekly follow-up) in Sokoto, Nigeria. In total, 96% of children (n = 1,976 in the monthly follow-up group and 1,802 in the weekly follow-up group) were followed until program discharge, and 91% (n = 1,873 in the monthly follow-up group and 1,721 in the weekly follow-up group) were followed to 3 months postdischarge. The mean age at admission was 15.8 months (standard deviation [SD] 7.1), 2,097/3,945 (53.2%) were girls, and the mean midupper arm circumference (MUAC) at admission was 105.8 mm (SD 6.0). In a modified intention-to-treat analysis, the primary outcome of nutritional recovery, defined as having MUAC ≥125 mm on 2 consecutive visits, was analyzed using generalized linear models, with generalized estimating equations to account for clustering. Nutritional recovery was lower in the monthly follow-up group compared to the weekly group (1,036/1,976, 52.4% versus 1,059/1,802, 58.8%; risk difference: −6.8%), and noninferiority was not demonstrated (lower bound of the confidence interval [CI] was −11.5%, lower than the noninferiority margin of 10%). The proportion of children defaulting was lower in the monthly group than in the weekly group (109/1,976, 5.5% versus 151/1,802, 8.4%, p = 0.03). Three months postdischarge, children in the monthly group were less likely to relapse compared to those in the weekly group (58/976, 5.9% versus 78/1,005, 7.8%, p = 0.03), but cumulative mortality at 3 months postdischarge was higher in the monthly group (159/1,873, 8.5% versus 106/1,721, 6.2%, p < 0.001). Study results may depend on context-specific factors including baseline level of care and the clinical status of children presenting to health centers, and, thus, generalizability of these results may be limited.ConclusionsWhere feasible, a weekly schedule of clinic visits should be preferred to maintain effectiveness of SAM treatment. Where geographic coverage of programs is low or frequent travel to outpatient clinics is difficult or impossible, a monthly schedule of visits may provide an alternative model to deliver treatment to those in need. Modifications to the outpatient follow-up schedule, for example, weekly clinic visits until initial weight gain has been achieved followed by monthly visits, could increase the effectiveness of the model and add flexibility for program delivery.Trial registrationClinicalTrials.gov NCT03140904.

Nutritional, antioxidant and organoleptic properties of therapeutic-complementary-food formulated from locally available food materials for severe acute malnutrition management

BackgroundThe prevalence of severe acute malnutrition among children (< 5 years) due to low energy-protein density of local complementary foods and poor feeding practices is a great concern in developing countries, Nigeria inclusive. Hence, the aimed of this study was to formulate and evaluate the chemical composition, functional, antioxidant and organoleptic properties of low-cost complementary foods from locally accessible food material using household technologies. Using UNCEF guidelines, three complementary foods were formulated and their nutritional characteristics were compared with local complementary food (100% sorghum) and ready-to-using therapeutic food.ResultsProtein (g/100 g) and energy values (kcal./100 g) of formulated complementary foods varied from 16.16 to 16.93 and 418.08 to 474.13, respectively, and were significantly (p < 0.05) higher than OG (7.72; 378.71) (a 100% sorghum flour), but lower than P0 (539.8) (a read-to-eat therapeutic food). Mineral elements (mg/100 g) in the food samples were K (4175–6350.5), Ca (341.5–949), Fe (23.5–50.5) Zn (28–38.5), P (3855.6–4501), and Na (343.5–950.5), and were significantly lower than in P0, but higher in K, Fe and Zn than for OG. Sodium/Potassium and Calcium/Phosphorous molar ratios of the complementary foods ranged from 0.16 to 0.92 and 0.07 to 0.16 and were lower than P0 (0.64, 0.19) and OG (1.71, 0.2), respectively. Total essential amino acids (g/100 g protein) of the food samples varied from 23.53 to 25.94, and were comparable to OG (28.40) and P0 (32.74). Predicted biological value and essential amino acid index of P2 sample (53.53%, 59.85%) had the highest values, while P1 (46.0%, 52.94%) had the lowest, and these values were comparatively lower than P0 (67.53%, 72.69%), OG (55.91%, 62.03%), and recommended value (> 70%). Functional properties varied from 0.61 to 0.83, 124.2 to 176.2, 102.2 to 257.19, 0 to 1 and 164.7 to 373.3 for bulk density, oil absorption capacity, water absorption capacity, least gelation and swelling capacity, respectively. Antioxidant activity of formulated complementary foods ranged from 2.07 to 3.24%, 8.61 to 9.87 mg/g, 21.6 to 40.95% and 62.42 to 87.0% for DPPH, FRAP, Fe-chelation and OH-free radicals, respectively, and were significantly (p < 0.05) higher than in OG and PO. Sample P1 was significantly (p < 0.05) rated highest in appearance, aroma, taste, texture and overall acceptability above P2 and P3.ConclusionThe formulated complementary foods had enough nutrient and energy values to meet the requirements for infants as recommended for complementary foods and for amelioration of severe acute malnutrition in children. Nutritional and sensory evaluation revealed that addition of full fat milk to the P1 sample significantly improved its nutrient composition and organoleptic quality and contributed to its high acceptance compared to other formulations. Therefore, this complementary food is potentially suitable for use as complementary food and diet to manage severe acute malnutrition in Nigeria and other developing countries. However, there is a need for biological evaluation.

Nutritional and hematological profile of children with severe acute malnutrition rehabilitated with or without vitamin B12

Background: Aim of the study was to study the effect of vitamin B12 supplementation in children with severe acute malnutrition (SAM).Methods: A total of 100 children were enrolled in the study in two different time frames. Group A consisted of 50 children with SAM enrolled from November 2016 to May 2017 and managed as per existing national protocol for facility-based SAM management while group B consisted of 50 children enrolled from June 2017 to Dec 2017 who were tested for vitamin B12 deficiency on admission and supplemented with vitamin B12 in presence of vitamin B12 deficiency hematological and anthropometric parameters of both groups were compared at 12 weeks of rehabilitation. Results: At 12±1 weeks, 38% children from group A and 24% from group B were still anemic (p=0.13). No one from either group had folic acid deficiency while deficiency of vitamin B12 was present in 14% and 6% cases in group A and group B respectively (p&gt;0.05). Mean weight gain at 12±1 weeks, in group A and non-supplemented sub-group of group B was comparable (p&gt;0.59). However, mean weight gain in supplemented sub-group of group B was significantly higher compared to group A (p&gt;0.05) and non-supplemented sub-group of group B (p&lt;0.05).Conclusions: Significant number of SAM children remain anemic when treated with current guidelines. Additional vitamin B12 supplementation in vitamin B12 deficient group showed improvement in weight gain among SAM children.

CLINICAL PROFILE AND OUTCOME OF CHILDREN WITH SEVERE ACUTE MALNUTRITION ADMITTED AT NUTRITIONAL REHABILITATION CENTER OF MCCH-ASSOCIATED HOSPITAL OF GMC-ANANTNAG

Objectives: The objectives of this study were to study the clinical profile and outcome of children Admitted in NRC of MCCH-associated hospital of GMC-Anantnag. Methods: Children in the age group of 1 month-5 years, admitted to NRC of our hospital between April 2019 and May 2022 with severe acute malnutrition (SAM) were enrolled for the study. As per a predesigned pro forma, a detailed history was taken from mothers or caregivers and nutritional status assessment using standard anthropometric methods was performed. Classification of malnutrition was made according to the WHO guidelines. Anthropometric measurements including weight in kg and length/height in cm, weight for height, Z score, mid-upper arm circumference, and presence of edema were used to classify the grades of malnutrition. After basic workup and starting nutrition rehabilitation, serial weight gain was recorded. Outcome of patients (home discharge, referral to higher center, and death) was recorded and analyzed. Results: A total of 306 children with SAM admitted to NRC of our hospital were enrolled for the study. Majority were of 7–12 months of age (n=93; 30.4%), of female gender (n=178; 58.2%), were from nuclear families and from families with spacing between two children &lt;2 years. SAM was more among children of illiterate and unskilled parents and of parents in the lower and upper lower socioeconomic status (288, 94%). Acute gastroenteritis (n=206; 67.32%) and acute respiratory tract infection (n=158; 51.6%) were most predominant comorbidities seen among hospitalized children. Hypoglycemia (n=183; 59.80%) and hypokalemia (n=56; 18.30%) were most common metabolic derangements. Among the admitted children 119 (38.88%) had good weight gain (10 mg/kg/day), 136 (44.44%) had moderate weight gain (5-10gm/kg/day) and 51 (16.66%) had poor weight gain (&lt;5 g/kg/day). Out of 306 children admitted, 276 (91%) children were discharged after successful rehabilitation and 27 (9%) were transferred to higher center. No death was documented among SAM children during the study period. Conclusion: Malnutrition in under five children is high and multi-factorial. Hospital-based management of SAM is an important step in reducing the morbidity and mortality among such children.

Effect of nutritional intervention on anthropometric measurements of malnourished children at Nutritional Rehabilitation Center, Civil Hospital Ahmedabad under "Mission Balam Sukham" scheme.

Context:In Gujarat, 39.7% of children are underweight and 10.6% are severely wasted in under five years of age. Nutritional rehabilitation centers started by the Government of Gujarat under the “Mission Balam Sukham” program focused at providing an energy-dense diet and protein along with other nutrients to combat malnutrition in children by hospital admission.Aim:To estimate the effect of nutritional intervention on Anthropometric measurements of malnourished children at Nutritional Rehabilitation Center (NRC), Civil Hospital, Ahmedabad.Settings and Design:A hospital-based cross-sectional study was conducted at the NRC of B. J. Medical College, Civil Hospital, Ahmedabad, Gujarat.Methods and Material:It was a hospital-based cross-sectional study conducted at NRC, Civil Hospital, Ahmedabad from January 2017 till December 2017 (1-year duration). A total of 159 children, 0–5 years were admitted in NRC during this period and observed during their stay with three follow-up visits.Statistical Analysis Used:Z-test, one-way ANOVA on repeated measures test.Results:The majority of the admitted children were in the age group of 12–23 months. Overall mean weight at admission was 6.1 ± 1.7 Kg. The increase in mean weight at discharge was 6.5 ± 1.9 Kg. The mean weight on the third follow-up was 7.4 ± 1.9 Kg. Nearly 62.3% of severely malnourished children had improvement (cured) after treatment that was given during NRC admission.Conclusions:The present study confirmed the effectiveness of nutrition rehabilitation centers in the management of severe acute malnutrition.

Recovery of children following hospitalisation for complicated severe acute malnutrition

Nutritional recovery and hospital readmission following inpatient management of complicated severe acute malnutrition (SAM) are poorly characterised. We aimed to ascertain patterns and factors associated with hospital readmission, nutritional recovery and morbidity, in children discharged from hospital following management of complicated SAM in Zambia and Zimbabwe over 52‐weeks posthospitalization. Multivariable Fine‐Gray subdistribution hazard models, with death and loss to follow‐up as competing risks, were used to identify factors associated with hospital readmission; negative binomial regression to assess time to hospitalisation and ordinal logistic regression to model factors associated with nutritional recovery. A total of 649 children (53% male, median age 18.2 months) were discharged to continue community nutritional rehabilitation. All‐cause hospital readmission was 15.4% (95% CI 12.7, 18.6) over 52 weeks. Independent risk factors for time to readmission were cerebral palsy (adjusted subhazard ratio (aSHR): 2.96, 95% CI 1.56, 5.61) and nonoedematous SAM (aSHR: 1.64, 95%CI 1.03, 2.64). Unit increases in height‐for‐age Z‐score (HAZ) (aSHR: 0.82, 95% CI 0.71, 0.95) and enrolment in Zambia (aSHR: 0.52, 95% CI 0.28, 0.97) were associated with reduced subhazard of time to readmission. Young age, SAM at discharge, nonoedematous SAM and cerebral palsy were associated with poor nutritional recovery throughout follow‐up. Collectively, nonoedematous SAM, ongoing SAM at discharge, cerebral palsy and low HAZ are independent risk factors for readmission and poor nutritional recovery following complicated SAM. Children with these high‐risk features should be prioritised for additional convalescent care to improve long‐term outcomes.

Determinants of mortality\xa0among under-five children admitted with severe acute malnutrition in Addis Ababa, Ethiopia

BackgroundManagement of severe acute malnutrition (SAM) has been a program priority in Ethiopia, but it remains the leading cause of mortality in under-five children. Hence, this study aimed to identify the incidence density rate of mortality and determinants among under-five children with severe acute malnutrition in St. Paul’s Hospital Millennium Medical College, 2012 to 2019.MethodsA retrospective cohort study was conducted and data were collected using a structured checklist from 673 charts, of which 610 charts were included in the final analysis. The Kaplan-Meier survival curve with Log-rank test was used to estimate the survival time. Bi-variable and multi-variable Cox proportional hazard regression models were fitted to identify determinants of death. Schoenfeld residuals test was used to check a proportional hazard assumption. Goodness of fit of the final model was checked using Nelson Aalen cumulative hazard function against Cox-Snell residual.ResultsIn this study, 61 (10%) children died making the incidence density rate of death 5.6 (95% CI: 4.4, 7.2) per 1000 child-days. Shock (Adjusted Hazard Ratio) [AHR] =3.2; 95% CI: 1.6, 6.3)), IV fluid infusion (AHR = 5.2; 95% CI: 2.4, 10.4), supplementing F100 (AHR = 0.12; 95%CI: 0.06, 0.23) and zinc (AHR = 0.45; 95% CI: 0.22, 0.93) were determinants of death.ConclusionThe overall proportion of deaths was within the range put forth by the Sphere standard and the national SAM management protocol. Shock and IV fluid infusion increased the hazard of death, whereas F100 & zinc were found to decrease the likelihood death. Children with SAM presented with shock should be handled carefully and IV fluids should be given with precautions.

Optimal design for a psychosocial intervention on severely acute malnourished children in humanitarian settings: results of an expert survey

Background: Common psychosocial interventions focus on feeding, stimulation, emotional responsiveness and childcare and parenting. Inclusion of such a component in the outpatient management of severe acute malnutrition (SAM) children is recommended. However, clinical assessment of such interventions is tedious in humanitarian settings and modalities evidence on the impact of psychosocial interventions alongside nutrition protocol for SAM is scarce. This survey aimed to gather expert opinions on the optimal design of a combined psychosocial and nutrition intervention feasible in humanitarian settings. Methods: From March to May 2018, an online survey was emailed to international experts in nutrition and mental health and psychosocial support, mainly from academia and international non-governmental organisations (INGOs). It included multiple choices questions on the key components of an optimal combined intervention. Results: Of the 76 experts targeted, 20 responded. 11 (55%) belonged to INGOs, 2 (10%) to academia, and 4 (20%) to international organizations and donors. For most respondents, a combined intervention should be provided in weekly 45-minuites counselling sessions, provided individually (rather than in a group) and at home (rather than at a health center). None of the proposed ideal duration (two, four or six months) gained the majority of votes. Experts thought that 35% staff training should be in “Active listening for psychosocial support”, and 30% in “Early child development”, 25% in “Maternal depression” and 9% in “Anthropometric measurements”. They estimated that a combined intervention could improve SAM recovery rate by 10% (min-max: 0-19%) vs. the nutritional protocol alone. Qualitative results highlighted the importance of tailoring the intervention to the individual, the population and the settings; as well as considering feasibility and scalability at the design stage. Conclusion: These findings could guide further research on the impact of psychosocial interventions on SAM children’s health and development, and help designing innovative approaches to treat undernutrition.

Serum Phosphate Profile of Children With Severe Acute Malnutrition Treated With Locally Prepared Therapeutic Feeds: A Prospective Observational Study

Background: Malnutrition in children &lt; 5 years is a public health concern due to its associated high morbidity, mortality and serious long-term consequences. The World Health Organization (WHO) recommends 10 steps for the management of severe acute malnutrition (SAM) children which also involves correction of electrolyte disturbances. Treatment with diets having inadequate amounts of minerals like phosphate can result in refeeding syndrome and other abnormalities. We conducted the study among children with medically complicated SAM to evaluate their serum phosphate levels after receiving locally prepared therapeutic feeds and its associations of other factors. Methods: The study was conducted with 120 hospitalized SAM children aged 6 - 59 months with presence of other illnesses. All children were managed according to the WHO protocol and facility-based management of SAM guidelines of the government of India. Basic demographic details of the child were recorded. Weight of the child was recorded daily, while length/height and mid-upper arm circumference (MUAC) were recorded weekly. We evaluated changes in serum phosphate levels at three time points: on admission, during transition and at discharge. Binary logistic regression analysis was conducted to assess the association of hypophosphatemia with several other indicators. Results: Mean serum phosphate was 4.38 ± 1.07, 4.48 ± 1.16 and 5.13 ± 1.10 mg/dL on admission, during transition and at discharge, respectively. Hypophosphatemia was present among 30 (25%) children on admission, 28 (23.3%) children during transition and 10 (8.3%) children at discharge, which showed a decrease in the prevalence of hypophosphatemia from admission to transition and discharge using the current treatment. The finding also showed positive and significant changes in serum phosphate levels among children who were admitted without edema compared to those admitted with edema. Binary logistic regression estimates showed that older children, children with lower WAZ, hypokalemia, hyponatremia and anemia had higher odds of hypophosphatemia. Male children had lower odds of hypophosphatemia. Conclusion: The nutritional therapy with locally prepared starter and catch-up diet was effective in normalizing hypophosphatemia in the majority of children treated. Serum potassium and serum sodium levels were significantly associated with serum phosphate, indicating the need for careful monitoring of serum phosphate in the presence of hypokalemia and hyponatremia among SAM children. Int J Clin Pediatr. 2021;10(2-3):35-42 doi: https://doi.org/10.14740/ijcp458

A feasibility study using mid-upper arm circumference as the sole anthropometric criterion for admission and discharge in the outpatient treatment for severe acute malnutrition

BackgroundThe World Health Organization recommends the use of a weight-for-height Z-score (WHZ) and/or mid-upper arm circumference (MUAC) as anthropometric criteria for the admission and discharge of young children for the community-based management of severe acute malnutrition. However, using MUAC as a single anthropometric criterion for admission and discharge in therapeutic nutritional programs may offer operational advantages to simplify admission processes at therapeutic nutritional centers and improve program coverage.MethodsThis pragmatic, non-randomized, intervention study compared a standard outpatient nutritional program (n = 824) for the treatment of uncomplicated severe acute malnutrition using WHZ < − 3 and/or MUAC< 115 mm and/or bipedal edema for admission and discharge to a program (n = 1019) using MUAC as the sole anthropometric criterion for admission (MUAC< 120 mm) and discharge (MUAC ≥125 mm at two consecutive visits) in the Tahoua Region of Niger.ResultsCompared to the standard program, the MUAC-only program discharged more children as recovered (70.1% vs. 51.6%; aOR 2.31, 95%CI 1.79–2.98) and fewer children as non-respondent or defaulters, based on respective program definitions. The risk of non-response was high in both programs. Three months post-discharge, children who were discharged after recovery in the MUAC-only program had lower WHZ and MUAC measures. Sixty-three children ineligible for the MUAC-only program but eligible for a standard program (MUAC ≥120 mm and WHZ < -3) were followed for twelve weeks and the anthropometric status of 69.8% of these children did not deteriorate (i.e. MUAC ≥120 mm) despite not immediately receiving treatment in the MUAC-only program.ConclusionsThe results from this study share the first operational experience of using MUAC as sole anthropometric criterion for admission and discharge in Niger and overall support the consideration for MUAC-only programming: the MUAC-only model of care was associated with a higher recovery and a lower defaulter rate than the standard program with very few children found to be excluded from treatment with an admission criterion of MUAC < 120 mm. Further consideration of the appropriate MUAC-based discharge criterion as it relates to an increased risk of non-response and adverse post-discharge outcomes would be prudent.

Severe acute malnutrition in low- and middle-income countries

<h2>Abstract</h2> Low- and middle-income countries bear the greatest burden of malnutrition, especially those in sub-Saharan Africa and Asia. Children are particularly vulnerable. This article provides an overview for healthcare professionals working with children, giving definitions and practical advice for intervention and management. Severe acute malnutrition (SAM) is diagnosed in under 5s with severe wasting ("marasmus") and/or nutritional oedema ("kwashiorkor"). Wasting is identified using weight-for-height and comparing the child's value with WHO reference data or by measurement of mid-upper arm circumference. SAM is thought to result from a complex interaction between infections and poor diet or feeding practices occurring in the context of multiple adverse social-economic factors, with poor sanitation and hygiene increasing exposure to infection. The clinical management of SAM depends on whether there are complications such as anorexia and infections. Children with uncomplicated SAM are best managed in community programmes using ready-to-use therapeutic food and with close monitoring. The management of complicated SAM requires in-patient care and presents a huge challenge especially in health facilities with limited resources. Management guided by the WHO "Ten Steps", which account for the reductive adaptation that occurs in malnutrition reduces case-fatality but this often remains high. Prevention of SAM requires addressing the multifactorial underlying causes associated with poverty and food insecurity. Addressing malnutrition in children is essential to achieving many of the UN Sustainable Development Goals.

Improving recognition and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi: a quality improvement initiative

ABSTRACT Background Severe acute malnutrition (SAM) is common in low-income countries and is associated with high mortality in young children. Objective To improve recognition and management of SAM in a tertiary hospital in Malawi. Methods The impact of multifaceted quality improvement interventions in process measures pertaining to the identification and management of SAM was assessed. Interventions included focused training for clinical staff, reporting process measures to staff, and mobile phone-based group messaging for enhanced communication. This initiative focused on children aged 6–36 months admitted to Kamuzu Central Hospital in Malawi from September 2019 to March 2020. Before-after comparisons were made with baseline data from the year before, and process measures within this intervention period which included three plan-do-study-act (PDSA) cycles were compared. Results During the intervention period, 418 children had SAM and in-hospital mortality was 10.8%, which was not significantly different from the baseline period. Compared with the baseline period, there was significant improvement in the documentation of full anthropometrics on admission, blood glucose test within 24 hours of admission and HIV testing results by discharge. During the intervention period, amidst increasing patient census with each PDSA cycle, three process measures were maintained (documentation of full anthropometrics, determination of nutritional status and HIV testing results), and there was significant improvement in blood glucose documentation. Conclusion Significant improvement in key quality measures represents early progress towards the larger goal of improving patient outcomes, most notably mortality, in children admitted with SAM.

Effect of topical applications of sunflower seed oil on systemic fatty acid levels in under-two children under rehabilitation for severe acute malnutrition in Bangladesh: a randomized controlled trial

BackgroundChildren with severe acute malnutrition (SAM) have inadequate levels of fatty acids (FAs) and limited capacity for enteral nutritional rehabilitation. We hypothesized that topical high-linoleate sunflower seed oil (SSO) would be effective adjunctive treatment for children with SAM.MethodsThis study tested a prespecified secondary endpoint of a randomized, controlled, unblinded clinical trial with 212 children with SAM aged 2 to 24 months in two strata (2 to < 6 months, 6 to 24 months in a 1:2 ratio) at Dhaka Hospital of icddr,b, Bangladesh between January 2016 and December 2017. All children received standard-of-care management of SAM. Children randomized to the emollient group also received whole-body applications of 3 g/kg SSO three times daily for 10 days. We applied difference-in-difference analysis and unsupervised clustering analysis using t-distributed stochastic neighbor embedding (t-SNE) to visualize changes in FA levels in blood from day 0 to day 10 of children with SAM treated with emollient compared to no-emollient.ResultsEmollient therapy led to systematically higher increases in 26 of 29 FAs over time compared to the control. These effects were driven primarily by changes in younger subjects (27 of 29 FAs). Several FAs, especially those most abundant in SSO showed high-magnitude but non-significant incremental increases from day 0 to day 10 in the emollient group vs. the no-emollient group; for linoleic acid, a 237 μg/mL increase was attributable to enteral feeding and an incremental 98 μg/mL increase (41%) was due to emollient therapy. Behenic acid (22:0), gamma-linolenic acid (18:3n6), and eicosapentaenoic acid (20:5n3) were significantly increased in the younger age stratum; minimal changes were seen in the older children.ConclusionsSSO therapy for SAM augmented the impact of enteral feeding in increasing levels of several FAs in young children. Further research is warranted into optimizing this novel approach for nutritional rehabilitation of children with SAM, especially those < 6 months.Trial registrationClinicalTrials.gov: NCT02616289.

Azithromycin for uncomplicated severe acute malnutrition: study protocol for a pilot randomized controlled trial

BackgroundGiven the high risk of infectious mortality among children with severe acute malnutrition (SAM), the World Health Organization recommends routine administration of a broad-spectrum antibiotic like amoxicillin as part of the management of uncomplicated SAM. However, evidence for the efficacy of amoxicillin to improve nutritional recovery or reduce mortality has been mixed. With a long half-life and evidence of efficacy to reduce mortality in high-risk populations, azithromycin is a potential alternative to amoxicillin in the management of SAM. In this pilot study, we aim to compare the efficacy of azithromycin to amoxicillin to improve nutritional outcomes in children with uncomplicated SAM.MethodsThis pilot randomized controlled trial will enroll 300 children with uncomplicated SAM from 6 Centre de Santé et de Promotion Sociale in the Boromo health district in Burkina Faso. Eligible children are randomized to receive a single directly observed dose of oral azithromycin or a 7-day course of oral amoxicillin in addition to the standard package of care for uncomplicated SAM. Enrolled children are followed weekly until nutritional recovery, and all children return for a final study visit at 8 weeks after enrollment. Anthropometric indicators, vital status, and clinical outcomes are monitored at each visit and compared by arm. Primary feasibility outcomes include enrollment potential, refusals, loss to follow-up, and completeness of data collection. The primary clinical outcome is weight gain (g/kg/day) over the 8-week study period.DiscussionThis pilot trial will establish the feasibility of conducting a full-scale randomized controlled trial to evaluate alternative antibiotics in this setting and provide preliminary evidence for the efficacy of azithromycin compared to amoxicillin to improve outcomes for children with SAM.Trial registrationThis trial was first registered on clinicaltrials.gov on 26 June 2018 (NCT03568643).