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Gluning I, Kerac M, Bailey J, Bander A, Opondo C. The management of moderate acute malnutrition in children aged 6-59 months in low- and middle-income countries: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2021; 115:1317-1329. [PMID: 34535798 DOI: 10.1093/trstmh/trab137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/11/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malnutrition is a leading cause of morbidity and mortality in children aged <5 y, especially in low- and middle-income countries (LMICs). Unlike severe acute malnutrition, moderate acute malnutrition (MAM) affects greater numbers globally, and guidelines lack a robust evidence base. This systematic review and meta-analysis assessed the evidence for lipid-based nutrient supplements (LNSs), fortified blended flours (FBFs) and nutrition counselling, in the treatment of MAM. METHODS Four databases were systematically searched for studies conducted in LMICs that compared the effectiveness of food-based products with any comparator group in promoting recovery from MAM in children aged 6-59 mo. Where appropriate, pooled estimates of effect were estimated using random-effects meta-analyses. RESULTS A total of 13 trials were identified for inclusion. All used active controls. There was evidence of increased probability of recovery (gaining normal weight-for-height and/or mid-upper arm circumference) among children treated with LNSs compared with children treated with FBFs (risk ratio 1.05, 95% CI 1.01 to 1.09, p=0·009). CONCLUSION Based on a relatively small number of studies mainly from Africa, LNSs are superior to FBFs in improving anthropometric recovery from MAM. Current evidence for the use of food supplements in MAM treatment is based on comparisons with active controls. Future studies should assess a wider range of comparator groups, such as nutrition education/counselling alone, and outcomes, including body composition, morbidity and development.
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Affiliation(s)
- Imara Gluning
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Brighton and Sussex University Hospitals Trust, Brighton, BN2 5BE, UK
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Centre for MARCH (Maternal, Reproductive, Adolescent & Child Health Centre), London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Jeanette Bailey
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,International Rescue Committee, New York, NY, 10168-1289, USA
| | - Amela Bander
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, OX3 7LF, UK
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Phillips E, Ngure F, Smith LE, Makule E, Turner PC, Nelson R, Kimanya M, Stoltzfus R, Kassim N. Protocol for the trial to establish a causal linkage between mycotoxin exposure and child stunting: a cluster randomized trial. BMC Public Health 2020; 20:598. [PMID: 32357944 PMCID: PMC7193337 DOI: 10.1186/s12889-020-08694-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Background The number of stunted children has fallen globally but continues to increase in Africa. Stunting is estimated to contribute to 14–17% of child deaths under 5 years of age and is a risk factor for poor cognitive and motor development and educational outcomes. Inadequate dietary intake and disease are thought to be the immediate causes of undernutrition and stunting. However, improving infant diets through complementary feeding interventions has been shown to only modestly reduce stunting. Multiple observational studies demonstrate a dose response relationship between fetal and post-natal aflatoxin exposure and reduced linear growth. Methods This community-based cluster randomized trial will measure the effect of a reduced aflatoxin diet on length-for-age Z scores at 18 months in central Tanzania. All 52 health facilities in the Kongwa District of Dodoma Region were randomized into two groups. Starting at 6 months of age, participants in the intervention group receive a low-aflatoxin pre-blended porridge flour containing maize and groundnut (ratio 4:1 respectively) and low-aflatoxin groundnut flour, whereas in the control group the same porridge mix and groundnut flour are promoted through education but acquired by the household. Both groups will receive the same infant and young child feeding education and a thermos flask. A total of 3120 infants between 6 weeks and 3 months of age will be recruited into the study over 1 year. Data will be collected four times – at recruitment and when the infants are 6, 12 and 18 months of age. In a cohort of 600 infants, additional data will be collected at 9 and 15 months of age. The primary outcome is length-for-age at 18 months. Secondary outcomes include the Z scores for weight-for-age, middle upper arm circumference and head circumference, and the blood biomarker aflatoxin-albumin in the full sample, with the urine biomarker aflatoxin M1 analyzed in the cohort only. Discussion Better understanding the etiology of childhood stunting can lead to more appropriate interventions and policies to further reduce linear growth faltering and meet the Sustainable Development Goals. Trial registration NCT03940547, (April 24, 2019).
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Affiliation(s)
| | | | - Laura E Smith
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - Edna Makule
- Department of Food Biotechnology and Nutritional Sciences, School of Life Science and Bio-Engineering, The Nelson Mandela African Institution of Science and Technology (NM-AIST), P.O.Box 447, Arusha, Tanzania
| | - Paul C Turner
- MIAEH, School of Public Health, University of Maryland, College Park, MD, 20740, USA
| | - Rebeca Nelson
- School of Integrative Plant Science, Plant Pathology and Plant-Microbe Biology Section, Cornell University, Ithaca, USA
| | - Martin Kimanya
- Department of Food Biotechnology and Nutritional Sciences, School of Life Science and Bio-Engineering, The Nelson Mandela African Institution of Science and Technology (NM-AIST), P.O.Box 447, Arusha, Tanzania
| | | | - Neema Kassim
- Department of Food Biotechnology and Nutritional Sciences, School of Life Science and Bio-Engineering, The Nelson Mandela African Institution of Science and Technology (NM-AIST), P.O.Box 447, Arusha, Tanzania
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Langlois BK, Cliffer IR, Nikiema L, Suri DJ, Garanet F, Shen Y, Zeba AN, Walton SM, Lanou HB, Webb P, Rogers BL. Factors that May Influence the Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso. Curr Dev Nutr 2020; 4:nzaa002. [PMID: 31998858 PMCID: PMC6981338 DOI: 10.1093/cdn/nzaa002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/06/2019] [Accepted: 01/02/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A trial in Burkina Faso compared the cost-effectiveness of 4 specialized nutritious foods (SNFs) used to prevent stunting and wasting in children aged 6-23 mo. OBJECTIVES This article explores differences in SNF use that may have influenced effectiveness, specifically in relation to consumption by the recipient child and by any other person (i.e., sharing), other diversion from the recipient child, preparation, storage, and hygiene. METHODS Subsamples from a geographically clustered, longitudinal trial with random assignment to Corn Soy Blend Plus with oil (CSB+ w/oil), Corn Soy Whey Blend with oil (CSWB w/oil), Super Cereal Plus (SC+), or ready-to-use supplementary food (RUSF) were selected for in-depth interviews, in-home observations, and focus group discussions. RESULTS Sharing was common in all arms, with the highest reported in SC+ (73%) and highest observed in CSWB w/oil (36%). Some reported giving the ration away (highest in SC+ at 17%) or using it for other purposes (highest in CSWB w/oil at 17%). The recipient child was observed consuming the ration in 49% of households on average (38-60% by arm in CSB+ w/oil and RUSF, respectively). Qualitative reports of bitterness and spoilage emerged in the CSWB w/oil arm. Most observed households (excluding RUSF) did not prepare porridge daily as instructed (35-46% by arm). Household water samples showed either high-risk or unsafe contamination with Escherichia coli (72-78% by arm). Low percentages were observed handwashing (both child and server) before consuming the porridge. CONCLUSIONS The SNFs were not prepared or served as intended and diversion from the recipient was common. Storage conditions may have resulted in spoilage of the ration containing whey before reaching recipients. This article provides context about factors that may have influenced the effectiveness of these SNFs. Programming and household use of SNFs are as important as their nutrient composition. This trial was registered at clinicaltrials.gov as NCT02071563.
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Affiliation(s)
- Breanne K Langlois
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Ilana R Cliffer
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Laetitia Nikiema
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Devika J Suri
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Franck Garanet
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Ye Shen
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Augustin N Zeba
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Shelley M Walton
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Hermann B Lanou
- Health Sciences Research Institute, National Center for Science and Technology Research, Ouagadougou, Burkina Faso
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Beatrice L Rogers
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
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Cichon B, Fabiansen C, Iuel-Brockdorf AS, Yaméogo CW, Ritz C, Christensen VB, Filteau S, Briend A, Michaelsen KF, Friis H. Impact of food supplements on hemoglobin, iron status, and inflammation in children with moderate acute malnutrition: a 2 × 2 × 3 factorial randomized trial in Burkina Faso. Am J Clin Nutr 2018; 107:278-286. [PMID: 29529160 DOI: 10.1093/ajcn/nqx050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/29/2017] [Indexed: 11/14/2022] Open
Abstract
Background Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplements (LNSs) or corn-soy blends (CSBs) but little is known about the impact of these supplements on hemoglobin, iron status, and inflammation. Objective The objective of this study was to investigate the impact of supplementary foods for treatment of MAM on hemoglobin, iron status, inflammation, and malaria. Design A randomized 2 × 2 × 3 factorial trial was conducted in Burkina Faso. Children aged 6-23 mo with MAM received 500 kcal/d as LNS or CSB, containing either dehulled soy (DS) or soy isolate (SI) and different quantities of dry skimmed milk (0%, 20% or 50% of total protein) for 12 wk. The trial was double-blind with regard to quality of soy and quantity of milk, but not matrix (CSB compared to LNS). Hemoglobin, serum ferritin (SF), serum soluble transferrin receptor (sTfR), serum C-reactive protein (CRP), serum α1-acid glycoprotein (AGP), and malaria antigens were measured at inclusion and after supplementation. Results Between September 2013 and August 2014, 1609 children were enrolled. Among these, 61 (3.8%) were lost to follow-up. During the 12-wk supplementation period, prevalence of anemia, low SF adjusted for inflammation (SFAI), elevated sTfR, and iron-deficiency anemia decreased by 16.9, 8.7, 12.6 and 10.5 percentage points. Children who received LNS compared to CSB had higher hemoglobin (2 g/L; 95% CI: 1, 4 g/L), SFAI (4.2 µg/L; 95% CI: 2.9, 5.5 µg/L), and CRP (0.8 mg/L; 95% CI: 0.4, 1.2 mg/L) and lower sTfR (-0.9 mg/L, 95% CI: -1.3, -0.6 mg/L) after the intervention. Replacing DS with SI or increasing milk content did not affect hemoglobin, SFAI, sTfR, or CRP. Conclusion Supplementation with LNS compared to CSB led to better hemoglobin and iron status, but overall prevalence of anemia remained high. The higher concentrations of acute-phase proteins in children who received LNSs requires further investigation. This trial was registered at www.controlled-trials.com as ISRCTN42569496.
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Affiliation(s)
- Bernardette Cichon
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Doctors Without Borders, Denmark, Copenhagen, Denmark
| | - Christian Fabiansen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Doctors Without Borders, Denmark, Copenhagen, Denmark
| | - Ann-Sophie Iuel-Brockdorf
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Doctors Without Borders, Denmark, Copenhagen, Denmark
| | - Charles W Yaméogo
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Department of Biomedical and Public Health, Research Institute for Health Sciences, Ouagadougou, Burkina Faso
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Vibeke B Christensen
- Doctors Without Borders, Denmark, Copenhagen, Denmark.,Department of Pediatrics, Righospitalet, Copenhagen, Denmark
| | - Suzanne Filteau
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark.,Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, University of Tampere, Tampere, Finland
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg, Denmark
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