Improving screening for malnourished children at high risk of death: a study of children aged 6-59 months in rural Senegal

Effect of a simplified approach on recovery of children 6-59 months with wasting in Ethiopia: A noninferiority, cluster randomized controlled trial

Worldwide, nearly 45 million children under the age of 5 years were affected by wasting in 2022. Ethiopia has been challenged by disasters increasing the caseload of children with wasting. This study aimed to determine the effect of a simplified approach on recovery of children with acute malnutrition as compared with the standard protocol. A cluster randomized, controlled, noninferiority trial was carried out in three regions of Ethiopia from December 4, 2021, to July 30, 2022. A total of 58 clusters (health posts) were randomized into intervention and control groups. Children with SAM in the intervention groups received two sachets of Ready-to-Use Therapeutic Food (RUTF), whereas children in the control groups received RUTF based on their body weight. Children with moderate acute malnutrition (MAM) received one sachet of RUTF and one sachet of Ready-to-Use Supplementary Food (RUSF) daily in the intervention and control groups, respectively. Per protocol (PP) and intention-to-treat analysis were used to compare recovery at a noninferiority margin of 15%. Data were collected from 55 health posts and 1032 children. In the PP analysis, the recovery rate of children with wasting among the simplified group (97.8%) was noninferior to the standard protocol group (97.7%), p = 0.399. The RUTF cost per treatment of child with SAM was 56.55 USD for the standard versus 42.78 USD for the simplified approach. The simplified approach is noninferior to the standard protocol in terms of recovery and has a lower cost of RUTF. Further study is recommended to assess the effectiveness of the simplified approach in emergency contexts.

Neonatal anthropometric indicators of infant growth and mortality in Burkina Faso

OBJECTIVE

Most evidence supporting screening for undernutrition is for children aged 6-59 months. However, the highest risk of mortality and highest incidence of wasting occurs in the first 6 months of life. We evaluated relationships between neonatal anthropometric indicators, including birth weight, weight-for-age Z-score (WAZ), weight-for-length Z-score (WLZ), length-for-age Z-score (LAZ) and mid-upper arm circumference (MUAC) and mortality and growth at 6 months of age among infants in Burkina Faso.

DESIGN

Data arose from a randomised controlled trial evaluating neonatal azithromycin administration for the prevention of child mortality. We evaluated relationships between baseline anthropometric measures and mortality, wasting (WLZ < -2), stunting (LAZ < -2) and underweight (WAZ < -2) at 6 months of age were estimated using logistic regression models adjusted for the child's age and sex.

SETTING

Five regions of Burkina Faso.

PARTICIPANTS

Infants aged 8-27 d followed until 6 months of age.

RESULTS

Of 21 832 infants enrolled in the trial, 7·9 % were low birth weight (<2500 g), 13·3 % were wasted, 7·7 % were stunted and 7·4 % were underweight at enrolment. All anthropometric deficits were associated with mortality by 6 months of age, with WAZ the strongest predictor (WAZ < -2 to ≥ -3 at enrolment v. WAZ ≥ -2: adjusted OR, 3·91, 95 % CI, 2·21, 6·56). Low WAZ was also associated with wasting, stunting, and underweight at 6 months.

CONCLUSIONS

Interventions for identifying infants at highest risk of mortality and growth failure should consider WAZ as part of their screening protocol.

Maternal and household factors affecting the dietary diversity of preschool children in eastern Ethiopia: a cross-sectional study

OBJECTIVE

Investigate the association between the dietary diversity of preschool children and proximate factors including household food insecurity, maternal food choice, preferences, khat use, and levels of depressive symptoms.

DESIGN

Cross-sectional survey of randomly selected households.

SETTING

Haramaya Health and Demographic Surveillance site in Eastern Ethiopia, predominantly smallholder farming households.

PARTICIPANTS

678 preschool children (24-59 months) and their mothers.

METHODS

The key outcome, the adequacy of dietary diversity of preschool children, was calculated using a 24-hour parental dietary recall. Binary logistic regression was then used to identify maternal and household factors associated with dietary adequacy versus inadequacy.

RESULTS

The majority (80.53%) of surveyed children had low dietary diversity (mean Dietary Diversity (MDD)) score of 3.06±1.70 on a 7-point scale). Approximately 80% of households exhibited food insecurity. Households with greater food security (adjusted OR (AOR)=1.96, 95% CI 1.19 to 3.23), healthier maternal food choice (AOR=2.19, 95% CI 1.12 to 4.31) and broader maternal food preferences (AOR=4.95, 95% CI 1.11 to 21.95) were all associated with higher dietary diversity of their preschool children (p≤0.05). Other covariates associated with adequate child dietary diversity included improved household drinking water sources (AOR=1.84, 95% CI 1.16 to 2.92) and family planning use (AOR=1.69, 95% CI 1.00 to 2.86). Despite predictions, however, maternal depression and khat consumption were not identified as factors.

CONCLUSIONS

The dietary diversity of preschool children is extremely low-a pattern observed in both food-secure and food-insecure households. Key factors include maternal selection of food for convenience and ease, preferences that do not include animal protein or healthier food choices, and lack of access to improved drinking water sources. Interventions around maternal food choice and preferences could improve preschool children's nutritional health.

Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm randomized controlled trial

BACKGROUND

Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol.

METHODS

This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ.

DISCUSSION

This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.

Multilevel analysis of trends and predictors of concurrent wasting and stunting among children 6-59 months in Ethiopia from 2000 to 2019

Introduction

Emerging evidence indicates that children can be concurrently wasted and stunted (WaSt), increasing their mortality risk. However, more is needed to know about WaSt in Ethiopia. Therefore, this study aimed to determine the trends and predictors of WaSt using Ethiopian Demographic and Health Survey datasets from 2000 and 2019.

Methods

The study included a total weighted sample of 34,930 children aged 6-59 months. Descriptive and weighted multilevel mixed-effects (fixed and random effects) logistic regression analyses were carried out. The Intraclass Correlation Coefficient (ICC) and the Median Odds Ratio (MOR) were calculated.

Results

The prevalence of WaSt was 1,682 (4.82%) with a significantly decreasing trend, yielding a percent change of -57.51% (-69.37% to -23.52%) from 2000 to 2019. In the adjusted model, the odds of WaSt increased in boys, children with a shorter preceding birth interval, small birth size, delayed initiation of complementary foods, diarrhea, fever, and anemia, mother's lack of formal education, and being a farmer, and poor/middle wealth index, and lack of mass media exposure. WaSt was inversely related to the child's age. Adjusted ICC and MOR were 31.16% and 3.20%, respectively.

Conclusion and recommendations

The study highlights the importance of considering individual and community-level factors to address WaSt, such as timely initiation of complementary foods, improving access to health services, quality diet, and prevention of communicable diseases. Furthermore, programs that have positive impacts on formal education and employment opportunities for girls, as well as that increase access to mass media, are required.

Post-Recovery Relapse of Children Treated with a Simplified, Combined Nutrition Treatment Protocol in Mali: A Prospective Cohort Study

The present study aimed to determine the 6-month incidence of relapse and associated factors among children who recovered from acute malnutrition (AM) following mid-upper arm circumference (MUAC)-based simplified combined treatment using the ComPAS protocol. A prospective cohort of 420 children who had reached a MUAC ≥ 125 mm for two consecutive measures was monitored between December 2020 and October 2021. Children were seen at home fortnightly for 6 months. The overall 6-month cumulative incidence of relapse [95%CI] into MUAC < 125 mm and/or edema was 26.1% [21.7; 30.8] and 1.7% [0.6; 3.6] to MUAC < 115 mm and/or edema. Relapse was similar among children initially admitted to treatment with a MUAC < 115 mm and/or oedema and among those with a MUAC ≥ 115 mm but <125 mm. Relapse was predicted by lower anthropometry both at admission to and discharge from treatment, and a higher number of illness episodes per month of follow-up. Having a vaccination card, using an improved water source, having agriculture as the main source of income, and increases in caregiver workload during follow-up all protected from relapse. Children discharged as recovered from AM remain at risk of relapsing into AM. To achieve reduction in relapse, recovery criteria may need to be revised and post-discharge strategies tested.

Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children

OBJECTIVE

To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children.

DESIGN

Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations.

SETTING

Community-based, prospective studies from twelve countries in Africa and Asia.

PARTICIPANTS

Children aged 6-59 months living in the study areas.

RESULTS

For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone.

CONCLUSIONS

Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.

Anthropometric criteria for best-identifying children at high risk of mortality: a pooled analysis of twelve cohorts

OBJECTIVE

To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme implications.

DESIGN

A multiple cohort individual data meta-analysis of mortality risk (within 6 months of measurement) by anthropometric case definitions. Sensitivity, specificity, informedness and inclusivity in predicting mortality, face validity and compatibility with current standards and practice were assessed and operational consequences were modelled.

SETTING

Community-based cohort studies in twelve low-income countries between 1977 and 2013 in settings where treatment of wasting was not widespread.

PARTICIPANTS

Children aged 6 to 59 months.

RESULTS

Of the twelve anthropometric case definitions examined, four (weight-for-age Z-score (WAZ) <-2), (mid-upper arm circumference (MUAC) <125 mm), (MUAC < 115 mm or WAZ < -3) and (WAZ < -3) had the highest informedness in predicting mortality. A combined case definition (MUAC < 115 mm or WAZ < -3) was better at predicting deaths associated with weight-for-height Z-score <-3 and concurrent wasting and stunting (WaSt) than the single WAZ < -3 case definition. After the assessment of all criteria, the combined case definition performed best. The simulated workload for programmes admitting based on MUAC < 115 mm or WAZ < -3, when adjusted with a proxy for required intensity and/or duration of treatment, was 1·87 times larger than programmes admitting on MUAC < 115 mm alone.

CONCLUSIONS

A combined case definition detects nearly all deaths associated with severe anthropometric deficits suggesting that therapeutic feeding programmes may achieve higher impact (prevent mortality and improve coverage) by using it. There remain operational questions to examine further before wide-scale adoption can be recommended.

Anthropometric deficits and the associated risk of death by age and sex in children aged 6-59 months: A meta-analysis

Risk of death from undernutrition is thought to be higher in younger than in older children, but evidence is mixed. Research also demonstrates sex differences whereby boys have a higher prevalence of undernutrition than girls. This analysis described mortality risk associated with anthropometric deficits (wasting, underweight and stunting) in children 6-59 months by age and sex. We categorised children into younger (6-23 months) and older (24-59 months) age groups. Age and sex variations in near-term (within 6 months) mortality risk, associated with individual anthropometric deficits were assessed in a secondary analysis of multi-country cohort data. A random effects meta-analysis was performed. Data from seven low-or-middle-income-countries collected between 1977 and 2013 were analysed. One thousand twenty deaths were recorded for children with anthropometric deficits. Pooled meta-analysis estimates showed no differences by age in absolute mortality risk for wasting (RR 1.08, p = 0.826 for MUAC < 125 mm; RR 1.35, p = 0.272 for WHZ < -2). For underweight and stunting, absolute risk of death was higher in younger (RR 2.57, p < 0.001) compared with older children (RR 2.83, p < 0.001). For all deficits, there were no differences in mortality risk for girls compared with boys. There were no differences in the risk of mortality between younger and older wasted children, supporting continued inclusion of all children under-five in wasting treatment programmes. The risk of mortality associated with underweight and stunting was higher among younger children, suggesting that prevention programmes might be justified in focusing on younger children where resources are limited. There were no sex differences by age in mortality risk for all deficits.

Effectiveness of Acute Malnutrition Treatment at Health Center and Community Levels with a Simplified, Combined Protocol in Mali: An Observational Cohort Study

A simplified, combined protocol was created that admits children with a mid-upper-arm circumference (MUAC) of <125 mm or edema to malnutrition treatment with ready-to-use therapeutic food (RUTF) that involves prescribing two daily RUTF sachets to children with MUAC < 115 mm or edema and one daily sachet to those with 115 mm ≤ MUAC < 125 mm. This treatment was previously shown to result in non-inferior programmatic outcomes compared with standard treatment. We aimed at observing its effectiveness in a routine setting at scale, including via delivery by community health workers (CHWs). A total of 27,800 children were admitted to the simplified, combined treatment. Treatment resulted in a 92% overall recovery, with a mean length of stay of 40 days and a mean RUTF consumption of 62 sachets per child treated. Among children admitted with MUAC < 115 mm or edema, 87% recovered with a mean length of stay of 55 days and consuming an average of 96 RUTF sachets. The recovery in all sub-groups studied exceeded 85%. Treatment by CHWs resulted in a similar (94%) recovery to treatment by formal healthcare workers (92%). The simplified, combined protocol resulted in high recovery and low RUTF consumption per child treated and can safely be adopted by CHWs to provide treatment at the community level.

Scaling severe acute malnutrition treatment with community health workers: a geospatial coverage analysis in rural Mali

BACKGROUND

In 2015, the Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated Community Case Management (iCCM). This paper aims to analyze the impact of including community health workers (CHWs) as treatment providers outside the Health Facilities (HFs) on the coverage of SAM treatment when scaling up the intervention in the three largest districts of the Kayes Region in Mali.

METHODS

A baseline coverage assessment was conducted in August 2017 in the three districts before the CHWs started treating SAM. The end-line assessment was conducted one year later, in August 2018. Coverage was assessed by the standardized methodology called Semi-Quantitative Evaluation of Access and Coverage (SQUEAC). The primary outcome was treatment coverage and other variables evaluated were the geographical distribution of the HFs, CHW's sites and overlapping between both health providers, the estimation of children with geographical access to health care and the estimation of children screened for acute malnutrition in their communities.

RESULTS

Treatment coverage increased in Kayes (28.7-57.1%) and Bafoulabé (20.4-61.1%) but did not in Kita (28.4-28.5%). The decentralization of treatment has not had the same impact on coverage in all districts, with significant differences. The geospatial analyses showed that Kita had a high proportion of overlap between HFs and/or CHWs 48.7% (39.2-58.2), a high proportion of children without geographical access to health care 70.4% (70.1-70.6), and a high proportion of children not screened for SAM in their communities 52.2% (51.9-52.5).

CONCLUSIONS

Working with CHWs in SAM increases treatment coverage, but other critical aspects need to be considered by policymakers if this intervention model is intended to be scaled up at the country level. To improve families' access to nutritional health care, before establishing decentralized treatment in a whole region it must be considered the geographical location of CHWs. This previous assessment will avoid overlap among health providers and ensure the coverage of all unserved areas according to their population densities need.

TRIAL REGISTRATION

ISRCTN registry with ID 1990746. https://doi.org/10.1186/ISRCTN14990746.

How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies

Children with weight-for-age z-score (WAZ) <-3 have a high risk of death, yet this indicator is not widely used in nutrition treatment programming. This pooled secondary data analysis of children aged 6-59 months aimed to examine the prevalence, treatment outcomes, and growth trajectories of children with WAZ <-3 versus children with WAZ ≥-3 receiving outpatient treatment for wasting and/or nutritional oedema, to inform future protocols. Binary treatment outcomes between WAZ <-3 and WAZ ≥-3 admissions were compared using logistic regression. Recovery was defined as attaining mid-upper-arm circumference ≥12.5 cm and weight-for-height z-score ≥-2, without oedema, within a period of 17 weeks of admission. Data from 24,829 children from 9 countries drawn from 13 datasets were included. 55% of wasted children had WAZ <-3. Children admitted with WAZ <-3 compared to those with WAZ ≥-3 had lower recovery rates (28.3% vs. 48.7%), higher risk of death (1.8% vs. 0.7%), and higher risk of transfer to inpatient care (6.2% vs. 3.8%). Growth trajectories showed that children with WAZ <-3 had markedly lower anthropometry at the start and end of care, however, their patterns of anthropometric gains were very similar to those with WAZ ≥-3. If moderately wasted children with WAZ <-3 were treated in therapeutic programmes alongside severely wasted children, we estimate caseloads would increase by 32%. Our findings suggest that wasted children with WAZ <-3 are an especially vulnerable group and those with moderate wasting and WAZ <-3 likely require a higher intensity of nutritional support than is currently recommended. Longer or improved treatment may be necessary, and the timeline and definition of recovery likely need review.

Measuring the Overall Burden of Early Childhood Malnutrition in Ghana: A Comparison of Estimates From Multiple Data Sources

BACKGROUND

Childhood malnutrition contributes to nearly half (45%) of all deaths among children under 5 globally. The United Nations' Sustainable Development Goals (SDGs) aims to end all forms of malnutrition by 2030; however, measuring progress towards these goals is challenging, particularly in countries with emerging economies where nationally-representative data are limited. The primary objective of this study was to estimate the overall burden of childhood malnutrition in Ghana at national and regional levels using 3 data sources.

METHODS

Using data from the long-standing Ghana Demographic and Health Surveys (GDHS), Ghana Multiple Indicator Cluster Survey (GMICS), and the emerging Ghana Socioeconomic Panel Survey (GSPS), we compared the prevalence of malnutrition using the extended composite index of anthropometric failure (eCIAF) for the period 2008- 2011. This study included data for children aged 6-59 months and calculated all anthropometric z-scores based on the World Health Organization (WHO) Growth Standards. We tested for differences in malnutrition subtypes using two-group configural frequency analysis (CFA).

RESULTS

Of the 10 281 children (6532 from GMICS, 2141 from GDHS and 1608 from GSPS) included in the study, the only demographic difference observed was the children included in the GSPS were slightly older than those included in the GDHS and GMICS (median age of 36 vs 30 vs 33 months, P<.001). Based on the eCIAF, the overall prevalence of malnutrition at the national level was higher among children in the GSPS (57.3%, 95% CI: 53.9%-60.6%), followed by the GDHS (39.7%, 95% CI: 37.0%-42.5%), and then those in the GMICS (31.2%, 95% CI: 29.3%-33.1%). The two-group CFA showed that the 3 data sources also estimated different prevalence rates for most of the malnutrition subtypes included in the eCIAF.

CONCLUSION

Depending on the data source adopted, our estimates of eCIAF showed that between one-third and half of all Ghanaian children aged 6-59 months had at least one form of malnutrition over the period 2008-2011. These eCIAF estimates should complement the commonly reported measures such as stunting and wasting when interpreting the severity of malnutrition in the country to inform policy decisions.

How Can Nutrition Research Better Reflect the Relationship Between Wasting and Stunting in Children? Learnings from the Wasting and Stunting Project

Childhood wasting and stunting affect large numbers of children globally. Both are important risk factors for illness and death yet, despite the fact that these conditions can share common risk factors and are often seen in the same child, they are commonly portrayed as relatively distinct manifestations of undernutrition. In 2014, the Wasting and Stunting project was launched by the Emergency Nutrition Network. Its aim was to better understand the complex relationship and associations between wasting and stunting and examine whether current separations that were apparent in approaches to policy, financing, and programs were justified or useful. Based on the project's work, this article aims to bring a wasting and stunting lens to how research is designed and financed in order for the nutrition community to better understand, prevent, and treat child undernutrition. Discussion of lessons learnt focuses on the synergy and temporal relationships between children's weight loss and linear growth faltering, the proximal and distal factors that drive diverse forms of undernutrition, and identifying and targeting people most at risk. Supporting progress in all these areas requires research collaborations across interest groups that highlight the value of research that moves beyond a focus on single forms of undernutrition, and ensures that there is equal attention given to wasting as to other forms of malnutrition, wherever it is present.

Concurrent wasting and stunting among children 6-59 months: an analysis using district-level survey data in Mozambique

Background

In the past it was believed that wasting and stunting were independent of each other. Recent work has shown that they can occur concurrently in a child and that increases considerably the risk of mortality. Concurrent wasting and stunting (WaSt) is currently defined as WHZ < -2 AND HAZ < -2. Wasting is measured by WHZ and MUAC and evidence shows that they tend to identify different sets of children. Our study aimed to look at the effect of adding MUAC on the prevalence and burden of WaSt, and to assess diagnosis of WaSt with a single measurement.

Methods

We analyzed population-based anthropometric surveys from 37 districts in Mozambique conducted by the Government of Mozambique between 2017 and 2019. We proposed a new case-definition for WaSt that includes MUAC in acknowledgement of the different children with wasting diagnosed by WHZ and MUAC. We estimated how many WaSt cases are eligible to be included in the existing treatment program in Mozambique by calculating the True Positive and False Positive Values of WaSt using our proposed case-definition against the wasting admission criteria. AUC of ROC curves used for MUAC and WAZ and optimal cut-offs were determined using Youden’s Index.

Results

Including MUAC in the concurrent WaSt case-definition identified more children with WaSt compared to the original case-definition and more younger children and girls were identified. Using both MUAC and WHZ and enrolling severe and moderate wasting is already picking up most of the WaSt cases: 100% in health facilities and 79.40% with MUAC mass screenings at community level. Cut-off values from the ROC curve for the proposed case-definition were MUAC ≤133 mm and WAZ ≤ 2.145 Z-scores, however, they  yielded many false positive values.

Conclusion

WaSt case-definition should include MUAC. WaSt should commence to be reported in surveys and Mozambique should also start monitoring and treating children with WaSt. A cost-effective approach to identify all children with WaSt without adding too many false positive is needed, as well as understanding how to achieve optimal treatment outcomes within existing programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00508-9.

The relationship between wasting and stunting in young children: A systematic review

In 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low- and middle-income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near-term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid-upper-arm circumference combined with weight-for-age Z score might effectively identify children at most risk of near-term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.

Response to Malnutrition Treatment in Low Weight-for-Age Children: Secondary Analyses of Children 6-59 Months in the ComPAS Cluster Randomized Controlled Trial

Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5–12.5 cm) and a severely low WAZ (<−3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<−3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < −3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < −3.0.

Prevalence and determinants of concurrent wasting and stunting and other indicators of malnutrition among children 6-59 months old in Kersa, Ethiopia

Malnutrition is the leading cause of poor child health in Ethiopia, and progress to avert it is unacceptably slow. In addition, little is known about the magnitude and factors associated with concurrent wasting and stunting (WaSt). Therefore, this study aimed to assess the prevalence and factors associated with WaSt, wasting, stunting and underweight among children 6-59 months in Kersa Health and Demographic Surveillance System, Ethiopia. Data from a total of 1091 children and their parents' were analysed from a cross-sectional study. Household questionnaires and anthropometric measurements were used for data collection. Height-for-age, weight-for-height and weight-for-age indices are expressed as standard deviation units from the mean for the reference group. Multivariate analyses were conducted to identify factors associated with WaSt, wasting, stunting and underweight. Statistical significance was declared at p < 0.05. The prevalence of indicators of malnutrition was WaSt (5.8%), wasting (16.8%), stunting (53.9%) and underweight (36.9%). Children aged 6-17 months had a higher odds of wasting (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.12-2.75) compared with those aged 36-59 months, whereas children aged 18-35 months (aOR 2.4, 95% CI 1.65-3.47) and 36-59 months (aOR 1.6, 95% CI 1.07-2.37) had higher odds of stunting compared with those aged 6-17 months. Similarly, children aged 18-35 months (aOR 1.6, 95% CI 1.07-2.37) and 36-59 months (aOR 2.2, 95% CI 1.52-3.10) had higher odds of underweight compared with children aged 6-17 months. Households that did not treat drinking water at point of use were at higher odds of WaSt (aOR 3.3, 95% CI 1.16-9.27) and stunting (aOR 1.9, 95% CI 1.31-2.85) compared with those who did treat drinking water. Boys were more likely to be WaSt, wasted, stunted and underweight. Cough was associated with WaSt, wasting and underweight. Furthermore, maternal education, maternal occupation and maternal age were significantly associated with wasting. Maternal body mass index (BMI) of less than 18.5 kg/m² and maternal BMI between 18.5 and 25 kg/m² were associated with child stunting. In Kersa, the prevalence of WaSt, wasting, stunting and underweight is very high and requires urgent public health intervention. This study highlights point-of-use water treatment, maternal education, hygiene and sanitation, child health service utilization and maternal BMI as important areas to improve to target child malnutrition. Furthermore, a community-based programmatic and policy direction for early identification and management of WaSt in addition to other indicators of malnutrition is recommended.

"No weight for height" case detection strategies for therapeutic feeding programs: sensitivity to acute malnutrition and target composition based on representative surveys in humanitarian settings

Background

One newly proposed approach to determining eligibility of children aged 6–59 months for therapeutic feeding programs (TFPs) is to use mid-upper arm circumference (MUAC) < 115 mm, bilateral oedema or Weight-for-Age Z-score (WAZ) < − 3 as admission criteria (MUAC+SWAZ). We explored potential consequences of this approach on the eligibility for treatment, as compared with the existing WHO normative guidance. We also compared sensitivity and specificity parameters of this approach for detecting wasted children to the previously described “Expanded MUAC” approach.

Methods

We analyzed data from 558 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and those who are both wasted and stunted (WA + ST), and calculated proportions of previously eligible children who would now be excluded from treatment, as well as proportions of non-malnourished children among those who would become eligible. We also analyzed the expected changes in the number and demographics (sex, age) of the selected populations of children according to the different admission approaches.

Results

Both MUAC+SWAZ and Expanded MUAC case detection approaches substantially increase the sensitivity in detecting SAM, as compared to an approach which restricts detection of SAM cases to MUAC< 115 mm and oedema. Improved sensitivity however is attained at the expense of specificity and would require a very large increase of the size of TFPs, while still missing a non-negligible proportion (20–25%) of the SAM caseload. While our results confirm the sensitivity of the MUAC+SWAZ case detection approach in detecting WA + ST (over 80%), they show, on the other hand, that about half of the additional target detected by using SWAZ criterion will be neither SAM nor WA + ST.

Conclusions

These results suggest that recently promoted approaches to case detection inflate TFPs’ targets through the allocation of treatment to large numbers of children who have not been shown to require this type of support, including a significant proportion of non-acutely malnourished children in the MUAC+SWAZ approach. Considering the scarcity of resources for the implementation of TFPs, the rationale of abandoning the use of WHZ and of these alternative case detection strategies need to be critically reviewed.

Impact of Different Levels of Supervision on the Recovery of Severely Malnourished Children Treated by Community Health Workers in Mali

(1) Background: The Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated community case management (iCCM). This paper evaluates the most effective model of supervision for treating SAM using community health workers (CHWs). Methods (2): This study was a prospective non-randomized community intervention trial with two intervention groups and one control group with different levels of supervision. It was conducted in three districts in rural areas of the Kayes Region. In the high supervision group, CHWs received supportive supervision for the iCCM package and nutrition-specific supervision. In the light supervision group, CHWs received supportive supervision based on the iCCM package. The control group had no specific supervision. (3) Results: A total of 6112 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 81.4% in those treated by CHWs in the high supervision group, 86.2% in the light supervision group, and 66.9% in the control group. Children treated by the CHWs who received some supervision had better outcomes than those treated by unsupervised CHWs (p < 0.001). There was no difference between areas with light and high supervision, although those with high supervision performed better in most of the tasks analyzed. (4) Conclusions: Public policies in low-income countries should be adapted, and their model of supervision of CHWs for SAM treatment in the community should be evaluated.

Biannual azithromycin distribution and child mortality among malnourished children: A subgroup analysis of the MORDOR cluster-randomized trial in Niger

BACKGROUND

Biannual azithromycin distribution has been shown to reduce child mortality as well as increase antimicrobial resistance. Targeting distributions to vulnerable subgroups such as malnourished children is one approach to reaching those at the highest risk of mortality while limiting selection for resistance. The objective of this analysis was to assess whether the effect of azithromycin on mortality differs by nutritional status.

METHODS AND FINDINGS

A large simple trial randomized communities in Niger to receive biannual distributions of azithromycin or placebo to children 1-59 months old over a 2-year timeframe. In exploratory subgroup analyses, the effect of azithromycin distribution on child mortality was assessed for underweight subgroups using weight-for-age Z-score (WAZ) thresholds of -2 and -3. Modification of the effect of azithromycin on mortality by underweight status was examined on the additive and multiplicative scale. Between December 2014 and August 2017, 27,222 children 1-11 months of age from 593 communities had weight measured at their first study visit. Overall, the average age among included children was 4.7 months (interquartile range [IQR] 3-6), 49.5% were female, 23% had a WAZ < -2, and 10% had a WAZ < -3. This analysis included 523 deaths in communities assigned to azithromycin and 661 deaths in communities assigned to placebo. The mortality rate was lower in communities assigned to azithromycin than placebo overall, with larger reductions among children with lower WAZ: -12.6 deaths per 1,000 person-years (95% CI -18.5 to -6.9, P < 0.001) overall, -17.0 (95% CI -28.0 to -7.0, P = 0.001) among children with WAZ < -2, and -25.6 (95% CI -42.6 to -9.6, P = 0.003) among children with WAZ < -3. No statistically significant evidence of effect modification was demonstrated by WAZ subgroup on either the additive or multiplicative scale (WAZ < -2, additive: 95% CI -6.4 to 16.8, P = 0.34; WAZ < -2, multiplicative: 95% CI 0.8 to 1.4, P = 0.50, WAZ < -3, additive: 95% CI -2.2 to 31.1, P = 0.14; WAZ < -3, multiplicative: 95% CI 0.9 to 1.7, P = 0.26). The estimated number of deaths averted with azithromycin was 388 (95% CI 214 to 574) overall, 116 (95% CI 48 to 192) among children with WAZ < -2, and 76 (95% CI 27 to 127) among children with WAZ < -3. Limitations include the availability of a single weight measurement on only the youngest children and the lack of power to detect small effect sizes with this rare outcome. Despite the trial's large size, formal tests for effect modification did not reach statistical significance at the 95% confidence level.

CONCLUSIONS

Although mortality rates were higher in the underweight subgroups, this study was unable to demonstrate that nutritional status modified the effect of biannual azithromycin distribution on mortality. Even if the effect were greater among underweight children, a nontargeted intervention would result in the greatest absolute number of deaths averted.

TRIAL REGISTRATION

The MORDOR trial is registered at clinicaltrials.gov NCT02047981.

Clinical Outcome of Febrile Tanzanian Children with Severe Malnutrition Using Anthropometry in Comparison to Clinical Signs

Children with malnutrition compared with those without are at higher risk of infection, with more severe outcomes. How clinicians assess nutritional risk factors in febrile children in primary care varies. We conducted a post hoc subgroup analysis of febrile children with severe malnutrition enrolled in a randomized, controlled trial in primary care centers in Tanzania. The clinical outcome of children with severe malnutrition defined by anthropometric measures and clinical signs was compared between two electronic clinical diagnostic algorithms: ePOCT, which uses weight-for-age and mid-upper arm circumference to identify and manage severe malnutrition, and ALMANACH, which uses the clinical signs of edema of both feet and visible severe wasting. Those identified as having severe malnutrition by the algorithms in each arm were prescribed antibiotics and referred to the hospital. From December 2014 to February 2016, 106 febrile children were enrolled and randomized in the parent study, and met the criteria to be included in the present analysis. ePOCT identified 56/57 children with severe malnutrition using anthropometric measures, whereas ALMANACH identified 2/49 children with severe malnutrition using clinical signs. The proportion of clinical failure, defined as the development of severe symptoms by day 7 or persisting symptoms at day 7 (per-protocol), was 1.8% (1/56) in the ePOCT arm versus 16.7% (8/48) in the Algorithm for the MANagement of Childhood illnesses arm (risk difference -14.9%, 95% CI -26.0%, -3.8%; risk ratio 0.11, 95% CI 0.01, 0.83). Using anthropometric measures to identify and manage febrile children with severe malnutrition may have resulted in better clinical outcomes than by using clinical signs alone.

The optimal mid-upper-arm circumference cutoffs to screen severe acute malnutrition in Vietnamese children

Severe acute malnutrition (SAM) remains a main cause of mortality among children under five years old. Vietnam needs further study to establish the optimal mid-upper-arm circumference (MUAC) cutoff for improving the accuracy of the MUAC indicator in screening SAM children aged 6-59 months. A survey was conducted at all 16 subdistricts across four provinces in Northern Midlands and mountainous areas. The data of 4,764 children showed that an optimal MUAC cutoff of 13.5 cm would allow the inclusion of 65% of children with weight-for-height z-scores (WHZs) below -3SD. A combination of MUAC and WHZ may achieve a higher impact on therapeutic feeding programs for SAM children. The MUAC cutoff of 13.5 cm (65% sensitivity and 72% specificity) should be used as the cutoff for improving and/or preventing SAM status among children under 5 in the Midlands and mountainous areas in Vietnam.

Concurrently wasted and stunted children 6-59 months in Karamoja, Uganda: prevalence and case detection

We assessed prevalence of concurrently wasted and stunted (WaSt) and explored the overlaps between wasted, stunted, underweight and low mid‐upper arm circumference (MUAC) among children aged 6–59 months in Karamoja, Uganda. We also determined optimal weight‐for‐age (WAZ) and MUAC thresholds for detecting WaSt. We conducted secondary data analysis with 2015–2018 Food Security and Nutrition Assessment (FSNA) cross‐sectional survey datasets from Karamoja. Wasting, stunting and underweight were defined as <−2.0 z‐scores using WHO growth standards. Low MUAC was defined as <12.5 cm. We defined WaSt as concurrent wasting and stunting. Prevalence of WaSt was 4.96% (95% CI [4.64, 5.29]). WaSt was more prevalent in lean than harvest season (5.21% vs. 4.53%; p = .018). About half (53.92%) of WaSt children had low MUAC, and all were underweight. Younger children aged <36 months had more WaSt, particularly males. Males with WaSt had higher median MUAC than females (12.50 vs. 12.10 cm; p < .001). A WAZ <−2.60 threshold detected WaSt with excellent sensitivity (99.02%) and high specificity (90.71%). MUAC threshold <13.20 cm had good sensitivity (81.58%) and moderate specificity (76.15%) to detect WaSt. WaSt prevalence of 5% is a public health concern, given its high mortality risk. All children with WaSt were underweight and half had low MUAC. WAZ and MUAC could be useful tools for detecting WaSt. Prevalence monitoring and prospective studies on WAZ and MUAC cut‐offs for WaSt detection are recommended. Future consideration to integrate WAZ into therapeutic feeding programmes is recommended to detect and treat WaSt children.

Concurrently wasted and stunted 6-59 months children admitted to the outpatient therapeutic feeding programme in Karamoja, Uganda: Prevalence, characteristics, treatment outcomes and response

This study assessed the prevalence of concurrently wasted and stunted (WaSt) children, their characteristics, treatment outcomes and response; and factors associated with time to recovery among children aged 6–59 months admitted to Outpatient Therapeutic Care (OTC) in Karamoja, Uganda. We conducted a retrospective cohort study with data from January 2016 to October 2017 for children admitted to nine OTCs in Karamoja. We defined wasted, stunted and underweight as 2.0 Z-scores below the median per WHO growth standards and < 12.5 cm for low Mid-Upper Arm Circumference (MUAC). WaSt was defined as concurrently wasted and stunted. Out of 788 eligible children included in the analysis; 48.7% (95% CI; 45.2–52.2) had WaSt. WaSt was common among males; 56.3% (95% CI; 51.3–61.3). Median age was 18 months in WaSt versus 12 months in non-WaSt children (p < 0.001). All WaSt children were underweight; and more severely wasted than non-WaSt children. During recovery, WaSt children gained weight more rapidly than non-WaSt children (2.2g/kg/day vs. 1.7g/kg/day). WaSt children had lower recovery rate (58.0% vs. 65.4%; p = 0.037). The difference in median time of recovery between WaSt and non-WaSt children (63 days vs. 56 days; p = 0.465) was not significant. Factors associated with time to recovery were children aged 24–59 months (aHR = 1.30; 95% CI;1.07–1.57;), children with MUAC 10.5–11.4 cm (aHR = 2.03; 95% CI; 1.55–2.66), MUAC ≥ 11.5 cm at admission (aHR = 3.31; 95% CI; 2.17–5.02) and living in Moroto (aHR = 3.34; 95% CI; 2.60–4.30) and Nakapiripirit (aHR = 1.95; 95% CI; 1.51–2.53) districts. The magnitude of children with WaSt in OTC shows that existing therapeutic feeding protocols could be used to detect and treat WaSt children. Further research is needed to identify and address the factors associated with sub-optimal recovery in WaSt children for effective OTC programming in Karamoja.

The Forgotten Agenda of Wasting in Southeast Asia: Burden, Determinants and Overlap with Stunting: A Review of Nationally Representative Cross-Sectional Demographic and Health Surveys in Six Countries

Childhood wasting is among the most prevalent forms of undernutrition globally. The Southeast Asia region is home to many wasted children, but wasting is not recognized as a public health problem and its epidemiology is yet to be fully examined. This analysis aimed to determine the burden of wasting, its predictors, and the level of wasting and stunting concurrence. Datasets from Demographic and Health Surveys and Multiple Indicator Cluster Surveys in six countries in the region were analyzed. The pooled weighted prevalence for wasting and concurrent wasting and stunting among children 0–59 months in the six countries was 8.9%, 95% CI (8.0–9.9) and 1.6%, 95% CI (1.5–1.8), respectively. This prevalence is approximately 12-fold higher than the 0.7% prevalence of high-income countries; and translated into an absolute number of 1,088,747 children affected by wasting and 272,563 concurrent wasting and stunting. Wasting prevalence was 50 percent higher in the 0–23-month age group. Predictors for wasting included source of drinking water, wealth index, urban residence, child’s age and history of illness and mother’s body mass index. In conclusion, our analysis showed that wasting is a serious public health problem in the region that should be addressed urgently using both preventive and curative approaches.

Anthropometric assessment of children's nutritional status: a new approach based on an adaptation of Waterlow's classification

Background

The methodology currently used for nutritional assessment of populations classifies children according to four conditions: eutrophy, wasting, stunting, and overweight. However, children can be stunted and wasted concomitantly. Similarly, they can be stunted and overweight. These conditions are associated with greater susceptibility to mortality or chronic diseases, respectively. This work presents an adaptation of Waterlow’s classification (AWC), which discriminates six nutritional conditions. Additionally, it provides a command routine in Stata, which processes the z-scores of the anthropometric indices height-for-age and weight-for-height and presents the respective prevalence of the nutritional conditions.

Methods

Data from two household surveys were used to demonstrate the application of AWC, which were conducted in 1992 (n = 1229) and 2015 (n = 987), with probabilistic samples of children (< 5 years) in Alagoas, Northeast Brazil. AWC is based on a cross-classification scheme, involving the categories obtained with height-for-age (z < − 2; z ≥ − 2) and weight-for-height (z < − 2; − 2 to 2; z > 2).

Results

The prevalence obtained with AWC in 1992 and 2015 was, respectively: eutrophy (71.0/80.2), stunting (20.8/2.7), wasting (0.8/2.1), concurrent stunting and wasting (0.5/0.0), overweight (4.8/14.4) and short stature with overweight (2.0/0.5). The prevalence of wasting, concurrent wasting and stunting, and for short stature with overweight was never higher than 2.3%. Possibly these values should be much higher in countries where there is a high prevalence of undernutrition. In total, 472 children had low height-for-age. By the usual anthropometric classification, they would be classified as chronic undernourished. However, 39 (8.3%) of them were also overweight and seven (1.5%) had concurrent stunting and wasting, a condition at extreme risk of mortality, which is perhaps the explanation for its low prevalence in cross-sectional studies.

Conclusion

In addition to identifying wasted, stunted and overweight children, AWC also identified children with two other conditions, which are generally neglected in most nutritional surveys. Each of these nutritional conditions have different characteristics (aetiology, preventive, and therapeutic approach, damage to the patient’s health, and priority level in public policy). Such aspects justify their identification in the distinct scenarios where nutritional surveys are developed.

Comparison of anthropometric indicators to predict mortality in a population-based prospective study of children under 5 years in Niger

OBJECTIVE

In the present study, we aimed to compare anthropometric indicators as predictors of mortality in a community-based setting.

DESIGN

We conducted a population-based longitudinal study nested in a cluster-randomized trial. We assessed weight, height and mid-upper arm circumference (MUAC) on children 12 months after the trial began and used the trial's annual census and monitoring visits to assess mortality over 2 years.

SETTING

Niger.

PARTICIPANTS

Children aged 6-60 months during the study.

RESULTS

Of 1023 children included in the study at baseline, height-for-age Z-score, weight-for-age Z-score, weight-for-height Z-score and MUAC classified 777 (76·0 %), 630 (61·6 %), 131 (12·9 %) and eighty (7·8 %) children as moderately to severely malnourished, respectively. Over the 2-year study period, fifty-eight children (5·7 %) died. MUAC had the greatest AUC (0·68, 95 % CI 0·61, 0·75) and had the strongest association with mortality in this sample (hazard ratio = 2·21, 95 % CI 1·26, 3·89, P = 0·006).

CONCLUSIONS

MUAC appears to be a better predictor of mortality than other anthropometric indicators in this community-based, high-malnutrition setting in Niger.