Supplementary Feeding of Moderately Wasted Children in Sierra Leone Reduces Severe Acute Malnutrition and Death When Compared to Nutrition Counseling: a Retrospective Cohort Study

Mortality among children aged 28 days-17 years with pneumonia who are not severely undernourished and the effect of macronutrient supplementation: a systematic review and meta-analysis

OBJECTIVE

Pneumonia is associated with four times higher odds of death among children with severe undernutrition. However, there is an equipoise for the mortality of children without severe undernutrition and the impact of macronutrient interventions. We collated evidence on mortality, anthropometric outcomes and the effect of macronutrient interventions in the management of non-severely undernourished children (28 days-17 years) with pneumonia globally.

DESIGN

Systematic review and meta-analysis using a priori criteria developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

DATA SOURCES

PubMed, Medline, EMBASE, Web of Science, Google Scholar, Scopus, Cochrane Central and bibliographies were searched between January 2000 and July 2024.

ELIGIBILITY CRITERIA

We included articles conducted among children between 28 days and 17 years with pneumonia and non-severe malnutrition that reported on mortality and changes in anthropometric status or macronutrient supplementation. Studies conducted exclusively among adults, on micronutrient supplementation, case studies, commentaries and reviews were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened, abstracted the data and conducted risk of bias (RoB) using standard criteria including the RoB in non-randomised follow-up studies of exposure for observational studies and the revised Cochrane RoB assessment tool for randomised studies (RoB 2.0). Heterogeneity was assessed using the I2 statistic, and subgroup analysis was done. Data were analysed using both narrative and quantitative synthesis. Quantitative synthesis was done using the maximum likelihood random-effects model in STATA V.18.0, with the 'meta_es' command.

RESULTS

A total of 15 articles were included (11 conducted in sub-Saharan Africa and four in Asia), with 169 901 participants overall. The mortality among non-severely undernourished children with pneumonia was 3.0% (95% CI 2% to 5%, I2=99.38%), with a range of 1-13% across studies. Children with moderate undernutrition had a higher overall mortality, 9.0% (95% CI 6% to 13%, I2=89.50%), than well-nourished children, with a range of 3-19% across studies. Only one of the 15 studies reported anthropometric outcomes during follow-up and compared mortality rates of those who did versus did not receive macronutrients. The study results were inconclusive.

CONCLUSIONS

Mortality among non-severely undernourished children with pneumonia ranges between 1-13% globally. There is inadequate follow-up nutritional assessment and management for non-severely undernourished children with pneumonia.

PROSPERO REGISTRATION NUMBER

CRD42021257272.

The Cost and Cost-Effectiveness of an Integrated Wasting Prevention and Screening Intervention Package in Burkina Faso and Mali

BACKGROUND

Little is known about costs and cost effectiveness of interventions that integrate wasting prevention into screening for child wasting.

OBJECTIVES

This study's objective was to estimate the cost and cost-effectiveness of an intervention that integrated behavior change communication (BCC) and small-quantity lipid-based nutrient supplements (SQ-LNS) into platforms for wasting screening in Burkina Faso (a facility-based platform, where BCC was enhanced compared with standard care) and Mali (a community-based platform, with standard BCC).

METHODS

Activity-based costing was used to estimate the cost per child-contact for the intervention and the comparison group, which did not receive the intervention. Costs were ascertained from accounting records, interviews, surveys, and observations. The number of child-contacts was calculated using population size estimates and average attendance rates for each service. Costs per disability-adjusted life year (DALY) averted were estimated using a Markov model populated with data from the parent trials on impact of wasting incidence and treatment coverage.

RESULTS

In the intervention group in Burkina Faso, the cost per child-contact of facility-based screening was $0.85 of enhanced BCC was $4.28, and of SQ-LNS was $8.86. In Mali, the cost per child-contact of community-based screening was $0.57, standard BCC was $0.72, and SQ-LNS was $4.14. Although no SQ-LNS costs were incurred in the comparison groups (hence lower total costs), costs per child-contact for screening and BCC were higher because coverage of these services was lower. The intervention package cost $1073 per DALY averted in Burkina Faso and $747 in Mali.

CONCLUSIONS

Integration of wasting prevention into screening for child wasting led to higher total costs but lower unit costs than standard screening due to increased coverage. Greater cost-effectiveness could be achieved if BCC were strengthened and led to improved caregiver health and nutrition practices and if screening triggered appropriate use of services and higher treatment coverage.

Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis

In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

Evidence on the impact of community health workers in the prevention, identification, and management of undernutrition amongst children under the age of five in conflict-affected or fragile settings: a systematic literature review

BACKGROUND

Malnutrition, specifically undernutrition, is a significant global challenge that contributes to nearly half of deaths in children under the age of five. The burden of undernutrition is disproportionately borne by conflict-affected, fragile settings (CAFS); children living in a conflict zone being more than twice as likely to suffer from malnourishment. Community health worker (CHW) models have been employed in CAFS to improve healthcare coverage and identify and treat illnesses. However, there lacks systematic evidence on the impact of CHW models in preventing, identifying, and managing child undernutrition in CAFS. We conducted this review to systematically evaluate evidence of CHW models in preventing, identifying, and managing undernutrition in children under the age of five in CAFS.

METHODOLOGY

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. The search strategy was developed using the Population-Intervention-Comparisons-Outcomes-Setting framework as a guide. Searches were performed using Ovid online database search platform, searching the databases of Ovid MEDLINE(R), COCHRANE, Embase Classic, Embase, Econlit, Global Health, SCOPUS, and Social Policy and Practice. Peer-reviewed publications were eligible for inclusion if they evaluated an intervention using a CHW model that aims to prevent, identify, or manage some form of undernutrition in children under five in a CAFS.

RESULTS

We identified 25 studies-spanning 10 countries-that were included in the systematic review. CHW models were implemented alongside a variety of interventions, including behaviour change communication, supplementary foods, nutrition counselling, and integrated community health programmes. Key barriers in implementing successful CHW models include disruption of programmes due to active conflict, states of emergency, militancy, or political unrest; weak links between the community-based interventions and public health system; weak health system capacity that impeded referral and follow-ups; and cost of care and care-seeking. Key facilitators include CHWs' connection to the community, close proximity of programmes to the community, supervision, and investment in high quality training and tools.

CONCLUSIONS

The findings suggest that CHW models may be effective, cost-effective, acceptable, feasible, and scalable in the prevention, identification, and management child undernutrition in CAFS. The study findings also confirmed a need for greater evidence in the field. These findings may inform policymaking, programme implementation, and design to strengthen best practices for CHW models addressing child undernutrition in CAFS.

Treatment outcomes and associated factors for hospitalization of children treated for acute malnutrition under the OptiMA simplified protocol: a prospective observational cohort in rural Niger

Introduction

Globally, access to treatment for severe and moderate acute malnutrition is very low, in part because different protocols and products are used in separate programs. New approaches, defining acute malnutrition (AM) as mid-upper arm circumference (MUAC) < 125 mm or oedema, are being investigated to compare effectiveness to current programs. Optimizing Malnutrition treatment (OptiMA) is one such strategy that treats AM with one product - ready-to-use therapeutic food, or RUTF - at reduced dosage as the child improves.

Methods

This study aimed to determine whether OptiMA achieved effectiveness benchmarks established in the Nigerien National Nutrition protocol. A prospective cohort study of children in the rural Mirriah district evaluated outcomes among children 6-59 months with uncomplicated AM treated under OptiMA. In a parallel, unconnected program in one of the two trial sites, all non-malnourished children 6-23 months of age were provided small quantity lipid-based nutritional supplements (SQ-LNS). A multivariate logistic regression identified factors associated with hospitalization.

Results

From July-December 2019, 1,105 children were included for analysis. Prior to treatment, 39.3% of children received SQ-LNS. Recovery, non-response, and mortality rates were 82.3%, 12.6%, and 0.7%, respectively, and the hospitalization rate was 15.1%. Children who received SQ-LNS before an episode of AM were 43% less likely to be hospitalized (ORa=0.57; 0.39-0.85, p = 0.004).

Discussion

OptiMA had acceptable recovery compared to the Nigerien reference but non-response was high. Children who received SQ-LNS before treatment under OptiMA were less likely to be hospitalized, showing potential health benefits of combining simplified treatment protocols with food-based prevention in an area with a high burden of malnutrition such as rural Niger.