Birthweight, HIV exposure and infant feeding as predictors of malnutrition in Botswanan infants

Cardio-Metabolic Health of Offspring Exposed in Utero to Human Immuno-Deficiency Virus and Anti-Retroviral Treatment: A Systematic Review

BACKGROUND

Antiretroviral treatment (ART) use during pregnancy continues to rise as it is known to decrease the likelihood of HIV transmission from mother to child. However, it is still unknown whether foetal exposure to (ART) may affect the foetal environment, predisposing the offspring to cardiometabolic risk. Therefore, the aim of this study was to systematically review the cardio-metabolic effects of in utero exposure to HIV/ART on offspring.

METHODS

We carried out a systematic review and obtained literature from the Google scholar, PubMed, ProQuest, Web of Science, and Scopus databases. Two independent reviewers evaluated the titles, abstracts, and full-length English contents. Data from the eligible studies were included.

RESULTS

The search yielded 7596 records. After assessing all of these records, 35 of the full-length articles were included in this systematic review. Several studies showed that low birth weight, small head circumference, and altered mitochondrial content were more common among HIV-exposed uninfected (HEU) children compared to HIV-unexposed uninfected children (HUU). A few studies demonstrated elevated triglyceride levels, lower levels of insulin, and increased blood pressure, oxidative stress, vascular dysfunction, cardiac damage, and myocardial dysfunction among HEU children compared with HUU children.

CONCLUSION

Most findings showed that there were cardio-metabolic health risk factors among HEU children, indicating that maternal exposure to HIV and ART may negatively affect foetal health, which may lead to cardio-metabolic morbidity later in life.

"It has changed my life": unconditional cash transfers and personalized infant feeding support- a feasibility intervention trial among women living with HIV in western Kenya

BACKGROUND

The syndemic effects of poverty, food insecurity and living with HIV are recognized as global health priorities, including through the United Nations Sustainability Goals 1, 2 and 3. Today, women and girls account for 63% of all new HIV infections in eastern and southern Africa, including Kenya. Pregnant and postpartum women living with HIV in this setting face unique challenges including increased financial insecurity as women leave the work force to care for their newborn infants. This contributes to poverty, food scarcity and stress.

METHODS

To address financial insecurity, improve infant feeding and reduce stress among mothers living with HIV in this setting, we developed a multilevel intervention, Supporting Healthy Mothers, consisting of 10 monthly unconditional cash transfers (10,000 KES, ~$75 USD/month) and personalized infant feeding support from pregnancy to 7 months postpartum. We conducted a non-randomized feasibility trial of this intervention among women engaged in HIV care in Kisumu, Kenya. From February 23, 2022 to March 23, 2022, we enrolled a total of 40 women who were 20-35 weeks pregnant-20 women to the intervention group at a public clinic, and 20 women to the control group at a similar clinic. Our aim was to assess feasibility, acceptability, and the potential impact of the intervention on food security, infant feeding and maternal mental health.

RESULTS

Analyzing data from all 40 participants, we found a significant reduction in food insecurity scores from baseline for the intervention group when compared to the control group at 6 weeks and 6 months postpartum (p = 0.0008 and p < 0.0001, respectively). Qualitative exit interviews with intervention group participants confirmed women felt more financially secure and had newly acquired practical knowledge and skills related to infant feeding. Women found the two intervention components highly acceptable and described an overall positive impact on wellbeing.

CONCLUSIONS

The Supporting Healthy Mothers intervention has potential to positively impact women across the perinatal period and beyond by increasing financial security and supporting women to overcome infant feeding challenges and should be assessed in larger trials.

TRIAL REGISTRATION

Supporting Healthy Mothers was registered with ClinicalTrials.gov Protocol Registration and Results System, initially published on February 1, 2022.

CLINICALTRIALS

gov ID: NCT05219552 Protocol ID: K23MH116807.

Comparison of Feeding Practices and Growth of Urbanized African Infants Aged 6-12 Months Old by Maternal HIV Status in Gauteng Province, South Africa

Appropriate feeding practices are protective against malnutrition and poor growth. We compared feeding practices and growth in HIV-exposed-uninfected (HEU) and HIV-unexposed-uninfected (HUU) between 6-12 months of age in urbanized African infants in South Africa. A repeated cross-sectional analysis was used to determine differences in infant feeding practices and anthropometric measures by HIV exposure status at 6, 9, and 12 months in the Siyakhula study. The study included 181 infants (86 HEU; 95 HUU). Breastfeeding rates were lower in HEU vs. HUU infants at 9 (35.6% vs. 57.3%; p = 0.013) and 12 months (24.7% vs. 48.0%; p = 0.005). Introduction to early complementary foods was common (HEU = 16.2 ± 11.0 vs. HUU = 12.8 ± 9.3 weeks; p = 0.118). Lower weight-for-age Z-scores (WAZ) and head circumference-for-age Z-scores (HCZ) were found in HEU infants at birth. At 6 months, WAZ, length-for-age Z-scores (LAZ), HCZ, and mid-upper-arm circumference-for-age Z-scores (MUACAZ) were lower in HEU vs. HUU infants. At 9 months, lower WAZ, LAZ, and MUACAZ were found in HEU vs. HUU infants. At 12 months, lower WAZ, MUACAZ, and weight-for-length Z-scores (-0.2 ± 1.2 vs. 0.2 ± 1.2; p = 0.020) were observed. HEU infants had lower rates of breastfeeding and poorer growth compared to HUU infants. Maternal HIV exposure affects the feeding practices and growth of infants.

Children who are HIV-exposed and uninfected: evidence for action

Prior to widespread availability of antiretroviral therapy (ART) in sub-Saharan Africa, children who were HIV-exposed but uninfected (HEU) had increased mortality, morbidity and undernutrition compared with children who were HIV-unexposed. Scale-up of ART has led to impressive declines in vertical HIV transmission, but over 15 million children are now HEU, 90% of whom live in sub-Saharan Africa. There are ongoing health disparities among children who are HEU, with higher mortality, morbidity and stunting and modest impairments in early child development, which collectively hamper health and human capital in high prevalence countries. The underlying causes are multifactorial and include exposure to HIV, co-infections and a skewed antenatal inflammatory milieu, particularly if mothers start ART once they have advanced disease, as well as socioeconomic risk factors, which may cluster in HIV-affected households. Improving maternal health through early and sustained ART, ensuring optimal breastfeeding, and implementing evidence-based priority interventions for all children in areas of high HIV prevalence, will likely improve outcomes. A more comprehensive intervention package based on the Nurturing Care Framework may have particular benefits for children who are HEU, to close health gaps and ensure that the next generation of HIV-free children survive and thrive, and lead healthy and productive lives.

Disparities in childhood composite index of anthropometric failure prevalence and determinants across Ethiopian administrative zones

BACKGROUND

The prevalence of under-five children's undernutrition in Ethiopia is among the highest in the world. This study aimed at exploring the prevalence and risk factors of the composite index for anthropometric failure (CIAF) of under-five children in Ethiopia by incorporating the zonal (district) effects.

METHODS

The data was drawn from Ethiopian Demographic and Health Surveys (EDHSs), a population-based cross-sectional study of 29,599 under-five year children from 72 Zones in the years 2000, 2005, 2011, and 2016. Fixed effect variables related to child and maternal-household were included in the model. We adopted a generalized mixed model with CIAF as outcome variable and Zones as random effects.

RESULTS

The prevalence of CIAF in Ethiopia was 53.78% with the highest prevalence of 61.30% in 2000 and the lowest prevalence of 46.58% in 2016. The model result revealed that being a female child, absence of comorbidity, singleton births, and the first order of birth showed significantly lower CIAF prevalence than their counterparts. Among the household characteristics, children from mothers of underweight body mass index, uneducated parents, poor household sanitation, and rural residents were more likely to be undernourished than their counterparts. Based on the best linear unbiased prediction for the zonal-level random effect, significant variations of CIAF among zones were observed.

CONCLUSION

The generalized linear mixed-effects model results identified gender of the child, size of child at birth, dietary diversity, birth type, place of residence, age of the child, parental level of education, wealth index, sanitation facilities, and media exposure as main drivers of CIAF. Disparities of CIAF were observed between and within the Ethiopian administrative Zones over time.

Growth patterns and clinical outcomes in association with breastfeeding duration in HIV exposed and unexposed infants: a cohort study in KwaZulu Natal, South Africa

Background

Exclusive breastfeeding for 6 months and breastfeeding with complementary feeds until 12 months for HIV exposed and uninfected (HEU) infants or 24 months for HIV unexposed (HU) infants is the current World Health Organisation (WHO) recommendation for low and middle income countries (LMICs) to improve clinical outcomes and growth trajectories in infants. In a post-hoc evaluation of HEU and HU cohorts, we examine growth patterns and clinical outcomes in the first 9 months of infancy in association with breastfeeding duration.

Methods

Two cohorts of infants, HEU and HU from a low-socioeconomic township in South Africa, were evaluated from birth until 9 months of age. Clinical, anthropometric and infant feeding data were analysed. Standard descriptive statistics and regression analysis were performed to determine the effect of HIV exposure and breastfeeding duration on growth and clinical outcomes.

Results

Included in this secondary analysis were 123 HEU and 157 HU infants breastfed for a median of 26 and 14 weeks respectively. Median WLZ score was significantly (p < 0.001) lower in HEU than HU infants at 3, 6 and 9 months (− 0.19 vs 2.09; − 0.81 vs 0.28; 0.05 vs 0.97 respectively). The median LAZ score was significantly lower among HU infants at 3 and 6 months (− 1.63 vs 0.91, p < 0.001; − 0.37 vs 0.51, p < 0.01) and a significantly higher proportion of HU was classified as stunted (LAZ < -2SD) at 3 and 6 months (3.9% vs 44.9%, p < 0.001; 4.8% vs 20.9%, p < 0.001 respectively) independent of breastfeeding duration. A higher proportion of HEU infants experienced one or more episodes of skin rash (44.5% vs 12.8%) and upper respiratory tract infection (URTI) (30.1% vs 10.9%) (p < 0.0001). In a multivariable analysis, the odds of occurrence of wasting, skin rash, URTI or any clinical adverse event in HEU infants were 2.86, 7.06, 3.01 and 8.89 times higher than HU infants after adjusting for breastfeeding duration.

Conclusion

Our study has generated additional evidence that HEU infants are at substantial risk of infectious morbidity and decreased growth trajectories however we have further demonstrated that these adverse outcomes were independent of breastfeeding duration.

Nutrition, growth, and other factors associated with early cognitive and motor development in Sub-Saharan Africa: a scoping review

BACKGROUND

Food insecurity, poverty and exposure to infectious disease are well-established drivers of malnutrition in children in Sub-Saharan Africa. Early development of cognitive and motor skills - the foundations for learning - may also be compromised by the same or additional factors that restrict physical growth. However, little is known about factors associated with early child development in this region, which limits the scope to intervene effectively. To address this knowledge gap, we compared studies that have examined factors associated with early cognitive and/or motor development within this population.

METHODS

Predetermined criteria were used to examine four publication databases (PsycInfo, Embase, Web of Science and Medline) and identify studies considering the determinants of cognitive and motor development in children aged 0-8 years in Sub-Saharan Africa.

RESULTS

In total, 51 quantitative studies met the inclusion criteria, reporting on 30% of countries across the region. Within these papers, factors associated with early child development were grouped into five themes: Nutrition, Growth and Anthropometry, Maternal Health, Malaria and HIV, and Household. Food security and dietary diversity were associated with positive developmental outcomes, whereas exposure to HIV, malaria, poor maternal mental health, poor sanitation, maternal alcohol abuse and stunting were indicators of poor cognitive and motor development.

DISCUSSION

In this synthesis of research findings obtained across Sub-Saharan Africa, factors that restrict physical growth are also shown to hinder the development of early cognitive and motor skills, although additional factors also influence early developmental outcomes. The study also reviews the methodological limitations of conducting research using Western methods in sub-Saharan Africa.

Beyond Early Infant Diagnosis: Changing the Approach to HIV-Exposed Infants

Despite dramatic global progress with implementing prevention of mother-to-child HIV transmission (PMTCT) programs, there were 160,000 new pediatric HIV infections in 2016. More than 50% of infant HIV infections now occur in the postpartum period, reflecting the relatively high coverage of interventions in the antenatal period and the need for greater attention to the breastfeeding mother and her HIV-exposed infant (HEI). Early diagnosis and treatment are critical to prevent morbidity and mortality in HIV-infected children; however, early infant HIV testing rates remain low in most high HIV-burden countries. Furthermore, systematic retention and follow-up of HEI in the postpartum period and ascertainment of final HIV status remain major program gaps. Despite multiple calls to action to improve infant HIV testing rates, progress has been marginal due to a lack of focus on the critical health care needs of HEI coupled with health system barriers that result in fragmented services for HIV-infected mothers and their families. In this paper, we describe the available evidence on the health outcomes of HEI, define a comprehensive care package for HEI that extends beyond early HIV testing, and describe successful examples of integrated services for HEI.

The epidemiology of undernutrition and its determinants in children under five years in Ghana

BACKGROUND

Understanding the burden and contextual risk factors is critical for developing appropriate interventions to control undernutrition.

METHODS

This study used data from the 2014 Ghana Demographic and Health Survey to estimate the prevalence of underweight, stunting, and wasting. Single multiple logistic regressions were used to identify the factors associated with underweight, wasting and stunting. The study involved 2720 children aged 0-59 months old and mother pairs. All analyses were done in STATA/IC version 15.0. Statistical significance was set at p<0.05.

RESULTS

The prevalence of underweight, wasting and stunting were 10.4%, 5.3%, and 18.4% respectively. The age of the child was associated with underweight, wasting and stunting, whereas the sex was associated with wasting and stunting. Normal or overweight/obese maternal body mass index category, high woman's autonomy and middle-class wealth index were associated with a lower odds of undernutrition. The factors that were associated with a higher odds of child undernutrition included: low birth weight (<2.5 kg), minimum dietary diversity score (MDDS), a higher (≥4th) birth order number of child, primary educational level of husband/partner and domicile in the northern region of Ghana.

CONCLUSION

There is still a high burden of child undernutrition in Ghana. The age, sex, birth weight, birth order and the MDDS of the child were the immediate factors associated with child undernutrition. The intermediate factors that were associated with child undernutrition were mainly maternal related factors and included maternal nutritional status and autonomy. Distal level factors which were associated with a higher odds of child undernutrition were the wealth index of the household, paternal educational status and region of residence. We recommend that interventions and policies for undernutrition should address socioeconomic inequalities at the community level while factoring in women empowerment programmes.

Impact of maternal HIV exposure, feeding status, and microbiome on infant cellular immunity

At least one-third of infants born in sub-Saharan Africa have been exposed to the effects of maternal HIV infection and antiretroviral treatment. Intrauterine HIV exposure is associated with increased rates of morbidity and mortality in children. Although the mechanisms responsible for poor infant health with HIV-1 exposure are likely to be multifactorial, we posit that the maternal environment during gestation and in the perinatal period results in altered infant immunity and is possibly the strongest contributing factor responsible for the disproportionally high infectious events among HIV-exposed infants who remain HIV uninfected. This review provides a synthesis of studies reporting the impact of intrauterine HIV exposure, feeding practices, and microbiota on immune ontogeny in the first year of life in HIV-exposed uninfected infants.