Child mortality as predicted by nutritional status and recent weight velocity in children under two in rural Africa

Malnutrition, sarcopenia, and frailty assessment in pediatric transplantation

Nutrition assessment can be challenging in children with end-stage organ disease and in those requiring an organ transplant. The effect of poor nutrition status can exert long-lasting effects on children with end-stage organ disease requiring transplantation. Malnutrition, sarcopenia, and frailty are conditions that require provision of optimal nutrition to prevent or support the treatment of these conditions. Unfortunately, the literature on the assessment of malnutrition, sarcopenia, and frailty in pediatric end-stage organ disease is scarce, thus leading to confusion on how to effectively identify them. Recently, the addition of a variety of validated nutrition and functional assessment techniques has assisted with appropriate assessment of these conditions. The objective of this narrative review is to provide an overview of the current literature for pediatric assessment of malnutrition, sarcopenia, and frailty in the setting of solid organ transplantation and provide practicing nutrition clinicians a solid foundation for learning how to effectively assess these conditions with the current literature available.

Association between diagnostic criteria for severe acute malnutrition and hospital mortality in children aged 6-59 months in the eastern Democratic Republic of Congo: the Lwiro cohort study

Background

Few studies have assessed the relationship between weight-for-height (WHZ) and mid-upper arm circumference (MUAC) with hospital mortality considering confounders. The particularity of MUAC for age (MUACZ) is less documented.

Objective

This study aims to investigate this relationship in a region endemic for severe acute malnutrition (SAM).

Methods

This is a retrospective cohort based on a database of children admitted from 1987 to 2008 in South Kivu, eastern DRC. Our outcome was hospital mortality. To estimate the strength of the association between mortality and nutritional indices, the relative risk (RR) with its 95% confidence interval (95% CI) was calculated. In addition to univariate analyses, we constructed multivariate models from binomial regression.

Results

A total of 9,969 children aged 6 to 59 months were selected with a median age of 23 months. 40.9% had SAM (according to the criteria WHZ < -3 and/or MUAC<115 mm and/or the presence of nutritional edema) including 30.2% with nutritional edema and 35.2% had both SAM and chronic malnutrition. The overall hospital mortality was 8.0% and was higher at the beginning of data collection (17.9% in 1987). In univariate analyses, children with a WHZ < -3 had a risk almost 3 times higher of dying than children without SAM. WHZ was more associated with in-hospital mortality than MUAC or MUACZ. Multivariate models confirmed the univariate results. The risk of death was also increased by the presence of edema.

Conclusion

In our study, WHZ was the indicator more associated with hospital death compared with MUAC or MUACZ. As such, we recommend that all criteria shall continue to be used for admission to therapeutic SAM programs. Efforts should be encouraged to find simple tools allowing the community to accurately measure WHZ and MUACZ.

Effects of emollient therapy with sunflower seed oil on neonatal growth and morbidity in Uttar Pradesh, India: a cluster-randomized, open-label, controlled trial

BACKGROUND

Newborn oil massage is a widespread practice. Vigorous massage with potentially harmful products and forced removal of vernix may disrupt skin barrier integrity. Hospitalized, very-preterm infants treated with sunflower seed oil (SSO) have demonstrated improved growth but community-based data on growth and health outcomes are lacking.

OBJECTIVES

We aimed to test whether SSO therapy enhances neonatal growth and reduces morbidity at the population level.

METHODS

We conducted an open-label, controlled trial in rural Uttar Pradesh, India, randomly allocating 276 village clusters equally to comparison (usual care) and intervention comprised of promotion of improved massage practices exclusively with SSO, using intention-to-treat and per-protocol mixed-effects regression analysis.

RESULTS

We enrolled 13,478 and 13,109 newborn infants in demographically similar intervention and comparison arms, respectively. Adherence to exclusive SSO increased from 22.6% of intervention infants enrolled in the first study quartile to 37.2% in the last quartile. Intervention infants gained significantly more weight, by 0.94 g · kg-1 · d-1 (95% CI: 0.07, 1.82 g · kg-1 · d-1, P = 0.03), than comparison infants by intention-to-treat analysis. Restricted cubic spline regression revealed the largest benefits in weight gain (2-4 g · kg-1 · d-1) occurred in infants weighing <2000 g at birth. Weight gain in intervention infants was higher by 1.31 g · kg-1 · d-1 (95% CI: 0.17, 2.46 g · kg-1 · d-1; P = 0.02) by per-protocol analysis. Morbidities were similar by intention-to-treat analysis but in per-protocol analysis rates of hospitalization and of any illness were reduced by 36% (OR: 0.64; 95% CI: 0.44, 0.94; P = 0.02) and 44% (OR: 0.56; 95% CI: 0.40, 0.77; P < 0.001), respectively, in treated infants.

CONCLUSIONS

SSO therapy improved neonatal growth, and reduced morbidities when applied exclusively, across the facility-community continuum of care at the population level. Further research is needed to improve demand for recommended therapy inside hospital as well as in community settings, and to confirm these results in other settings.This trial was registered at www.isrctn.com as ISRCTN38965585 and http://ctri.nic.in as CTRI/2014/12/005282.

Anthropometric Criteria for Identifying Infants Under 6 Months of Age at Risk of Morbidity and Mortality: A Systematic Review

BACKGROUND

There is increasing global focus on small and nutritionally at-risk infants aged <6 months (<6 m). Current WHO guidelines recommend weight-for-length z-score (WLZ) for enrolment to malnutrition treatment programmes but acknowledge a weak evidence-base. This review aims to inform future guidelines by examining which anthropometric criteria best identify infants <6 m at high risk of mortality/morbidity.

METHODS

We searched Medline, EMBASE, CINAHL, Global Health, Cochrane Library and POPLINE for studies conducted in low- and middle-income countries and published between 1990 and October 2020. We included studies reporting anthropometric assessment of nutritional status in infants <6 m and assessed the association with subsequent morbidity or mortality.

RESULTS

A total of 19 studies were included in the final review, covering 20 countries, predominantly in sub-Saharan Africa. WLZ had poor reliability and poor prognostic ability to identify infants at risk of death. Mid-upper arm circumference (MUAC) and weight-for-age z-score (WAZ) were better at identifying infants at risk of mortality/morbidity. MUAC-for-age z-score did not perform better than using a single MUAC cut-off. Suggested MUAC cut-offs for this age group varied by context, ranging from 10.5 to 11.5 cm. The assessment for reliability showed that length was difficult to measure, making WLZ the least reliable indicator overall.

CONCLUSION

Evidence from our review suggests that a change in current practice is necessary. To better identify small and nutritionally at-risk infants <6 m WAZ and/or MUAC rather than WLZ should be used. Future research should explore possible benefits for programme coverage, impact and cost-effectiveness. Research should also examine if context-specific MUAC thresholds are needed.

Comparing Attained Weight and Weight Velocity during the First 6 Months in Predicting Child Undernutrition and Mortality

BACKGROUND

The first 6 mo of life are critical for subsequent risk of undernutrition and mortality. The predictive abilities of attained weight at the end of each month and monthly weight velocity for undernutrition and mortality need to be compared.

OBJECTIVES

This study aimed to examine the predictive abilities of different weight metrics during the first 6 mo of life in predicting undernutrition and mortality.

METHODS

This study used a cohort of infants in Tanzania. Weight and length were measured monthly from birth to 18 mo of age. Three weight metrics during the first 6 mo of life were considered as predictors, including attained weight-for-age z score (WAZ) at the end of each month, monthly change in WAZ, and monthly weight velocity z score (WVZ). Logistic models were used with undernutrition (at 6 or 12 mo) and mortality (over the first 18 mo) as outcomes. AUC values were compared across metrics.

RESULTS

For predicting wasting at 6 mo, WVZ (AUC: 0.80) had a greater predictive ability than attained WAZ (AUC: 0.76) and change in WAZ (AUC: 0.71) during the second month of life. After 2 mo, attained WAZ (AUC: 0.81-0.89) had greater predictive abilities than WVZ (AUC: 0.71-0.77) and change in WAZ (AUC: 0.65-0.67). For predicting stunting at 6 mo, attained WAZ (AUC: 0.75-0.79) had consistently greater predictive abilities than WVZ (AUC: 0.56-0.66) and change in WAZ (AUC: 0.50-0.57). The weight metrics had similar abilities in predicting mortality, with the AUC rarely reaching >0.65.

CONCLUSIONS

Attained weight at the end of each month had greater abilities than monthly weight velocity in the same month in predicting undernutrition. Attained weight remains a useful indicator for identifying infants at greater risk of undernutrition.

Clinical and laboratory features associated with mortality in children with severe malnutrition in Papua New Guinea

Background: The World Health Organization has a clinical and syndromic approach to the management of severe acute malnutrition which recognises that laboratory investigations are often not possible where children with severe malnutrition present. In low- and middle-income countries including Papua New Guinea, rates of death from severe malnutrition in many hospitals remain 10% or more.Aim: To evaluate the clinical predictors of death and the association between disturbances of electrolytes and haematological investigations in children with severe malnutrition and the risk of mortality.Methods: The clinical and laboratory predictors of death in a prospective cohort of 150 children with severe malnutrition admitted to a provincial hospital in Papua New Guinea were analysed. The clinical signs and electrolytes, complete blood count and liver function tests at presentation and on Days 3 and 5 were recorded.Results: The strongest independent predictors of mortality at assessment on admission were a low child Glasgow coma scale (≤12), hypoxaemia (SpO₂ <90%), prolonged capillary refill (>3 seconds) and dysnatraemia (<130 or >150 mmol/L). The area under the receiver operating characteristics curve for these four variables was 0.93.Conclusions: That three of these four criteria correspond closely to the WHO Emergency Clinical Signs reinforces the value of a system of triage and risk assessment in children with severe malnutrition. If a child has emergency signs they should be managed in an area on the ward where close monitoring and supportive care can be provided, the WHO guidelines for severe malnutrition followed, and other specific care provided. Measurements of serum sodium, particularly in children with diarrhoea and dehydration, is also important in risk assessment and management.

Improving the rate of anthropometric measurements in the pediatric intensive care unit

BACKGROUND

Malnutrition occurs in approximately 25% of pediatric intensive care patients and correlates with increased length of stay, prolonged ventilation, and mortality. Anthropometric measurements should be obtained at admission and throughout hospitalization to evaluate nutrition status. We aimed to increase documentation, reporting, and discussion of anthropometric measurements, including height/length, weight, and occipital frontal circumference (OFC) within 24 hours of admission and weekly.

METHODS

A multifaceted process improvement model was implemented over 1 month. Interventions included education, recruiting nurse champions, process mapping, new equipment, and formal discussion of nutrition status during rounds. A proportions hypothesis test compared frequency of anthropometric measures obtained during each study phase: preintervention, postintervention, and sustainment.

RESULTS

In terms of admission metrics over respective study phases, the PICU had fluctuation in weights (91%, 98%, and 97%) and height (49%, 73%, and 71%) and increased rates in OFC (36%, 61%, and 65%). The cardiovascular intensive care unit (CVICU) had stable weights (100%, 100%, and 100%) and increased rates in height (87%, 94%, and 95%) and OFC (28%, 64%, and 86%), respectively. In terms of weekly metrics over study phases, the PICU had fluctuation in weights (91%, 89%, and 93%) and increased rates in heights (38%, 69%, and 76%) and OFC (45%, 76%, and 100%). The CVICU had increased rates in weights (98%, 100%, and 100%) and fluctuations in heights (50%, 83%, and 75%), and OFC (48%, 84%, and 75%).

CONCLUSIONS

Interventions increased rates of measurements. During the sustainment phase, there was regression in rates, although these remained above baseline. Additional interventions may increase compliance and foster change in unit culture.

Prevalence of Undernutrition and Anemia among Santal Adivasi Children, Birbhum District, West Bengal, India

India’s Adivasi scheduled tribe population is disproportionately affected by undernutrition and anemia, thereby prevailing in the poorest wealth deciles denominated as socially and economically vulnerable. This study was designed to assess the extent of child undernutrition (conventional and composite index of anthropometric failure (CIAF) classification), as well as the burden of anemia in children and its independent nutrition specific and sensitive drivers, moreover to reflect the living conditions of Santal Adivasis. The research survey was conducted in 21 Santal villages, Birbhum District, West Bengal, in 2015. An overall 307 children (aged 6–39 months) and their mothers (n = 288) were assessed for their hemoglobin (Hb) levels (HemoCue Hb201+) and anthropometric indices such as height/length, weight and mid-upper arm circumference (MUAC). Moreover, socio-demographic household characteristics were surveyed. The study confirmed Adivasi children lagging behind national average with a high prevalence of undernutrition (height-for-age z-score (HAZ) 51.9%, weight-for-age z-score (WAZ) 49.2%, weight-for-height z-score WHZ 19.0% and CIAF 61.6%) and of moderate and severe anemia (Hb < 10 g/dL, 73.3% altogether). Child’s age <24 months, low WAZ scores, morbidity (any fever, diarrhea or respiratory infection) on the checkup day or during previous week, low maternal Hb level, and lack of dietary diversification were identified as predictors for anemia, thereby warrant targeted interventions to decrease the high anemia rates assessed in the study site.

Early assessment of weight velocity can support frontline health workers in predicting malnutrition in HIV-exposed infants: preliminary results from a DREAM cohort in Malawi

BACKGROUND

Children born to HIV-positive mothers are particularly susceptible to malnutrition. Currently, monitoring programs rely on punctual anthropometric measurements to assess child growth. Growth velocities could be an additional tool in identifying critical time windows for prevention and implementation of early intervention for malnutrition.

METHODS

A retrospective analysis was conducted using data from 817 HIV exposed but uninfected children extracted from DREAM program database. By using the WHO reference for growth standards, patterns of weight velocity for different intervals of assessment from one to 18 months of age were explored. Odds ratios and multinomial logistic regressions between selected weight velocity Z-scores thresholds and successive malnutrition indices (at 6, 12, 18 months of age) were calculated.

RESULTS

Weight velocity was above the standard mean in the first 3 months, then progressively declined over time. In children with normal nutritional status, significant risks of becoming malnourished (mild malnutrition - underweight [OR 10.8; 95% CI: 4.5-26], chronic malnutrition - stunting [OR 8.3; 95% CI: 2-34.9] and acute malnutrition - wasting [OR 11.7; 95% CI: 1.5-90.5]) started when weight velocity Z-scores <0, at all interval ages. Multinomial regression showed that in the first 6 months, the weight velocity decrements strongly impacted on underweight (OR 17.9; 95% CI: 4-80.7), while the risk of Stunting occurred later at 18 months (OR 8.7; 95% CI: 4.3-17.6), with highest impact at the lowest thresholds.

CONCLUSIONS

The assessment of weight velocity Z-scores, coupled with the already validated malnutrition indices, can support frontline health workers in early prediction of child malnutrition and performing nutritional counselling in the context of HIV/AIDS and food insecurity.

Nutrition-specific and sensitive drivers of poor child nutrition in Kilte Awlaelo-Health and Demographic Surveillance Site, Tigray, Northern Ethiopia: implications for public health nutrition in resource-poor settings

Background: Child undernutrition is a prevalent health problem and poses various short and long-term consequences. Objective: This study seeks to investigate the burden of child undernutrition and its drivers in Kilte Awlaelo-Health and Demographic Surveillance Site, Tigray, northern Ethiopia. Methods: In 2015, cross-sectional data were collected from 1,525 children aged 6-23 months. Maternal and child nutritional status was assessed using the mid upper arm circumference. Child's dietary diversity score was calculated using 24-hours dietary recall method. Log-binomial regression and partial proportional odds model were fitted to examine the drivers of poor child nutrition and child dietary diversity (CDD), respectively. Results: The burden of undernutrition and inadequate CDD was 13.7% (95% CI: 12.1-15.5%) and 81.3% (95%CI: 79.2-83.1%), respectively. Maternal undernutrition (adjusted prevalence ratio, adjPR = 1.47; 95%CI: 1.14-1.89), low CDD (adjPR = 1.90; 95%CI: 1.22-2.97), and morbidity (adjPR = 1.83; 95%CI: 1.15-2.92) were the nutrition-specific drivers of child undernutrition. The nutrition-sensitive drivers were poverty (compared to the poorest, adjPR poor = 0.65 [95%CI:0.45-0.93], adjPR medium = 0.64 [95%CI: 0.44-0.93], adjPR wealthy = 0.46 [95%CI: 0.30-0.70], and adjPR wealthiest = 0.53 [95%CI: 0.34-0.82]), larger family size (adjPR = 1.10; 95%CI: 1.02-1.18), household head's employment insecurity (adjPR = 2.10; 95%CI: 1.43-3.09), and residing in highlands (adjPR = 1.93; 95%CI: 1.36-2.75). The data show that higher CDD was positively associated with wealth (OR wealthy = 3.06 [95%CI: 1.88-4.99], OR wealthiest = 2.57 [95%CI: 1.53-4.31]), but it was inversely associated with lack of diverse food crops production in highlands (OR = 0.23; 95%CI: 0.10-0.57]). Conclusions: Our findings suggest that the burden of poor child nutrition is very high in the study area. Multi-sectoral collaboration and cross-disciplinary interventions between agriculture, nutrition and health sectors are recommended to address child undernutrition in resource poor and food insecure rural communities of similar settings.

Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: III. Effect of case-load on malnutrition related mortality- policy implications

BACKGROUND

Severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <-3Z of the WHO2006 standards, or a mid-upper-arm circumference (MUAC) of < 115 mm or there is nutritional oedema. Although there has been a move to eliminate WHZ as a diagnostic criterion we have shown that children with a low WHZ have at least as high a mortality risk as those with a low MUAC. Here we take the estimated case fatality rates and published case-loads to estimate the proportion of total SAM related deaths occurring in children that would be excluded from treatment with a MUAC-only policy.

METHODS

The effect of varying case-load and mortality rates on the proportion of all deaths that would occur in admitted children was examined. We used the same calculations to estimate the proportion of all SAM-related deaths that would be excluded with a MUAC-only policy in 48 countries with very different relative case loads for SAM by only MUAC, only WHZ and children with both deficits. The case fatality rates (CFR) are taken from simulations, empirical data and the literature.

RESULTS

The relative number of cases of SAM by MUAC alone, WHZ alone and those with both criteria have a dominant effect on the proportion of all SAM-related deaths that would occur in children excluded from treatment by a MUAC-only program. Many countries, particularly in the Sahel, West Africa and South East Asia would fail to identify the majority of SAM-related deaths if a MUAC only program were to be implemented. Globally, the estimated minimum number of deaths that would occur among children excluded from treatment in our analyses is 300,000 annually.

CONCLUSIONS

The number, proportion or attributable fraction of children excluded from treatment with any change of current policy are the correct indicators to guide policy change. CRFs alone should not be used to guide policy in choosing whether or not to drop WHZ as a diagnostic for SAM. All the criteria for diagnosis of malnutrition need to be retained. It is critical that methods are found to identify those children with a low WHZ, but not a low MUAC, in the community so that they will not remain undetected.

Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: I. Empirical data demonstrates Simpson's paradox

BACKGROUND

According to WHO childhood severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <-3Z of the WHO2006 standards, the mid-upper-arm circumference (MUAC) is < 115 mm, there is nutritional oedema or any combination of these parameters. Recently there has been a move to eliminate WHZ as a diagnostic criterion on the assertion that children meeting the WHZ criterion are healthy, that MUAC is universally a superior prognostic indicator of mortality and that adding WHZ to the assessment does not improve the prediction; these assertions have lead to a controversy concerning the role of WHZ in the diagnosis of SAM.

METHODS

We examined the mortality experience of 76,887 6-60 month old severely malnourished children admitted for treatment to in-patient, out-patient or supplementary feeding facilities in 18 African countries, of whom 3588 died. They were divided into 7 different diagnostic categories for analysis of mortality rates by comparison of case fatality rates, relative risk of death and meta-analysis of the difference between children admitted using MUAC and WHZ criteria.

RESULTS

The mortality rate was higher in those children fulfilling the WHO2006 WHZ criterion than the MUAC criterion. This was the case for younger as well as older children and in all regions except for marasmic children in East Africa. Those fulfilling both criteria had a higher mortality. Nutritional oedema increased the risk of death. Having oedema and a low WHZ dramatically increased the mortality rate whereas addition of the MUAC criterion to either oedema-alone or oedema plus a low WHZ did not further increase the mortality rate. The data were subject to extreme confounding giving Simpson's paradox, which reversed the apparent mortality rates when children fulfilling both WHZ and MUAC criteria were included in the estimation of the risk of death of those fulfilling either the WHZ or MUAC criteria alone.

CONCLUSIONS

Children with a low WHZ, but a MUAC above the SAM cut-off point are at high risk of death. Simpson's paradox due to confounding from oedema and mathematical coupling may make previous statistical analyses which failed to distinguish the diagnostic groups an unreliable guide to policy. WHZ needs to be retained as an independent criterion for diagnosis of SAM and methods found to identify those children with a low WHZ, but not a low MUAC, in the community.

Filling the Gaps for Enhancing the Effectiveness of Community-Based Programs Combining Treatment and Prevention of Child Malnutrition: Results from the Rainbow Project 2015⁻17 in Zambia

BACKGROUND

Child malnutrition, in all its forms, is a public health priority in Zambia. After implementations based on a previous evaluation in 2012⁻14 were made, the efficacy of the Rainbow Project Supplementary Feeding Programs (SFPs) for the integrated management of severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and underweight was reassessed in 2015⁻17.

METHODS

The outcomes were compared with International Standards and with those of 2012⁻14. Cox proportional risk regression analysis was performed to identify predictors of mortality and defaulting.

RESULTS

The data for 900 under-five year-old malnourished children were analyzed. Rainbow's 2015⁻17 outcomes met International Standards, for total and also when stratified for different type of malnutrition. A better performance than 2012⁻14 was noted in the main areas previously identified as critical: mortality rates were halved (5.6% vs. 3.1%, p = 0.01); significant improvements in average weight gain and mean length of stay were registered for recovered children (p < 0.001). HIV infection (5.5; 1.9⁻15.9), WAZ <⁻3 (4.6; 1.3⁻16.1), and kwashiorkor (3.5; 1.2⁻9.5) remained the major predictors of mortality. Secondly, training community volunteers consistently increased the awareness of a child's HIV status (+30%; p < 0.001).

CONCLUSION

Rainbow SFPs provide an integrated community-based approach for the treatment and prevention of child malnutrition in Zambia, with its effectiveness significantly enhanced after the gaps in activities were filled.

An emergency cash transfer program promotes weight gain and reduces acute malnutrition risk among children 6-24 months old during a food crisis in Niger

Background

Assessment of the impact of emergency cash transfer programs on child nutritional status has been difficult to achieve due to the considerable logistic and ethical constraints that characterize humanitarian settings.

Methods

We present the findings from a quasi-experimental longitudinal study of a conditional emergency cash transfer program implemented by Concern Worldwide in 2012 during a food crisis in Tahoua, Niger, in which the use of a concurrent control group permits estimation of the program’s impact on child weight gain. Program beneficiaries received three transfers totaling approximately 65% of Niger’s gross national per capita income; mothers attended mandatory sessions on child and infant feeding and care practices. Dietary and anthropometric data from 211 vulnerable households and children targeted by the intervention were compared with 212 similarly vulnerable control households and children from the same 21 villages. We used multilevel mixed effects regression to estimate changes in weight and weight-for-height Z scores (WHZ) over time, and logistic regression to estimate the probability of acute malnutrition.

Results

We found the intervention to be associated with a 1.27 kg greater overall weight gain (P < 0.001) and a 1.82 greater overall gain in WHZ (P < 0.001). The odds of having acute malnutrition at the end of the intervention were 25 times higher among children in the comparison group than those in households receiving cash (P < 0.001).

Conclusions

We conclude that this emergency cash transfer program promoted child weight gain and reduced the risk of acute malnutrition among children in the context of a food crisis. We suspect that the use of strategic conditional terms and a valuable transfer size were key features in achieving this result. Limitations in study design prevent us from attributing impact to particular aspects of the program, and preclude a precise estimation of impact. Future studies of this nature would benefit from pre-baseline measurements, more exhaustive data collection on household characteristics and transfer use, and further investigation into the use of conditional terms in emergency settings.

Choosing Anthropometric Indicators to Monitor the Response to Treatment for Severe Acute Malnutrition in Rural Southern Ethiopia-Empirical Evidence

The World Health Organization (WHO) recommends the assessment of nutritional recovery using the same anthropometric indicator that was used to diagnose severe acute malnutrition (SAM) in children. However, related empirical evidence from low-income countries is lacking. Non-oedematous children (n = 661) aged 6-59 months admitted to a community-based outpatient therapeutic program for SAM in rural southern Ethiopia were studied. The response to treatment in children admitted to the program based on the mid-upper arm circumference (MUAC) measurement was defined by calculating the gains in average MUAC and weight during the first four weeks of treatment. The children showed significant anthropometric changes only when assessed with the same anthropometric indicator used to define SAM at admission. Children with the lowest MUAC at admission showed a significant gain in MUAC but not weight, and children with the lowest weight-for-height/length (WHZ) showed a significant gain in weight but not MUAC. The response to treatment was largest for children with the lowest anthropometric status at admission in either measurement. MUAC and weight gain are two independent anthropometric measures that can be used to monitor sufficient recovery in children treated for SAM. This study provides empirical evidence from a low-income country to support the recent World Health Organization recommendation.

Practical Application of Linear Growth Measurements in Clinical Research in Low- and Middle-Income Countries

BACKGROUND/AIMS

Childhood stunting is a prevalent problem in low- and middle-income countries and is associated with long-term adverse neurodevelopment and health outcomes. In this review, we define indicators of growth, discuss key challenges in their analysis and application, and offer suggestions for indicator selection in clinical research contexts.

METHODS

Critical review of the literature.

RESULTS

Linear growth is commonly expressed as length-for-age or height-for-age z-score (HAZ) in comparison to normative growth standards. Conditional HAZ corrects for regression to the mean where growth changes relate to previous status. In longitudinal studies, growth can be expressed as ΔHAZ at 2 time points. Multilevel modeling is preferable when more measurements per individual child are available over time. Height velocity z-score reference standards are available for children under the age of 2 years. Adjusting for covariates or confounders (e.g., birth weight, gestational age, sex, parental height, maternal education, socioeconomic status) is recommended in growth analyses.

CONCLUSION

The most suitable indicator(s) for linear growth can be selected based on the number of available measurements per child and the child's age. By following a step-by-step algorithm, growth analyses can be precisely and accurately performed to allow for improved comparability within and between studies.

Effects of unconditional cash transfers on the outcome of treatment for severe acute malnutrition (SAM): a cluster-randomised trial in the Democratic Republic of the Congo

BACKGROUND

Cash transfer programs (CTPs) aim to strengthen financial security for vulnerable households. This potentially enables improvements in diet, hygiene, health service access and investment in food production or income generation. The effect of CTPs on the outcome of children already severely malnourished is not well delineated. The objective of this study was to test whether CTPs will improve the outcome of children treated for severe acute malnutrition (SAM) in the Democratic Republic of the Congo over 6 months.

METHODS

We conducted a cluster-randomised controlled trial in children with uncomplicated SAM who received treatment according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. Analyses were by intention to treat.

RESULTS

The hazard ratio of reaching full recovery from SAM was 35% higher in the intervention group than the control group (adjusted hazard ratio, 1.35, 95% confidence interval (CI) = 1.10 to 1.69, P = 0.007). The adjusted hazard ratios in the intervention group for relapse to moderate acute malnutrition (MAM) and SAM were 0.21 (95% CI = 0.11 to 0.41, P = 0.001) and 0.30 (95% CI = 0.16 to 0.58, P = 0.001) respectively. Non-response and defaulting were lower when the households received cash. All the nutritional outcomes in the intervention group were significantly better than those in the control group. After 6 months, 80% of cash-intervened children had re-gained their mid-upper arm circumference measurements and weight-for-height/length Z-scores and showed evidence of catch-up. Less than 40% of the control group had a fully successful outcome, with many deteriorating after discharge. There was a significant increase in diet diversity and food consumption scores for both groups from baseline; the increase was significantly greater in the intervention group than the control group.

CONCLUSIONS

CTPs can increase recovery from SAM and decrease default, non-response and relapse rates during and following treatment. Household developmental support is critical in food insecure areas to maximise the efficiency of SAM treatment programs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02460848 . Registered on 27 May 2015.

Influence of malnutrition upon all-cause mortality among children in Swaziland

OBJECTIVE

To analyze the effect of the type of malnutrition, sex, age and the presence of edema upon all-cause mortality in children under 5 years of age.

MATERIAL AND METHODS

A cross-sectional study was conducted during 2010 and 2011 in Swaziland. Sex, age, weight and height were taken to classify nutritional status according to the 2006 WHO growth standards: stunting (low height for age), wasting (low weight for height or low body mass index for age) and underweight (low weight for age). The sample (309 boys and 244 girls under 5 years of age) was analyzed by sex and age groups (under and equal/over 12 months). The association between variables was evaluated using the χ² test. Cox regression analysis (HR, 95% CI) was used to assess the likelihood of mortality.

RESULTS

The mortality risk in malnourished children under one year of age was lower among females and increased in the presence of severe edema. Wasting combined with underweight increased the mortality risk in children under 12 months of age 5-fold, versus 11-fold in older children. The combination of stunting, wasting and underweight was closely associated to mortality. Stunting alone (not combined with wasting) did not significantly increase the mortality risk.

CONCLUSIONS

Sex, severe edema and wasting are predictors of mortality in malnourished children. Regardless of these factors, children with deficiencies referred to weight for height and weight for age present a greater mortality risk in comparison with children who present stunting only.

Using growth velocity to predict child mortality

BACKGROUND

Growth assessment based on the WHO child growth velocity standards can potentially be used to predict adverse health outcomes. Nevertheless, there are very few studies on growth velocity to predict mortality.

OBJECTIVES

We aimed to determine the ability of various growth velocity measures to predict child death within 3 mo and to compare it with those of attained growth measures.

DESIGN

Data from 5657 children <5 y old who were enrolled in a cohort study in the Democratic Republic of Congo were used. Children were measured up to 6 times in 3-mo intervals, and 246 (4.3%) children died during the study period. Generalized estimating equation (GEE) models informed the mortality risk within 3 mo for weight and length velocity z scores and 3-mo changes in midupper arm circumference (MUAC). We used receiver operating characteristic (ROC) curves to present balance in sensitivity and specificity to predict child death.

RESULTS

GEE models showed that children had an exponential increase in the risk of dying with decreasing growth velocity in all 4 indexes (1.2- to 2.4-fold for every unit decrease). A length and weight velocity z score of <-3 was associated with an 11.8- and a 7.9-fold increase, respectively, in the RR of death in the subsequent 3-mo period (95% CIs: 3.9, 35.5, and 3.9, 16.2, respectively). Weight and length velocity z scores had better predictive abilities [area under the ROC curves (AUCs) of 0.67 and 0.69] than did weight-for-age (AUC: 0.57) and length-for-age (AUC: 0.52) z scores. Among wasted children (weight-for-height z score <-2), the AUC of weight velocity z scores was 0.87. Absolute MUAC performed best among the attained indexes (AUC: 0.63), but longitudinal assessment of MUAC-based indexes did not increase the predictive value.

CONCLUSION

Although repeated growth measures are slightly more complex to implement, their superiority in mortality-predictive abilities suggests that these could be used more for identifying children at increased risk of death.

HIV infection, viral load, low birth weight, and nevirapine are independent influences on growth velocity in HIV-exposed South African infants

Data from a prospective multisite cohort study were used to examine the effect of HIV exposure, untreated HIV infection, and single-dose nevirapine on infant growth velocity. The 2009 WHO growth velocity standards constitute a new tool for this type of investigation and are in need of functional validation. In period 1 (3-24 wk), 65 HIV-infected, 502 HIV-exposed uninfected (HEU), and 216 HIV-unexposed infants were included. In period 2 (25-36 wk), 31 infants moved from the HEU group to the HIV-infected group. We compared weight velocity Z-scores (WVZ) and length velocity Z-scores (LVZ) by HIV group and assessed their independent influences. In period 1, mean WVZ (95% CI) was significantly (P < 0.001) lower in infected [-0.87 (-1.77, 0.04)] than HEU [0.81 (0.67, 0.94)] and unexposed [0.55 (0.33, 0.78)] infants. LVZ showed similar associations. In both periods, sick infants and those exposed to higher maternal viral loads had lower WVZ. Higher mean LVZ was associated with low birth weight. Infants that had received nevirapine had higher LVZ. In conclusion, HIV infection and not exposure was associated with low WVZ and LVZ in period 1. Eliminating infant HIV infection is a critical component in averting HIV-related poor growth patterns in infants in the first 6 mo of life.

Mid-upper arm circumference at age of routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the Gambia

OBJECTIVE

To determine the predictive value for death before 12 months of age of mid-upper arm circumference (MUAC) and weight-for-length Z score (WFLz).

METHODS

A retrospective cohort analysis of infants living in Keneba, in rural Gambia, was conducted. Anthropometric measures were obtained from demographic surveillance system records for infants registered between February 1974 and July 2008 who had had MUAC and WFLz recorded at 6-14 weeks of age and vital status recorded at least once more. Hazard ratios (HRs), population attributable fractions and areas under receiver operating characteristic (ROC) curves were estimated to assess the predictive value for death in infancy of MUAC and WFLz.

FINDINGS

Of 2876 infants included in the analysis, 40 died before the age of 12 months. The HR for death in this group versus in well-nourished infants was 5.8 (95% confidence interval, CI: 1.6-21) for a WFLz < -3. HRs for MUACs below the thresholds of 115 mm, 110 mm and 105 mm were 4.5 (95% CI: 1.4-15), 9.5 (95% CI: 2.6-35) and 23 (95% CI: 4.2-122), respectively. The attributable fractions for a MUAC < 130 mm and a WFLz < 0 were 51% and 13%, respectively. The areas under the ROC curve for death in infancy were 0.55 (95% CI: 0.46 to 0.64) for WFLz and 0.64 (95% CI: 0.55 to 0.73) for MUAC.

CONCLUSION

Among infants aged 6 to 14 weeks, unadjusted MUAC showed good performance in identifying infants at increased risk of death.