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Smith TJ, Arnold CD, Fischer PR, Trehan I, Hiffler L, Sitthideth D, Stein-Wexler R, Yeh J, Jones KS, Hampel D, Tancredi DJ, Schick MA, McBeth CN, Tan X, Allen LH, Sayasone S, Kounnavong S, Hess SY. A Predictive Model for Thiamine Responsive Disorders among Infants and Young Children: Results from a Prospective Cohort Study in Lao People's Democratic Republic. J Pediatr 2024:113961. [PMID: 38369233 DOI: 10.1016/j.jpeds.2024.113961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/12/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To develop a predictive model for thiamine responsive disorders (TRD) among infants and young children hospitalized with signs or symptoms suggestive of thiamine deficiency disorders (TDD) based on response to therapeutic thiamine in a high-risk setting. STUDY DESIGN Children aged 21 days to <18 months hospitalized with signs or symptoms suggestive of TDD in northern Lao PDR were treated with parenteral thiamine (100mg daily) for ≥3 days in addition to routine care. Physical examinations and recovery assessments were conducted frequently for 72 hours after thiamine was initiated. Individual case reports were independently reviewed by three pediatricians who assigned a TRD status (TRD or non-TRD), which served as the dependent variable in logistic regression models to identify predictors of TRD. Model performance was quantified by empirical area under the receiver operating characteristic curve (AUROC). RESULTS 449 children (median [Q1, Q3] 2.9 [1.7, 5.7] months old; 70.3% exclusively/predominantly breastfed) were enrolled; 60.8% had a TRD. Among 52 candidate variables, those most predictive of TRD were exclusive/predominant breastfeeding, hoarse voice/loss of voice, cyanosis, no eye contact and no diarrhea in the previous 2 weeks. The AUROC (95% CI) was 0.82 (0.78, 0.86). CONCLUSIONS In this study, the majority of children with signs or symptoms of TDD responded favorably to thiamine. While five specific features were predictive of TRD, the high prevalence of TRD suggests that thiamine should be administered to all infants and children presenting with any signs or symptoms consistent with TDD in similar high-risk settings. The usefulness of the predictive model in other contexts warrants further exploration and refinement.
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Affiliation(s)
- Taryn J Smith
- Institute for Global Nutrition, University of California Davis, Davis, California, USA;.
| | - Charles D Arnold
- Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA;; Pediatrics Department, Sheikh Shakhbout Medical City, Abu Dhabi, UAE;; Khalifa University, Abu Dhabi, UAE
| | - Indi Trehan
- Departments of Pediatrics, Global Health, and Epidemiology, University of Washington, Seattle, Washington, USA;; Lao Friends Hospital for Children, Luang Prabang, Lao PDR
| | | | - Dalaphone Sitthideth
- Lao Tropical and Public Health Institute, Vientiane Capital, Lao People's Democratic Republic
| | - Rebecca Stein-Wexler
- Department of Radiology, University of California Davis Health System, Sacramento, California, USA
| | - Jay Yeh
- Department of Pediatrics, Division of Cardiology, University of California Davis Health System, Sacramento, California, USA
| | - Kerry S Jones
- Nutritional Biomarker Laboratory, MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Daniela Hampel
- Institute for Global Nutrition, University of California Davis, Davis, California, USA;; USDA-Agricultural Research Service Western Human Nutrition Research Center, Davis, California, USA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis Health System, Sacramento, California, USA
| | - Michael A Schick
- Emergency Medicine, University of California Davis Health System, Sacramento, California, USA
| | - Christine N McBeth
- Emergency Medicine, University of California Davis Health System, Sacramento, California, USA
| | - Xiuping Tan
- Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Lindsay H Allen
- Institute for Global Nutrition, University of California Davis, Davis, California, USA;; USDA-Agricultural Research Service Western Human Nutrition Research Center, Davis, California, USA
| | - Somphou Sayasone
- Lao Tropical and Public Health Institute, Vientiane Capital, Lao People's Democratic Republic
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane Capital, Lao People's Democratic Republic
| | - Sonja Y Hess
- Institute for Global Nutrition, University of California Davis, Davis, California, USA
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Hess SY, Smith TJ, Sitthideth D, Arnold CD, Tan X, Jones KS, Brown KH, Alayon S, Kounnavong S. Risk factors for anaemia among women and their young children hospitalised with suspected thiamine deficiency in northern Lao PDR. Matern Child Nutr 2024; 20:e13565. [PMID: 37803889 PMCID: PMC10749997 DOI: 10.1111/mcn.13565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/17/2023] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
Anaemia among women and young children remains a major public health concern. This secondary study describes the anaemia prevalence among young hospitalised children and their mothers in northern Lao People's Democratic Republic and explores possible nutritional causes and risk factors for anaemia. Hospitalised children (ages 21 days to <18 months) with clinical symptoms suggestive of thiamine deficiency disorders were eligible along with their mothers. Venous blood was collected for determination of haemoglobin, ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), erythrocyte glutathione reductase activation coefficient (EGRac), thiamine diphosphate (ThDP) and acute phase proteins. Risk factors for anaemia were modelled using minimally adjusted logistic regression controlling for age. Haemoglobin results were available for 436 women (mean ± SD age 24.7 ± 6.4 years; 1.6% pregnant) and 427 children (4.3 ± 3.5 months; 60.3% male). Anaemia prevalence (Hb < 120 g/L for nonpregnant women and <110 g/L for pregnant women and children) was 30.7% among women and 55.2% among children. In bivariate analyses, biomarkers significantly associated with anaemia in women were ferritin, sTfR, RBP, EGRac and ThDP. Other risk factors for women were lower BMI, mid-upper arm circumference < 23.5 cm, lower education, lower socioeconomic index, food insecurity, Hmong ethnicity, not/rarely having attended antenatal care, not having taken antenatal iron-containing supplements and not meeting minimum dietary diversity. Risk factors for anaemia among children were older age, male sex, stunting, sTfR, ThDP and alpha-1-acid-glycoprotein. Anaemia was common among women and their hospitalised children and was associated with micronutrient deficiencies and socioeconomic, dietary and health care-seeking risk factors, suggesting that multiple strategies are required to prevent anaemia among women and children.
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Affiliation(s)
- Sonja Y. Hess
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Taryn J. Smith
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Dalaphone Sitthideth
- Lao Tropical and Public Health InstituteVientianeLao People's Democratic Republic
| | - Charles D. Arnold
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Xiuping Tan
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Kerry S. Jones
- Nutritional Biomarker Laboratory, MRC Epidemiology UnitUniversity of CambridgeCambridgeUK
| | - Kenneth H. Brown
- Institute for Global Nutrition and Department of NutritionUniversity of California DavisDavisCaliforniaUSA
| | - Silvia Alayon
- USAID Advancing NutritionArlingtonVirginiaUSA
- Save the ChildrenWashingtonWashington, D.C.USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health InstituteVientianeLao People's Democratic Republic
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Smith TJ, Tan X, Arnold CD, Sitthideth D, Kounnavong S, Hess SY. Traditional prenatal and postpartum food restrictions among women in northern Lao PDR. Matern Child Nutr 2021; 18:e13273. [PMID: 34595830 PMCID: PMC8710103 DOI: 10.1111/mcn.13273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/28/2021] [Accepted: 09/01/2021] [Indexed: 11/04/2022]
Abstract
Culturally determined food restrictions are common among pregnant and postpartum women in Asia. This study aimed to describe perinatal dietary restrictions, factors associated with food avoidances and attainment of minimum dietary diversity (MDD‐W) among women in Lao PDR. Mother–child (aged 21 days to <18 months) dyads (n = 682) were enrolled into a cohort study in northern Lao PDR and interviewed at one time point postpartum. During pregnancy and postpartum, 1.6% and 97% of women reported following dietary restrictions, respectively. Cluster analysis identified four distinct postpartum dietary patterns: most restrictive (throughout first 2 months postpartum); least restrictive; 2 weeks highly restrictive and 1 month highly restrictive, followed by 19%, 15%, 5% and 62% of women, respectively. Greater maternal age, gravidity and higher household socioeconomic status were associated with allowing more diverse foods, while women from food insecure households followed more restrictive diets for longer. Women belonging to the Hmong ethnic group followed a highly restrictive diet of white rice and chicken for the first month postpartum. MDD‐W was achieved by 10% of women restricting their diet at the time of the interview compared with 17% of women who were consuming their normal diet (p = 0.04). Postpartum dietary restrictions are widespread among women in northern Lao PDR. These highly restrictive diets, low dietary diversity and food insecurity likely contribute to micronutrient deficiencies in women that may have important consequences for their breastfed infants through reduced breastmilk micronutrient content, which requires further exploration. Culturally appropriate strategies to increase micronutrient intakes among women should be considered.
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Affiliation(s)
- Taryn J Smith
- Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Xiuping Tan
- Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Charles D Arnold
- Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Dalaphone Sitthideth
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Sonja Y Hess
- Institute for Global Nutrition, University of California Davis, Davis, California, USA
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Smith T, Tan X, Arnold C, Sitthideth D, Kounnavong S, Hess S. Strategies to Increase Micronutrient Intakes Among Laotian Women Adhering to Traditional Postpartum Dietary Restrictions. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab046_116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Culturally determined restrictive postpartum diets are common in Lao PDR, placing lactating women and breastfed infants at high risk of micronutrient deficiencies. The objective of this analysis was to explore if fortified condiments and supplements would be suitable strategies to improve micronutrient intakes among women adhering to dietary restrictions.
Methods
Mother-child (aged 21 days - <18 months) dyads (n = 680) were enrolled into a prospective cohort study in Lao PDR. Women were interviewed about foods and condiments that were consumed or restricted in weekly (for the first four weeks) and monthly intervals postpartum, and if they would be willing to take supplements during this time if provided to them. Data on minimum dietary diversity for women (MDD-W) and household food insecurity was collected.
Results
Mean ± SD child and maternal age was 4.3 ± 3.3 mo and 24.7 ± 6.3 yr respectively, 95% of mothers were breastfeeding and 34% of households were moderately to severely food insecure. Almost all women (97%) reported adhering to food restrictions after childbirth for a median (IQR) length of time of 1 (1, 3) month (range 1 week to 36 months). White rice was consumed universally postpartum, however other diverse foods were highly restricted and consumed by < 32% of women in the first month. MDD-W was achieved by 10.4% of women currently restricting their diet and 16.4% who had resumed/were consuming their normal diet (p = 0.04). Of the women interviewed about condiments (n = 480), 99%, 43% and 53% habitually consumed salt, fish sauce and soy sauce respectively. During the period of dietary restrictions, 54% and 38% of habitual consumers restricted fish and soy sauces respectively, while all women continued to consume salt. Of the women asked about supplement use (n = 415), 87% reported that they would take supplements during the period of dietary restrictions.
Conclusions
Postpartum dietary restrictions are widespread among women in Lao PDR. These highly restrictive diets and low dietary diversity likely contribute to micronutrient deficiencies in mothers that may have important consequences for their breastfed infants through reduced micronutrient content of breastmilk, which requires further exploration. Salt fortification and supplements could be viable strategies to increase micronutrient intakes among women.
Funding Sources
Bill & Melinda Gates Foundation.
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Affiliation(s)
| | | | - Charles Arnold
- Institute for Global Nutrition, University of California, Davis
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Barffour MA, Hinnouho GM, Wessells KR, Kounnavong S, Ratsavong K, Sitthideth D, Bounheuang B, Sengnam K, Chanhthavong B, Arnold CD, Brown KH, Larson CP, Hess SY. Effects of therapeutic zinc supplementation for diarrhea and two preventive zinc supplementation regimens on the incidence and duration of diarrhea and acute respiratory tract infections in rural Laotian children: A randomized controlled trial. J Glob Health 2021; 10:010424. [PMID: 32612816 PMCID: PMC7321011 DOI: 10.7189/jogh.10.010424] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Diarrhea and respiratory tract infections are leading causes of childhood morbidity and mortality. This individually randomized, double-blind placebo-controlled trial was designed to evaluate the effects of different zinc supplementation regimens on the incidence and duration of diarrhea and acute lower (ALRI) and upper (AURI) respiratory tract infections among rural Laotian children. The study included 3407 children, 6-23 months at enrollment. Methods Children were randomized to one of four study groups: therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days with each episode; TZ), daily preventive zinc tablets (7 mg/d; PZ), daily multiple micronutrient powder (10 mg/d zinc, 6 mg/d iron and 13 other micronutrients; MNP), or daily placebo powder for 9 months. Incidence and duration of diarrhea (≥3 liquid stools/24 hours), ALRI (persistent cough with wheezing, stridor or chest in-drawing) and AURI (purulent nasal discharge with cough) were assessed by parental report during weekly home visits and analyzed using negative binomial models. Results Baseline mean age was 14.2 ± 5.1 months, and 71% had low plasma zinc (<65 μg/dL). Overall diarrhea incidence (0.61 ± 0.01 episodes/100 days at risk) and duration (2.12 ± 0.03 days/episode) did not differ by study group. Age modified the impact of the interventions on diarrhea incidence (P = 0.06) and duration (P = 0.01). In children >18 months, TZ reduced diarrhea incidence by 24% vs MNP (P = 0.035), and 36% vs Control (P = 0.004), but there was no difference with PZ. This patterned remained when analyses were restricted to diarrhea episode occurring after the first treatment with TZ. Also, in children >18 months, TZ reduced diarrhea duration by 15% vs PZ (P = 0.03), and 16% vs Control (P = 0.03), but there was no difference with MNP. There were no overall effects of study group on incidence of ALRI (overall mean 0.005 ± 0.001 episodes/100 days, P = 0.14) or AURI (overall mean 0.09 ± 0.01 episodes/100 days, P = 0.72). Conclusions There was no overall impact of TZ, PZ or MNP on diarrhea, ALRI and AURI. However, in children >18 months, TZ significantly reduced both the duration of diarrhea episodes and the incidence of future diarrhea episodes compared with placebo. Trial registration ClinicalTrials.gov: NCT02428647.
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Affiliation(s)
- Maxwell A Barffour
- Institute for Global Nutrition, University of California, Davis, California, USA.,College of Health and Human Services, Public Health Program, Missouri State University, Springfield, Missouri, USA
| | - Guy-Marino Hinnouho
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - K Ryan Wessells
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Kethmany Ratsavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Dalaphone Sitthideth
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Bangone Bounheuang
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Khanpaseuth Sengnam
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Bigphone Chanhthavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Charles D Arnold
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Kenneth H Brown
- Institute for Global Nutrition, University of California, Davis, California, USA
| | - Charles P Larson
- School of Population and Global Health, McGill University, Montreal, Canada
| | - Sonja Y Hess
- Institute for Global Nutrition, University of California, Davis, California, USA
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Hess SY, Smith TJ, Fischer PR, Trehan I, Hiffler L, Arnold CD, Sitthideth D, Tancredi DJ, Schick MA, Yeh J, Stein-Wexler R, McBeth CN, Tan X, Nhiacha K, Kounnavong S. Establishing a case definition of thiamine responsive disorders among infants and young children in Lao PDR: protocol for a prospective cohort study. BMJ Open 2020; 10:e036539. [PMID: 32060165 PMCID: PMC7044841 DOI: 10.1136/bmjopen-2019-036539] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Diagnosis of infantile thiamine deficiency disorders (TDD) is challenging due to the non-specific, highly variable clinical presentation, often leading to misdiagnosis. Our primary objective is to develop a case definition for thiamine responsive disorders (TRD) to determine among hospitalised infants and young children, which clinical features and risk factors identify those who respond positively to thiamine administration. METHODS AND ANALYSIS This prospective study will enrol 662 children (aged 21 days to <18 months) seeking treatment for TDD symptoms. Children will be treated with intravenous or intramuscular thiamine (100 mg daily for a minimum of 3 days) alongside other interventions deemed appropriate. Baseline assessments, prior to thiamine administration, include a physical examination, echocardiogram and venous blood draw for the determination of thiamine biomarkers. Follow-up assessments include physical examinations (after 4, 8, 12, 24, 36, 48 and 72 hours), echocardiogram (after 24 and 48 hours) and one cranial ultrasound. During the hospital stay, maternal blood and breast-milk samples and diet, health, anthropometric and socio-demographic information will be collected for mother-child pairs. Using these data, a panel of expert paediatricians will determine TRD status for use as the dependent variable in logistic regression models. Models identifying predictors of TRD will be developed and validated for various scenarios. Clinical prediction model performance will be quantified by empirical area under the receiver operating characteristic curve, using resampling cross validation. A frequency-matched community-based cohort of mother-child pairs (n=265) will serve as comparison group for evaluation of potential risk factors for TRD. ETHICS AND DISSEMINATION Ethical approval has been obtained from The National Ethics Committee for Health Research, Ministry of Health, Lao PDR and the Institutional Review Board of the University of California Davis. The results will be disseminated via scientific articles, presentations and workshops with representatives of the Ministry of Health. TRIAL REGISTRATION NUMBER NCT03626337.
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Affiliation(s)
- Sonja Y Hess
- Department of Nutrition, Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Taryn J Smith
- Department of Nutrition, Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Philip R Fischer
- Pediatric and Adolescent Medicine, Mayo, Rochester, Minnesota, USA
| | - Indi Trehan
- Department of Pediatrics and Department of Global Health, University of Washington, Seattle, Washington, USA
- Lao Friends Hospital for Children, Luang Prabang, Lao People's Democratic Republic
| | | | - Charles D Arnold
- Department of Nutrition, Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Dalaphone Sitthideth
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis Health System, Sacramento, California, USA
| | - Michael A Schick
- Emergency Medicine, University of California Davis Health System, Sacramento, California, USA
| | - Jay Yeh
- Department of Pediatrics, Division of Cardiology, University of California Davis Health System, Sacramento, California, USA
| | - Rebecca Stein-Wexler
- Department of Radiology, University of California Davis Health System, Sacramento, California, USA
| | - Christine N McBeth
- Emergency Medicine, University of California Davis Health System, Sacramento, California, USA
| | - Xiuping Tan
- Department of Nutrition, Institute for Global Nutrition, University of California Davis, Davis, California, USA
| | - Kouyang Nhiacha
- Lao-Korea Children Hospital, Vientiane, Lao People's Democratic Republic
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Vientiane, Lao People's Democratic Republic
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