Health Outcomes, Pathogenesis and Epidemiology of Severe Acute Malnutrition (HOPE-SAM): rationale and methods of a longitudinal observational study

Survival status and its predictors among undernourished children on antiretroviral therapy in Bahir Dar city, Northwest Ethiopia, 2010 - 2020, a multicenter retrospective cohort study

BACKGROUND

In environments with limited resources, undernutrition is a serious public health risk. Its dual relationship to human immunodeficiency virus infection (HIV) leads to crises in a child's physical, emotional, social, and economic spheres of life. Nevertheless, little research has been done on the survival rate and risk factors that lead to poor survival outcomes in undernourished children receiving antiretroviral therapy. This study sought to evaluate survival status and its predictors among undernourished children on antiretroviral therapy (ART) in public health facilities, Bahir Dar city, September 1, 2010 - December 31, 2020.

METHODS

An institution-based retrospective cohort study design was used among 414 study participants from September 1, 2010 - December 31, 2020. A simple random sampling method was applied to select study participants. All collected data were entered into epi data version 4.6 and exported to STATA version 14.0 for analysis. Each independent predictor variable with a p-value < 0.05 in the multivariable Cox proportional hazard regression was considered statistically significant.

RESULTS

The overall incidence of mortality was 11.6 deaths per 1000 child year observation (95%CI: 7.7- 17.5). Baseline weight for age < -3 Z score (adjusted hazard ratio (AHR) = 4.9, 95% CI: 1.30-18.98), height for age < -3 Z score (AHR = 4.34, 95%CI 1.13-16.6), cotrimoxazole prophylaxis given (AHR = 0.27, 95%CI 0.08-0.87), hemoglobin level < 10 g/dl (AHR = 3.7, 95%CI 1.1-12.7), CD4 cells < threshold (AHR = 4.86, 95%CI 1.9-12.7), and WHO clinical disease stage III and IV (AHR = 8.1, 95%CI 1.97-33) were found independent predictors of mortality.

CONCLUSION AND RECOMMENDATION

The incidence of mortality was determined in the study to be 11.6 per 1000 child years. Mortality was predicted by severe stunting, severe underweight, a low hemoglobin level, a low CD4 count, and WHO clinical stages III and IV. But the risk of death is reduced by starting cotrimoxazole preventative therapy early. The risk factors that result in a low survival status should be the primary focus of all concerned bodies, and early cotrimoxazole preventive treatment initiation is strongly recommended.

Inflammation and epithelial repair predict mortality, hospital readmission, and growth recovery in complicated severe acute malnutrition

Severe acute malnutrition (SAM) is the most high-risk form of undernutrition, particularly when children require hospitalization for complications. Complicated SAM is a multisystem disease with high inpatient and postdischarge mortality, especially in children with comorbidities such as HIV; however, the underlying pathogenesis of complicated SAM is poorly understood. Targeted multiplex biomarker analysis in children hospitalized with SAM (n = 264) was conducted on plasma samples, and inflammatory markers were assessed on stool samples taken at recruitment, discharge, and 12 to 24 and 48 weeks after discharge from three hospitals in Zimbabwe and Zambia. Compared with adequately nourished controls (n = 173), we found that at baseline, complicated SAM was characterized by systemic, endothelial, and intestinal inflammation, which was exacerbated by HIV infection. This persisted over 48 weeks despite nutritional recovery and was associated with children's outcomes. Baseline plasma concentrations of vascular endothelial growth factor, glucagon-like peptide-2, and intestinal fatty acid-binding protein were independently associated with lower mortality or hospital readmission over the following 48 weeks. Following principal components analysis of baseline biomarkers, higher scores of a component representing growth factors was associated with greater weight-for-height z score recovery and lower mortality or hospital readmission over the 48 weeks. Conversely, components representing higher gut and systemic inflammation were associated with higher mortality or hospital readmission. These findings highlight the interplay between inflammation, which damages tissues, and growth factors, which mediate endothelial and epithelial regeneration, and support further studies investigating interventions to reduce inflammation and promote epithelial repair as an approach to reducing mortality and improving nutritional recovery.

Adequate calorie and protein administration via enteral nutrition may contribute to improved 30-day survival in patients with solid tumors at nutritional risk

BACKGROUND

Patients with cancer receiving adequate enteral nutrition (EN) have improved clinical outcomes. Unfortunately, discrepancies may exist between the amounts prescribed and received. This study aimed to investigate: (1) the receiving exclusive EN, (2) the relationship between inadequacy and unfavorable outcomes, and (3) the impact of inadequate EN administration on the survival of patients with cancer.

METHODS

This study included hospitalized patients with solid tumors who exclusively received EN and were evaluated using data extracted from electronic medical records. Nutritional risk was evaluated using Nutritional Risk Screening (NRS - 2002). EN adequacy was assessed from days 3-7 of hospitalization. Calorie and protein delivery by EN was classified as adequate (≥80 % of EN administration) or inadequate (<80 % of EN administration). Data were analyzed using dispersion and Bland-Altman plots, Pearson's chi-square and Fisher's exact tests, and Kaplan-Meier survival curves.

RESULTS

A total of 114 patients were evaluated (63.9 ± 13.1 years of age, 67.5 % male, 32.5 % with head and neck cancer, and 86.8 % at nutritional risk). During the 5-day evaluation period, only 14 % of the patients received the mean volume, proteins, and calories according to the EN prescription. A relationship was observed between inadequate EN (<80 %) and 30-day in-hospital mortality. This result was confirmed by Kaplan-Meier survival analysis (p = 0.020), which showed a survival benefit in patients at nutritional risk who received adequate calories and protein.

CONCLUSION

This study demonstrated significant caloric and protein deficits related with EN. Furthermore, adequate calorie and protein administration could contribute to improved survival in patients with cancer who are at a risk of malnutrition, however, randomized controlled trials are required to confirm whether adequate calorie administration could contribute to improved survival.

Severe acute malnutrition promotes bacterial binding over proinflammatory cytokine secretion by circulating innate immune cells

Children with severe acute malnutrition (SAM) have high infectious mortality and morbidity, implicating defects in their immune defenses. We hypothesized that circulating innate immune cells from children (0 to 59 months) hospitalized with SAM in Zambia and Zimbabwe (n = 141) have distinct capacity to respond to bacteria relative to adequately nourished healthy controls (n = 92). SAM inpatients had higher neutrophil and monocyte Escherichia coli binding capacity but lower monocyte activation and proinflammatory mediator secretion in response to lipopolysaccharide or heat-killed Salmonella typhimurium than controls. Among SAM cases, wasting severity was negatively associated with cytokine secretion, children with HIV had lower monocyte activation, and the youngest children released the least myeloperoxidase upon stimulation. Inpatient bacterial binding capacity and monocyte activation were associated with higher odds of persistent SAM at discharge, a risk factor for subsequent mortality. Thus, SAM shifts innate immune cell function, favoring bacterial containment over proinflammatory activation, which may contribute to health deficits after discharge.

Fat and lean mass predict time to hospital readmission or mortality in children treated for complicated severe acute malnutrition in Zimbabwe and Zambia

HIV and severe wasting are associated with post-discharge mortality and hospital readmission among children with complicated severe acute malnutrition (SAM); however, the reasons remain unclear. We assessed body composition at hospital discharge, stratified by HIV and oedema status, in a cohort of children with complicated SAM in three hospitals in Zambia and Zimbabwe. We measured skinfold thicknesses and bioelectrical impedance analysis (BIA) to investigate whether fat and lean mass were independent predictors of time to death or readmission. Cox proportional hazards models were used to estimate the association between death/readmission and discharge body composition. Mixed effects models were fitted to compare longitudinal changes in body composition over 1 year. At discharge, 284 and 546 children had complete BIA and skinfold measurements, respectively. Low discharge lean and peripheral fat mass were independently associated with death/hospital readmission. Each unit Z-score increase in impedance index and triceps skinfolds was associated with 48 % (adjusted hazard ratio 0·52, 95 % CI (0·30, 0·90)) and 17 % (adjusted hazard ratio 0·83, 95 % CI (0·71, 0·96)) lower hazard of death/readmission, respectively. HIV-positive v. HIV-negative children had lower gains in sum of skinfolds (mean difference -1·49, 95 % CI (-2·01, -0·97)) and impedance index Z-scores (-0·13, 95 % CI (-0·24, -0·01)) over 52 weeks. Children with non-oedematous v. oedematous SAM had lower mean changes in the sum of skinfolds (-1·47, 95 % CI (-1·97, -0·97)) and impedance index Z-scores (-0·23, 95 % CI (-0·36, -0·09)). Risk stratification to identify children at risk for mortality or readmission, and interventions to increase lean and peripheral fat mass, should be considered in the post-discharge care of these children.

Risk factors for inpatient mortality among children with severe acute malnutrition in Zimbabwe and Zambia

BACKGROUND/OBJECTIVES

Malnutrition underlies 45% of deaths in children under-5 years annually. Children hospitalised with complicated severe acute malnutrition (SAM) have unacceptably high mortality. We aimed to identify variables from early hospital admission (baseline factors) independently associated with inpatient mortality in this cohort to identify those most at risk.

SUBJECTS/METHODS

Observational study of 745 children aged 0-59 months admitted with complicated SAM at three hospitals in Zimbabwe/Zambia. Children underwent anthropometry and clinical assessment by a study physician within 72 h of enrolment, and caregivers provided sociodemographic data. Children were followed-up daily until discharge/death. A multivariable survival analysis identified the baseline factors independently associated with mortality.

RESULTS

70/745 (9.4%) children died in hospital. Age between 6-23 months [aHR 6.53, 95%CI 2.24-19.02], higher mid-upper arm circumference [aHR 0.73, 95%CI 0.59-0.89], presence of oedema [aHR 2.22, 95%CI 1.23-4.05], shock [aHR 8.18, 95%CI 3.79-17.65], sepsis [aHR 3.13, 95%CI 1.44-6.80], persistent diarrhoea [aHR 2.27, 95%CI 1.18-4.37], lack of a toilet at home [aHR 4.35, 95%CI 1.65-11.47], and recruitment at one Harare site [aHR 0.38, 95%CI 0.18-0.83] were all independently associated with inpatient mortality. Oedematous children had a significantly higher birthweight [2987 g vs 2757 g, p < 0.001] than those without oedema; higher birthweight was weakly associated with mortality [aHR 1.50 95%CI 0.97-2.31].

CONCLUSIONS

Children with oedema, low MUAC, baseline infections, shock and lack of home sanitation had a significantly increased risk of inpatient mortality following hospitalisation for complicated SAM. Children with high-risk features may require additional care. A better understanding of the pathophysiology of SAM is needed to identify adjunctive interventions.

Prolonged dysbiosis and altered immunity under nutritional intervention in a physiological mouse model of severe acute malnutrition

Severe acute malnutrition (SAM) is a multifactorial disease affecting millions of children worldwide. It is associated with changes in intestinal physiology, microbiota, and mucosal immunity, emphasizing the need for multidisciplinary studies to unravel its full pathogenesis. We established an experimental model in which weanling mice fed a high-deficiency diet mimic key anthropometric and physiological features of SAM in children. This diet alters the intestinal microbiota (less segmented filamentous bacteria, spatial proximity to epithelium), metabolism (decreased butyrate), and immune cell populations (depletion of LysoDC in Peyer's patches and intestinal Th17 cells). A nutritional intervention leads to a fast zoometric and intestinal physiology recovery but to an incomplete restoration of the intestinal microbiota, metabolism, and immune system. Altogether, we provide a preclinical model of SAM and have identified key markers to target with future interventions during the education of the immune system to improve SAM whole defects.

The Geriatric Nutritional Risk Index (GNRI) as a Prognostic Biomarker for Immune Checkpoint Inhibitor Response in Recurrent and/or Metastatic Head and Neck Cancer

Malnutrition is a frequent comorbidity in head and neck cancer patients and has been shown to impair immunotherapy response in other cancer types. The geriatric nutritional risk index (GNRI) assesses malnutrition using the patient's ideal weight, actual weight, and serum albumin. The aim of this study was to evaluate the prognostic relevance of malnutrition as determined by the GNRI for the response to immunotherapy in recurrent and/or metastatic head and neck squamous cell carcinoma (R/M HNSCC). A total of 162 patients with R/M HNSCC who received immune checkpoint inhibitors were included. The associations between the GNRI and progression-free survival (PFS), overall survival (OS), and the disease control rate (DCR) were computed. Univariable analysis showed worse PFS for GNRI ≤ 98 (p < 0.001), ECOG performance status (PS) ≥ 2 (p = 0.012), and enteral (p = 0.009) and parenteral (p = 0.015) nutritional supplementation, and worse OS for GNRI < 92 (p < 0.001), ECOG PS ≥ 2 (p < 0.001), and enteral (p = 0.008) and parenteral (p = 0.023) nutritional supplementation. In our multivariable model, GNRI ≤ 98 (p = 0.012) and ECOG PS ≥ 2 (p = 0.025) were independent prognostic factors for PFS. For OS, GNRI < 92 (p < 0.001) and ECOG PS ≥ 2 (p < 0.001) were independent prognostic factors. A GNRI ≤ 98 was significantly associated with a lower DCR compared to a GNRI > 98 (p = 0.001). In conclusion, our findings suggest that the GNRI may be an effective predictor for response to immunotherapy in R/M HNSCC.

Recovery of children following hospitalisation for complicated severe acute malnutrition

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

One‐in‐six children managed for SAM were readmitted into hospital over the first year after discharge and one‐in‐eight remained undernourished by 52 weeks of follow‐up.

Nonoedematous SAM, ongoing SAM at the time of discharge and underlying cerebral palsy were independent risk factors for hospital readmission and poor nutritional recovery.

Low HAZ was a risk factor for hospital readmission and poor nutritional recovery.

Postdischarge care should focus on children with disability, nonoedematous SAM at initial hospitalisation and have ongoing SAM at the time of discharge.

Stunting should be considered in the management of children with SAM.

Underlying Causes and Co-existence of Malnutrition and Infections: An Exceedingly Common Death Risk in Cancer

In nutrition science, malnutrition is a state of imbalance between intake and the needs of the organism, leading to metabolic changes, impaired physiological functions, and weight loss. Regardless of the countless efforts being taken and researched for years, the burden of malnutrition is still alarming and considered a significant agent of mortality across the globe. Around 45% of 12 million children deaths (0–5 years old) annually are due to malnutrition, mostly from developing countries. Malnutrition develops associations with other infections and leads to substantial clinical outcomes, such as mortality, more visits to hospitals, poor quality of life and physical frailty, and socioeconomic issues. Here, in this review, we intend to provide an overview of the current burden, underlying risk factors, and co-existence of malnutrition and other infections, such as cancer. Following the rising concern of the vicious interplay of malnutrition and other medical illnesses, we believed that this narrative review would highlight the need to re-make and re-define the future strategies by giving comprehensive and sustainable programs to alleviate poverty and combat the rampant infectious diseases and those nutrition-related health problems. Furthermore, the study also raises the concern for hospitalized malnourished cancer patients as it is crucially important to knowledge the caregiver healthcare staff for early interventions of providing nutritional support to delay or prevent the onset of malnutrition.

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

Context:

In Gujarat, 39.7% of children are underweight and 10.6% are severely wasted in under five years of age. Nutritional rehabilitation centers started by the Government of Gujarat under the “Mission Balam Sukham” program focused at providing an energy-dense diet and protein along with other nutrients to combat malnutrition in children by hospital admission.

Aim:

To estimate the effect of nutritional intervention on Anthropometric measurements of malnourished children at Nutritional Rehabilitation Center (NRC), Civil Hospital, Ahmedabad.

Settings and Design:

A hospital-based cross-sectional study was conducted at the NRC of B. J. Medical College, Civil Hospital, Ahmedabad, Gujarat.

Methods and Material:

It was a hospital-based cross-sectional study conducted at NRC, Civil Hospital, Ahmedabad from January 2017 till December 2017 (1-year duration). A total of 159 children, 0–5 years were admitted in NRC during this period and observed during their stay with three follow-up visits.

Statistical Analysis Used:

Z-test, one-way ANOVA on repeated measures test.

Results:

The majority of the admitted children were in the age group of 12–23 months. Overall mean weight at admission was 6.1 ± 1.7 Kg. The increase in mean weight at discharge was 6.5 ± 1.9 Kg. The mean weight on the third follow-up was 7.4 ± 1.9 Kg. Nearly 62.3% of severely malnourished children had improvement (cured) after treatment that was given during NRC admission.

Conclusions:

The present study confirmed the effectiveness of nutrition rehabilitation centers in the management of severe acute malnutrition.

Plasmodium chabaudi Infection Alters Intestinal Morphology and Mucosal Innate Immunity in Moderately Malnourished Mice

Plasmodium falciparum is a protozoan parasite which causes malarial disease in humans. Infections commonly occur in sub-Saharan Africa, a region with high rates of inadequate nutrient consumption resulting in malnutrition. The complex relationship between malaria and malnutrition and their effects on gut immunity and physiology are poorly understood. Here, we investigated the effect of malaria infection in the guts of moderately malnourished mice. We utilized a well-established low protein diet that is deficient in zinc and iron to induce moderate malnutrition and investigated mucosal tissue phenotype, permeability, and innate immune response in the gut. We observed that the infected moderately malnourished mice had lower parasite burden at the peak of infection, but damaged mucosal epithelial cells and high levels of FITC-Dextran concentration in the blood serum, indicating increased intestinal permeability. The small intestine in the moderately malnourished mice were also shorter after infection with malaria. This was accompanied with lower numbers of CD11b⁺ macrophages, CD11b⁺CD11c⁺ myeloid cells, and CD11c⁺ dendritic cells in large intestine. Despite the lower number of innate immune cells, macrophages in the moderately malnourished mice were highly activated as determined by MHCII expression and increased IFNγ production in the small intestine. Thus, our data suggest that malaria infection may exacerbate some of the abnormalities in the gut induced by moderate malnutrition.

Risk factors for postdischarge mortality following hospitalization for severe acute malnutrition in Zimbabwe and Zambia

BACKGROUND

Children discharged from hospital following management of complicated severe acute malnutrition (SAM) have a high risk of mortality, especially HIV-positive children. Few studies have examined mortality in the antiretroviral therapy (ART) era.

OBJECTIVES

Our objectives were to ascertain 52-wk mortality in children discharged from hospital for management of complicated SAM, and to identify independent predictors of mortality.

METHODS

A prospective cohort study was conducted in children enrolled from 3 hospitals in Zambia and Zimbabwe between July 2016 and March 2018. The primary outcome was mortality at 52 wk. Univariable and multivariable Cox regression models were used to identify independent risk factors for death, and to investigate whether HIV modifies these associations.

RESULTS

Of 745 children, median age at enrolment was 17.4 mo (IQR: 12.8, 22.1 mo), 21.7% were HIV-positive, and 64.4% had edema. Seventy children (9.4%; 95% CI: 7.4, 11.7%) died and 26 exited during hospitalization; 649 were followed postdischarge. At discharge, 43.9% had ongoing SAM and only 50.8% of HIV-positive children were receiving ART. Vital status was ascertained for 604 (93.1%), of whom 55 (9.1%; 95% CI: 6.9, 11.7%) died at median 16.6 wk (IQR: 9.4, 21.9 wk). Overall, 20.0% (95% CI: 13.5, 27.9%) and 5.6% (95% CI: 3.8, 7.9%) of HIV-positive and HIV-negative children, respectively, died [adjusted hazard ratio (aHR): 3.83; 95% CI: 2.15, 6.82]. Additional independent risk factors for mortality were ongoing SAM (aHR: 2.28; 95% CI: 1.22, 4.25), cerebral palsy (aHR: 5.60; 95% CI: 2.72, 11.50) and nonedematous SAM (aHR: 2.23; 95% CI: 1.24, 4.01), with no evidence of interaction with HIV status.

CONCLUSIONS

HIV-positive children have an almost 4-fold higher mortality than HIV-negative children in the year following hospitalization for complicated SAM. A better understanding of causes of death, an improved continuum of care for HIV and SAM, and targeted interventions to improve convalescence are needed.

Treatment outcomes of severe acute malnutrition and predictors of recovery in under-five children treated within outpatient therapeutic programs in Ethiopia: a systematic review and meta-analysis

Background

Severe acute malnutrition affects around 17 million under-five children in the world, of which the highest burden is accounted by Sub-Saharan Africa where Ethiopia is found. Though there are few individual, inconsistent and inconclusive studies, there is no nationally representative study on treatment outcomes of SAM in outpatient therapeutic feeding programs of Ethiopia. This study aimed at estimating the pooled treatment outcomes and predictors of recovery rate among under- five children with SAM in Ethiopia.

Methods

Electronic databases (PubMed, Medline (EBSCOhost), EMBASE (Elsevier), CINAHL (EBSCOhost), web of science, Scopus, Science Direct and Food Science and Technology Abstracts (FSTA)), and grey literature sources (Google scholar, Mednar, World Cat and google) were used to retrieve articles. The random effect model was used to estimate the pooled treatment outcomes. Hazard ratios were used to determine the predictors of recovery rate. Cochran’s Q, I², and univariate Meta regression were done for heterogeneity. Begg’s & Egger’s tests were used for publication bias.

Results

Nineteen articles with a total number of 23,395 under-five children with SAM were used for this meta-analysis. The pooled recovery, death, defaulter and non-recovery rates were 70% (95% CI: 64, 76), 2% (95% CI: 1, 2), 10% (95%CI: 7, 12), 15% (95% CI: 10, 20), respectively. Diarrhea (HR = 0.8, 95% CI: 0.75, 0.94), no edema (HR = 0.41, 95% CI: 0.33, 0.50) and amoxicillin (HR = 1.81, 95% CI: 1.18, 2.44) were independent predictors of recovery rate of children with SAM in Ethiopia. Publication year was found to be the potential source of heterogeneity between included studies.

Conclusion

The treatment outcomes of children with SAM from outpatient therapeutic feeding programs of Ethiopia are lower than the sphere guidelines, WHO and national recommendations. Diarrhea and no edema antagonized the recovery rate of children, while amoxicillin enhanced the recovery rate of children from SAM. Community health workers need to be trained. Especial attention should be given while treating children with diarrhea and severe wasting. Community mobilization is also recommended to improve community awareness about the therapeutic foods.

Clinico-biochemical profile of sick children with severe acute malnutrition

Objective

Severe acute malnutrition (SAM) classified as edematous and marasmus, however, Kwashiorker represents the most severe phenotype of edematous malnutrition. The aim of this study was to describe the clinico-biochemical profile in sick children with severe acute malnutrition.

Materials and Methods

This is a descriptive cross-sectional study, which included children aged 6 to 60 months, fulfilling the World Health Organization (WHO) criteria of severe acute malnutrition. We collected data on demography, anthropometry, history, and clinical examination. Investigations included arterial blood gas analysis, serum electrolytes, calcium, serum albumin, and blood sugar. P value < 0.05 was considered significant.

Results

One hundred twenty-two children with SAM were recruited, out of which 65 (53.27%) had edematous malnutrition and 57 (46.7%) had nonedematous malnutrition. Out of total children, 90 (73.77%) were discharged from hospital, 18 (14.7%) died, and 14 (11.4%) were left against medical advice. Out of 122 children with SAM, edematous children were younger (25.7 vs. 34.5 months, P = 0.002). Children with edematous malnutrition were more likely to have pneumonia (P = 0.04), acute gastroenteritis (P < 0.001), hyponatremia (P = 0.04), metabolic acidosis (P = 0.005), and hypocalcemia (P = 0.006) when compared with nonedematous children. Edematous malnutrition has 1.3 and 1.4 times more risk of death and leave against medical advice (LAMA) respectively as compared to nonedematous malnutrition. Mortality was higher in edematous malnutrition (12, 66.6%) than nonedematous malnutrition (6, 33.3%).

Conclusion

Edematous malnutrition was commonly prevalent in 1 to 3 years of children and clinical and biochemical abnormalities frequently co-exist with edematous malnutrition.

Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study

Background

In South Africa, 30.9% of children under five years with Severe Acute Malnutrition (SAM) died in 2018. We aimed to identify factors associated with mortality among children under five years hospitalized with SAM in Limpopo province, South Africa.

Methods

We conducted a cross-sectional study including children under five years admitted with SAM from 2014 to 2018 in public hospitals of Limpopo province. We extracted socio-demographic and clinical data from hospital records. We used logistic regression to identify factors associated with mortality.

Findings

We included 956 children, 50.2% (480/956) male and 49.8% (476/956) female. The median age was 13 months (inter quartile range: 9–19 months). The overall SAM mortality over the study period was 25.9% (248/956). The most common complications were diarrhea, 63.8% (610/956), and lower respiratory tract infections (LRTIs), 42.4% (405/956). Factors associated with mortality included herbal medication use (adjusted Odds Ratio (aOR): 2.2, 95% Confidence Interval (CI): 1.4–3.5, p = 0.001), poor appetite (aOR: 2.7, 95% CI: 1.4–5.2, p = 0.003), Mid-upper circumference (MUAC) <11.5 cm (aOR: 3.0, 95% CI: 1.9–4.7, p<0.001), lower respiratory tract infections (LRTIs) (aOR: 1.6, 95% CI: 1.2–2.0, p<0.001), anemia (aOR: 2.5, 95% CI: 1.1–5.3, p = 0.021), hypoglycemia (aOR: 12.4, 95% CI: 7.1–21.8, p<0.001) and human immunodeficiency virus (HIV) infection (aOR: 2.3, 95% CI: 1.6–3.3, p<0.001).

Interpretation

Herbal medication use, poor appetite, LRTIs, anemia, hypoglycemia, and HIV infection were associated with mortality among children with SAM. These factors should guide management of children with SAM.

Diet and the Human Gut Microbiome: An International Review

This review summarizes the key results of recently published studies on the effects of dietary change and nutritional intervention on the human microbiome from around the world, focusing on the USA, Canada, Europe, Asia, and Africa. It first explores mechanisms that might explain the ability of fiber-rich foods to suppress the incidence and mortality from westernized diseases, notably cancers of the colon, breast, liver, cardiovascular, infectious, and respiratory diseases, diabetes, and obesity (O'Keefe in Lancet Gastroenterol Hepatol 4(12):984-996, 2019; Am J Clin Nutr 110:265-266, 2019). It summarizes studies from Africa which suggest that disturbance of the colonic microbiome may exacerbate chronic malnutrition and growth failure in impoverished communities and highlights the importance of breast feeding. The American section discusses the role of the microbiome in the swelling population of patients with obesity and type 2 diabetes and examines the effects of race, ethnicity, geography, and climate on microbial diversity and metabolism. The studies from Europe and Asia extoll the benefits of whole foods and plant-based diets. The Asian studies examine the worrying changes from low-fat, high-carbohydrate diets to high-fat, low-carbohydrate ones and the increasing appearance of westernized diseases as in Africa and documents the ability of high-fiber traditional Chinese diets to reverse type 2 diabetes and control weight loss. In conclusion, most of the studies reviewed demonstrate clear changes in microbe abundances and in the production of fermentation products, such as short-chain fatty acids and phytochemicals following dietary change, but the significance of the microbiota changes to human health, with the possible exception of the stimulation of butyrogenic taxa by fiber-rich foods, is generally implied and not measured. Further studies are needed to determine how these changes in microbiota composition and metabolism can improve our health and be used to prevent and treat disease.

TAME trial: a multi-arm phase II randomised trial of four novel interventions for malnutrition enteropathy in Zambia and Zimbabwe - a study protocol

INTRODUCTION

Severe acute malnutrition (SAM) in children in many countries still carries unacceptably high mortality, especially when complicated by secondary infection or metabolic derangements. New therapies are urgently needed and we have identified mucosal healing in the intestine as a potential target for novel treatment approaches.

METHODS AND ANALYSIS

The TAME trial (Therapeutic Approaches for Malnutrition Enteropathy) will evaluate four novel treatments in an efficient multi-arm single-blind phase II design. In three hospitals in Zambia and Zimbabwe, 225 children with SAM will be randomised to one of these treatments or to standard care, once their inpatient treatment has reached the point of transition from stabilisation to increased nutritional intake. The four interventions are budesonide, bovine colostrum or N-acetyl glucosamine given orally or via nasogastric tube, or teduglutide given by subcutaneous injection. The primary endpoint will be a composite score of faecal inflammatory markers, and a range of secondary endpoints include clinical and laboratory endpoints. Treatments will be given daily for 14 days, and evaluation of the major endpoints will be at 14 to 18 days, with a final clinical evaluation at 28 days. In a subset of children in Zambia, endoscopic biopsies will be used to evaluate the effect of interventions in detail.

ETHICS AND DISSEMINATION

The study has been approved by the University of Zambia Biomedical Research Ethics Committee (006-09-17, dated 9^th July, 2018), and the Joint Research Ethics Committee of the University of Zimbabwe (24^th July, 2019). Caregivers will provide written informed consent for each participant. Findings will be disseminated through peer-reviewed journals, conference presentations and to caregivers at face-to-face meetings.

TRIAL REGISTRATION NUMBER

NCT03716115; Pre-results.

Assessing effectiveness of a novel mid-upper arm circumference Z-score tape in a community setting in Guatemala

Background

Mid-Upper Arm Circumference (MUAC) is an independent anthropometric measurement used to identify malnutrition in children. While much research has been dedicated to applying fixed estimates of MUAC to identify cases of malnutrition in children under 5 years of age, far less has been done with age-specific MUAC Z-score values across the continuum of age from birth through adolescence.

Methods

The present study examined the effectiveness of a novel MUAC Z-score tape, in the hands of community health volunteers, to identify children over the age of 5 who would benefit from nutritional rehabilitation. In January of 2019, 112 community health volunteers working within Children International in Guatemala were trained to use the MUAC Z-score tape and asked to collect measurements on children or youth in their communities.

Results

Of the 818 MUAC Z-score tape measurements obtained by volunteers, 88.26% (722/818) were concordant with nutritional risk status as predicted by BMI Z-score, and 90.95% (744/818) were concordant with MUAC Z-score tape measurements made by field medical staff. MUAC Z-scores identified 87.10% (27/31) of the severely or moderately undernourished children as determined by the BMI Z-score who would be candidates for the nutrition rehabilitation program (Z-score ≤ − 2) along with an additional six children that would not have been classified as such with BMI Z-score. A qualitative survey distributed to the volunteers showed moderate rates of understanding of nutritional risk using the tape, and 62.50% reported the tape was easy to use.

Conclusions

These quantitative and qualitative findings suggest that with more in-depth training and education the MUAC Z-score tape is a viable, low-cost, low-burden alternative for community-level nutritional status assessment among the population served by Children International in Guatemala.

Supplementary information

Supplementary information accompanies this paper at (10.1186/s13690-019-0370-0).

Current Understanding of Innate Immune Cell Dysfunction in Childhood Undernutrition

Undernutrition affects millions of children in low- and middle-income countries (LMIC) and underlies almost half of all deaths among children under 5 years old. The growth deficits that characterize childhood undernutrition (stunting and wasting) result from simultaneous underlying defects in multiple physiological processes, and current treatment regimens do not completely normalize these pathways. Most deaths among undernourished children are due to infections, indicating that their anti-pathogen immune responses are impaired. Defects in the body's first-line-of-defense against pathogens, the innate immune system, is a plausible yet understudied pathway that could contribute to this increased infection risk. In this review, we discuss the evidence for innate immune cell dysfunction from cohort studies of childhood undernutrition in LMIC, highlighting knowledge gaps in almost all innate immune cell types. We supplement these gaps with insights from relevant experimental models and make recommendations for how human and animal studies could be improved. A better understanding of innate immune function could inform future tractable immune-targeted interventions for childhood undernutrition to reduce mortality and improve long-term health, growth and development.