1
|
Bliznashka L, Grantz KH, Botton J, Berthé F, Garba S, Hanson KE, Grais RF, Isanaka S. Burden and risk factors for relapse following successful treatment of uncomplicated severe acute malnutrition in young children: Secondary analysis from a randomised trial in Niger. MATERNAL & CHILD NUTRITION 2022; 18:e13400. [PMID: 35866201 PMCID: PMC9480908 DOI: 10.1111/mcn.13400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/22/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
This study aimed to quantify the burden of relapse following successful treatment for uncomplicated severe acute malnutrition (SAM) and to identify associated risk factors in rural Niger. We used data from 1490 children aged 6−59 months discharged as recovered from an outpatient nutritional programme for SAM and followed for up to 12 weeks after admission. Postdischarge SAM relapse was defined as weight‐for‐height Z‐score <−3, mid‐upper arm circumference (MUAC) <115 mm or bipedal oedema after having been discharged as recovered. Postdischarge hospitalisation was defined as admission to inpatient SAM treatment or hospitalisation for any cause after having been discharged as recovered. We used multivariate log‐binomial models to identify independent risk factors. After programmatic discharge, 114 (8%) children relapsed to SAM and 89 (6%) were hospitalised. Factors associated with SAM relapse were discharge during the lean season (relative risk [RR] = 1.80 [95% confidence interval [CI] = 1.22−2.67]) and larger household size (RR = 1.56 [95% CI = 1.01−2.41]), whereas older child age (RR = 0.94 [95% CI = 0.88−1.00]), higher child MUAC at discharge (RR = 0.93 [95% CI = 0.87−1.00]) and maternal literacy (RR = 0.54 [95% CI = 0.29−0.98]) were protective factors. Discharge during the lean season (RR = 2.27 [95% CI = 1.46−3.51]) was independently associated with postdischarge hospitalisation. Future nutritional programmes in the context of Niger may consider modification of anthropometric discharge criteria or the provision of additional home support or follow‐up during the lean season as potential interventions to prevent relapse. More research including postdischarge follow‐up is needed to better understand the sustainability of treatment outcomes after discharge and the type of intervention that may best sustain recovery over time. Clinical Trial Registration: ClinicalTrials.gov number, NCT01613547. Following successful discharge from a community‐based nutritional programme for severe acute malnutrition (SAM) treatment in rural Niger, the prevalence of SAM relapse was 8% and the prevalence of postdischarge hospitalisation was 6% within 12 weeks from admission. Factors associated with SAM relapse were child age at programme admission, child mid‐upper arm circumference (MUAC) at discharge, discharge from the nutritional programme during the lean season, and maternal literacy. Anthropometry at discharge was a primary risk factor for relapse. MUAC at discharge performed better than weight‐for‐height Z‐score (WHZ) in classifying SAM relapse cases. ‘Optimal’ cut‐offs, defined using the Liu method which maximises the product of the sensitivity and specificity, were MUAC of 121 mm with 66% sensitivity and 67% specificity and WHZ of −1.38 with 54% sensitivity and 57% specificity. Future programmes may consider additional support or follow‐up of children at high risk of postdischarge relapse or hospitalisation, including those discharged during the lean season. Modification of current anthropometric discharge criteria may also be explored as an actionable target to further reduce the risk of relapse.
Collapse
Affiliation(s)
- Lilia Bliznashka
- Global Academy of Agriculture and Food Systems University of Edinburgh Edinburgh United Kingdom
| | - Kyra H. Grantz
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
| | - Jérémie Botton
- Faculty of Pharmacy University Paris‐Sud, University Paris‐Saclay Châtenay‐Malabry France
| | | | | | | | | | - Sheila Isanaka
- Department of Research Epicentre Paris France
- Department of Nutrition Harvard T. H., Chan School of Public Health Boston Massachusetts USA
- Department of Global Health and Population Harvard T. H., Chan School of Public Health Boston Massachusetts USA
| |
Collapse
|
2
|
Girma T, James PT, Abdissa A, Luo H, Getu Y, Fantaye Y, Sadler K, Bahwere P. Nutrition status and morbidity of Ethiopian children after recovery from severe acute malnutrition: Prospective matched cohort study. PLoS One 2022; 17:e0264719. [PMID: 35271590 PMCID: PMC8912152 DOI: 10.1371/journal.pone.0264719] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/15/2022] [Indexed: 11/18/2022] Open
Abstract
After recovery, children with severe acute malnutrition (SAM) remain vulnerable to sub-optimal growth and malnutrition relapse. Although there is an increased interest in understanding these problems, data are scarce, and contextual factors can cause variability. We prospectively followed a cohort of Ethiopian children (215 post-SAM cases and 215 non-wasted controls), monthly for one year. The post-SAM cases were: age 6–59 months at admission into the community management of acute malnutrition (CMAM) program and being successfully discharged from CMAM (MUAC>11.0cm, weight gain of 20%, absence of oedema and clinically stable for two consecutive weeks). The controls were apparently healthy children from same village who had no history of an episode of AM and were matched 1:1 to a post-SAM child by age and sex. The primary outcomes were: cumulative incidence of acute malnutrition; growth trajectory; cumulative incidence of reported common morbidities, and cumulative proportion and incidence of deaths. The burden of common morbidities was higher among post-SAM than controls; post-SAM children had more frequent illness episodes (Incidence Rate Ratio of any illness 1.39, 95% CI: 1.14, 1.71; p<0.001). The prevalence of SAM was consistently higher among post-SAM cases than the control group, having a 14 times higher risk of developing SAM (Incidence Rate Ratio: 14.1; 95% CI: 3.5, 122.5; p<0.001). The divergence in weight and growth trajectory remained the same during the study period. Our results advocate for the design of post-discharge interventions that aim to prevent the reoccurrence of acute malnutrition, reduce morbidity and promote catch-up growth. Research is needed to define the appropriate package of post-discharge interventions.
Collapse
Affiliation(s)
- Tsinuel Girma
- Department of Pediatrics and Child Health, Jimma University, Jimma, Ethiopia
- * E-mail:
| | - Philip T. James
- Valid International, Oxford, United Kingdom
- Emergency Nutrition Network, Kidlington, United Kingdom
| | - Alemseged Abdissa
- Department of Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Hanqi Luo
- Valid International, Oxford, United Kingdom
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Yesufe Getu
- Valid International, Oxford, United Kingdom
- Department of Physiology, Jimma University, Jimma, Ethiopia
| | - Yilak Fantaye
- Valid International, Oxford, United Kingdom
- Alameda County Public Health Department, Oakland, CA, United States of America
| | | | - Paluku Bahwere
- Valid International, Oxford, United Kingdom
- Center for Epidemiology, Biostatistics, and Clinical Research, School of Public Health, Free University of Brussels, Brussels, Belgium
| |
Collapse
|
3
|
Mutunga M, Rutishauser-Perera A, Laillou A, Prak S, Berger J, Wieringa FT, Bahwere P. The relationship between wasting and stunting in Cambodian children: Secondary analysis of longitudinal data of children below 24 months of age followed up until the age of 59 months. PLoS One 2021; 16:e0259765. [PMID: 34794170 PMCID: PMC8601787 DOI: 10.1371/journal.pone.0259765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 10/27/2021] [Indexed: 01/22/2023] Open
Abstract
The interrelationship between wasting and stunting has been poorly investigated. We assessed the association between two indicators of linear growth, height-for-age Z-score (HAZ) change and occurrence of accelerated linear growth, and selected indicators of wasting and wasting reversal in 5,172 Cambodian children aged less than 24 months at enrolment in the 'MyHealth' study. The specific objectives were to evaluate the relationship between temporal changes in wasting and 1) change in HAZ and 2) episodes of accelerated linear growth. At enrolment, the stunting and wasting prevalence were 22.2 (21.0;23.3) % and 9.1 (8.1;10.1) %, respectively, and reached 41.4 (39.3;43.6) %, and 12.4 (11.5;13.3) % respectively, two years later. Between 14-19% of stunted children were also wasted throughout the whole study period. For each centimetre increase in Mid-Upper Arm Circumference (MUAC) from the previous assessment, the HAZ increased by 0.162 (0.150; 0.174) Z-score. We also observed a delayed positive association between the weight for height Z score (WHZ) unit increase and HAZ change of +0.10 to +0.22 units consistent with a positive relationship between linear growth and an increase in WHZ occurring with a lag of approximately three months. A similar positive correlation was observed for the occurrence of an episode of accelerated linear growth. These results show that interventions to prevent and treat wasting can contribute to stunting reduction and call for integrated wasting and stunting programming.
Collapse
Affiliation(s)
- Mueni Mutunga
- United Nations Children’s Fund (UNICEF) East Asia Pacific Regional Office, Bangkok, Thailand
- * E-mail:
| | | | - Arnaud Laillou
- United Nations Children’s Fund (UNICEF), Addis Ababa, Ethiopia
| | - Sophonneary Prak
- National Nutrition Program, Maternal and Child Health Center, Phnom Penh, Cambodia
| | - Jacques Berger
- Institut de Recherche pour le De´veloppement, Montpellier, France
| | | | - Paluku Bahwere
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de santé publique, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
4
|
Schaefer R, Mayberry A, Briend A, Manary M, Walker P, Stobaugh H, Hanson K, McGrath M, Black R. Relapse and regression to severe wasting in children under 5 years: A theoretical framework. MATERNAL & CHILD NUTRITION 2021; 17:e13107. [PMID: 33145990 PMCID: PMC7988852 DOI: 10.1111/mcn.13107] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/04/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022]
Abstract
Systematic reviews have highlighted that repeated severe wasting after receiving treatment is likely to be common, but standardised measurement is needed urgently. The Council of Research & Technical Advice for Acute Malnutrition (CORTASAM) released recommendations on standard measurement of relapse (wasting within 6 months after exiting treatment as per recommended discharge criteria), regression (wasting within 6 months after exiting treatment before reaching recommended discharge criteria) and reoccurrence (wasting after 6 months of exit from treatment as per recommended discharge criteria). We provide a theoretical framework of post-treatment relapse and regression to severe wasting to guide discussions, risk factor analyses, and development and evaluations of interventions. This framework highlights that there are factors that may impact risk of relapse and regression in addition to the impact of contextual factors associated with incidence and reoccurrence of severe wasting more generally. Factors hypothesised to be associated with relapse and regression relate specifically to the nutrition and health status of the child on admission to, during and exit from treatment and treatment interventions, platforms and approaches as well as type of exit from treatment (e.g., before reaching recommended criteria). These factors influence whether children reach full recovery, and poorer nutritional and immunological status at exit from treatment are more proximate determinants of risk of severe wasting after treatment, although post-treatment interventions may modify risks. The evidence base for many of these factors is weak. Our framework can guide research to improve our understanding of risks of relapse and regression and how to prevent them and inform programmes on what data to collect to evaluate relapse. Implementation research is needed to operationalise results in programmes and reduce post-treatment severe wasting at scale.
Collapse
Affiliation(s)
| | - Amy Mayberry
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - André Briend
- Center for Child Health ResearchTampere UniversityTampereFinland
- Department of Nutrition, Exercise and SportsUniversity of CopenhagenCopenhagenDenmark
| | - Mark Manary
- Department of PediatricsWashington University in St. LouisSt. LouisMissouriUSA
- School of Public Health and Family Medicine, College of MedicineUniversity of MalawiBlantyreMalawi
| | - Polly Walker
- No Wasted Lives TeamAction Against Hunger UKLondonUK
| | - Heather Stobaugh
- Action Against Hunger USNew YorkNew YorkUSA
- Friedman School Friedman School of Nutrition Science and PolicyTufts UniversityBostonMassachusettsUSA
| | | | | | - Robert Black
- Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMarylandUSA
| |
Collapse
|
5
|
Usta M, Ersoy A, Ayar Y, Budak F. The relationship between lymphocyte subsets, nutritional status and tuberculin reactivity in continuous ambulatory peritoneal dialysis and hemodialysis patients. Int Urol Nephrol 2020; 52:1167-1172. [PMID: 32323130 PMCID: PMC7271018 DOI: 10.1007/s11255-020-02467-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/13/2020] [Indexed: 11/25/2022]
Abstract
Aim Skin test anergy is common in patients with uremia and during maintenance hemodialysis treatment. However, up to date only one study concerning skin test in peritoneal dialysis patients has focused on the issue. Our cross-sectional controlled study was conducted to analyze the correlation of purified protein derivative (PPD) test response with demographical features, nutritional parameters and the distribution of peripheral blood lymphocyte subsets in peritoneal dialysis and hemodialysis patients Patients and methods Stable 30 hemodialysis (HD) patients (16 men, 14 women) and 30 continuous ambulatory peritoneal dialysis (PD) patients (17 men, 13 women) were included. Thirty healthy cases (15 men, 15 women) with a mean age of 32.4 ± 9.4 constituted the control group. Results In the HD group, 14 patients (46.6%) were PPD positive, and ın the PD group 16 patients (53.3%) were PPD positive. In the PPD-positive HD patients 64.2% (9/14), and in the PPD-positive PD patients 62.4% (10/16) had an induration of 10 mm or greater. In the control group, 21 of 30 patients (70%) were PPD positive. Comparison of both HD and PD groups with the control group showed significant differences in PPD reactivity (p < 0.01). Albumin levels were significantly high in the control groups (p < 0.01), and cholesterol levels were significantly high in the PD and the control groups (p < 0.05). Transferrin levels were significantly high in the PD (p < 0.01). The lymphocyte counts were significantly high in the control group compared to the HD patients (p < 0.05). The lymphocyte subset percentages CD19 were high in the control groups (p < 0.05), and CD16/56 was significantly high in the PD groups (p < 0.05). All the parameters were also similar between PPD-positive and -negative same groups. Conclusion The prevalence of PPD positivity was lower in the PD and HD groups. The PPD test responses were not related to the peripheral lymphocyte counts, subsets and malnutrition parameters.
Collapse
Affiliation(s)
- Mehmet Usta
- Department of Nephrology, Bursa City Hospital, Nilüfer, 16010, Bursa, Turkey
| | - Alpaslan Ersoy
- Department of Nephrology, Faculty of Medicine, Uludag University, Bursa, Turkey
| | - Yavuz Ayar
- Department of Nephrology, Bursa City Hospital, Nilüfer, 16010, Bursa, Turkey.
| | - Ferrah Budak
- Department of Microbiology and Immunology, Faculty of Medicine, Uludag University, Bursa, Turkey
| |
Collapse
|
6
|
Akomo P, Bahwere P, Murakami H, Banda C, Maganga E, Kathumba S, Sadler K, Collins S. Soya, maize and sorghum ready-to-use therapeutic foods are more effective in correcting anaemia and iron deficiency than the standard ready-to-use therapeutic food: randomized controlled trial. BMC Public Health 2019; 19:806. [PMID: 31234806 PMCID: PMC6591918 DOI: 10.1186/s12889-019-7170-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 06/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of anaemia and iron deficiency (ID) among children with severe acute malnutrition (SAM) and their correction during nutritional rehabilitation are not well documented. This study assessed anaemia and ID prevalence and their predictors at start of SAM treatment, and the efficacy of their treatment and effect on gut health of two novel Ready-To-Use Therapeutic foods (RUTF) prepared from soybean, maize and sorghum (SMS) with (MSMS-RUTF) or without added milk (FSMS-RUTF) compared to those of the standard formulation prepared from peanut and milk (PM-RUTF). METHODS This was a 3-arms parallel groups, simple randomised, controlled non-inferiority trial in 6-59 months old Central Malawian children with SAM. Anaemia was defined using altitude- and ethnicity-adjusted haemoglobin. Iron status was defined using soluble transferrin receptor (sTfR) and body iron stores (BIS). We used Pearson's chi-square test, t-test for paired or unpaired data, Kruskal-Wallis test for between-arm differences as appropriate and logistic regression to identify independent predictors of anaemia or iron deficiency anaemia (IDA). RESULTS The sample size was 389. At admission, the prevalence [%(95%CI)] of anaemia was 48.9(41.4-56.5)% while that of ID and IDA were 55.7(48.6-62.5)% and 34.3(28.2-41.0)% when using sTfR criterion and 29.1(24.4-34.4)% and 28.9(23.7-34.9)% when using BIS criterion, respectively. At discharge, nutrition rehabilitation with SMS-RUTF was associated with the lowest prevalence of anaemia [12.0(6.9-20.3)% for FSMS-RUTF, 18.2(11.9-26.8)% for MSMS-RUTF and 24.5(15.8-35.9)% for PM-RUTF; p = 0.023] and IDA [7.9(3.4-17.3)% for FSMS-RUTF, 10.9(4.8-22.6)% for MSMS-RUTF and 20.5(10.7-35.5)% for PM-RUTF; p = 0.028]. SMS-RUTF was also associated with the highest increase in BIS [Change in BIS (95%CI)] among the iron deplete at admission [6.2 (3.7; 8.6), 3.2 (0.8; 5.6), 2.2 (0.2; 4.3) for the same study arms; Anova p = 0.045]. Compared to P-RUTF, FSMS-RUTF had the highest adjusted recovery rate [OR (95%CI = 0.3 (0.2-0.5) with p < 0.001 for FSMS-RUTF and 0.6 (0.3-1.0) with p = 0.068 for MSMS-RUTF]. No effect of iron content on risk of iron overload or gut inflammation was observed. CONCLUSIONS Anaemia and ID are common among children with SAM. FSMS-RUTF is more efficacious in treating anaemia and correcting BIS among this group than PM-RUTF. TRIAL REGISTRATION This study was registered on 15 April 2015 ( PACTR201505001101224 ).
Collapse
Affiliation(s)
- Peter Akomo
- Valid Nutrition, Cuibín Farm, Derry Duff, Bantry, Co., Cork, Republic of Ireland
| | - Paluku Bahwere
- Valid International, 35 Leopold Street, Oxford, OX4 1TW UK
- Centre de Recherche en Epidémiologie, Biostatistique et Recherche Clinique, Ecole de santé publique, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Hitoshi Murakami
- Nutrition Improvement Department, Ajinomoto Co., Inc., Tokyo, Japan
| | - Chrissy Banda
- Valid International, 35 Leopold Street, Oxford, OX4 1TW UK
| | | | | | - Kate Sadler
- Valid International, 35 Leopold Street, Oxford, OX4 1TW UK
| | - Steve Collins
- Valid Nutrition, Cuibín Farm, Derry Duff, Bantry, Co., Cork, Republic of Ireland
- Valid International, 35 Leopold Street, Oxford, OX4 1TW UK
| |
Collapse
|
7
|
O’Sullivan NP, Lelijveld N, Rutishauser-Perera A, Kerac M, James P. Follow-up between 6 and 24 months after discharge from treatment for severe acute malnutrition in children aged 6-59 months: A systematic review. PLoS One 2018; 13:e0202053. [PMID: 30161151 PMCID: PMC6116928 DOI: 10.1371/journal.pone.0202053] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/26/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) is a major global health problem affecting some 16.9 million children under five. Little is known about what happens to children 6-24 months post-discharge as this window often falls through the gap between studies on SFPs and those focusing on longer-term effects. METHODS A protocol was registered on PROSPERO (PROSPERO 2017:CRD42017065650). Embase, Global Health and MEDLINE In-Process and Non-Indexed Citations were systematically searched with terms related to SAM, nutritional intervention and follow-up between June and August 2017. Studies were selected if they included children who experienced an episode of SAM, received a therapeutic feeding intervention, were discharged as cured and presented any outcome from follow-up between 6-24 months later. RESULTS 3,691 articles were retrieved from the search, 55 full-texts were screened and seven met the inclusion criteria. Loss-to-follow-up, mortality, relapse, morbidity and anthropometry were outcomes reported. Between 0.0% and 45.1% of cohorts were lost-to-follow-up. Of those discharged as nutritionally cured, mortality ranged from 0.06% to 10.4% at an average of 12 months post-discharge. Relapse was inconsistently defined, measured, and reported, ranging from 0% to 6.3%. Two studies reported improved weight-for-height z-scores, whilst three studies that reported height-for-age z-scores found either limited or no improvement. CONCLUSIONS Overall, there is a scarcity of studies that follow-up children 6-24 months post-discharge from SAM treatment. Limited data that exists suggest that children may exhibit sustained vulnerability even after achieving nutritional cure, including heightened mortality and morbidity risk and persistent stunting. Prospective cohort studies assessing a wider range of outcomes in children post-SAM treatment are a priority, as are intervention studies exploring how to improve post-SAM outcomes and identify high-risk children.
Collapse
Affiliation(s)
- Natasha Phillipa O’Sullivan
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Brighton and Sussex Medical School, Falmer, East Sussex, United Kingdom
| | - Natasha Lelijveld
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Action Against Hunger, London, United Kingdom
| | | | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Maternal, Adolescent, Reproductive, and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Philip James
- Medical Research Council (MRC) Unit The Gambia at the London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|