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Bourdon C, Diallo AH, Mohammad Sayeem Bin Shahid AS, Khan MA, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Otieno CA, Oduol CO, Lancioni CL, Manyasi C, McGrath CJ, Maronga C, Lwanga C, Brals D, Ahmed D, Mondal D, Denno DM, Mangale DI, Chimwezi E, Mbale E, Mupere E, Salauddin Mamun GM, Ouédraogo I, Berkley JA, Njunge JM, Njirammadzi J, Mukisa J, Thitiri J, Walson JL, Jemutai J, Tickell KD, Shahrin L, Mallewa M, Hossain MI, Chisti MJ, Timbwa M, Mburu M, Ngari MM, Ngao N, Aber P, Harawa PP, Sukhtankar P, Bandsma RH, Bamouni RM, Molyneux S, Mwaringa S, Shaima SN, Ali SA, Afsana SM, Banu S, Ahmed T, Voskuijl WP, Kazi Z. Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort. EClinicalMedicine 2024; 70:102530. [PMID: 38510373 PMCID: PMC10950691 DOI: 10.1016/j.eclinm.2024.102530] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
Background Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries. Methods We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates. Findings We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions. Interpretation Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support. Funding Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.
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Affiliation(s)
- Celine Bourdon
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Abdoulaye Hama Diallo
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
- Department of Public Health, Centre Muraz Research Institute, Bobo-Dioulasso, Burkina Faso
| | | | - Md Alfazal Khan
- Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ali Faisal Saleem
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | - Caroline Tigoi
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | | | | | - Christine J. McGrath
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Christopher Maronga
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christopher Lwanga
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Daniella Brals
- Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Dilruba Ahmed
- Clinical Microbiology and Immunology Laboratory, Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Dinesh Mondal
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Donna M. Denno
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Emmanuel Chimwezi
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Emmie Mbale
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Gazi Md Salauddin Mamun
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Issaka Ouédraogo
- Department of Pediatrics, Banfora Referral Regional Hospital, Banfora, Burkina Faso
| | - James A. Berkley
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - James M. Njunge
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Jenala Njirammadzi
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - John Mukisa
- Department of Immunology and Department of Molecular Biology Makerere University College of Health Sciences, Kampala, Uganda
| | - Johnstone Thitiri
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Judd L. Walson
- Departments of International Health and Medicine, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Julie Jemutai
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kirkby D. Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Lubaba Shahrin
- Hospitals, Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Macpherson Mallewa
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Md Iqbal Hossain
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Molline Timbwa
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Moses Mburu
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Moses M. Ngari
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Narshion Ngao
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Peace Aber
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Philliness Prisca Harawa
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Priya Sukhtankar
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert H.J. Bandsma
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Sassy Molyneux
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Health Systems and Research Ethics Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shalton Mwaringa
- Clinical Research Department, KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shamsun Nahar Shaima
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Syed Asad Ali
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Syeda Momena Afsana
- Clinical Biochemistry Laboratory, Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sayera Banu
- Infectious Diseases Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Wieger P. Voskuijl
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Amsterdam UMC, Location University of Amsterdam, Amsterdam Institute for Global Child Health, Emma Children’s Hospital, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam UMC, Location University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Meibergdreef 9, Amsterdam, the Netherlands
| | - Zaubina Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
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2
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Wen B, Farooqui A, Bourdon C, Tarafdar N, Ngari M, Chimwezi E, Thitiri J, Mwalekwa L, Walson JL, Voskuijl W, Berkley JA, Bandsma RHJ. Intestinal disturbances associated with mortality of children with complicated severe malnutrition. Commun Med (Lond) 2023; 3:128. [PMID: 37773543 PMCID: PMC10541881 DOI: 10.1038/s43856-023-00355-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 09/11/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Children admitted to hospital with complicated severe malnutrition (CSM) have high mortality despite compliance with standard WHO management guidelines. Limited data suggests a relationship between intestinal dysfunction and poor prognosis in CSM, but this has not been explicitly studied. This study aimed to evaluate the role of intestinal disturbances in CSM mortality. METHODS A case-control study nested within a randomized control trial was conducted among children hospitalized with CSM in Kenya and Malawi. Children who died (cases, n = 68) were compared with those who were discharged, propensity matched to the cases on age, HIV and nutritional status (controls, n = 68) on fecal metabolomics that targeted about 70 commonly measured metabolites, and enteropathy markers: fecal myeloperoxidase (MPO), fecal calprotectin, and circulating intestinal fatty acid binding protein (I-FABP). RESULTS The fecal metabolomes of cases show specific reductions in amino acids, monosaccharides, and microbial fermentation products, when compared to controls. SCFA levels did not differ between groups. The overall fecal metabolomics signature moderately differentiates cases from controls (AUC = 0.72). Enteropathy markers do not differ between groups overall, although serum I-FABP is elevated in cases in a sensitivity analysis among non-edematous children. Integrative analysis with systemic data suggests an indirect role of intestinal inflammation in the causal path of mortality. CONCLUSIONS Intestinal disturbances appear to have an indirect association with acute mortality. Findings of the study improve our understanding of pathophysiological pathways underlying mortality of children with CSM.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - Amber Farooqui
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - Celine Bourdon
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Nawar Tarafdar
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Laura Mwalekwa
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Departments of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, WA, USA
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences (formerly College of Medicine), Blantyre, Malawi
| | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert H J Bandsma
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada.
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.
- Department of Biomedical Sciences, Kamuzu University of Health Sciences (formerly College of Medicine), Blantyre, Malawi.
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Wen B, Njunge JM, Bourdon C, Gonzales GB, Gichuki BM, Lee D, Wishart DS, Ngari M, Chimwezi E, Thitiri J, Mwalekwa L, Voskuijl W, Berkley JA, Bandsma RHJ. Systemic inflammation and metabolic disturbances underlie inpatient mortality among ill children with severe malnutrition. Sci Adv 2022; 8:eabj6779. [PMID: 35171682 PMCID: PMC8849276 DOI: 10.1126/sciadv.abj6779] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/23/2021] [Indexed: 06/14/2023]
Abstract
Children admitted to hospital with an acute illness and concurrent severe malnutrition [complicated severe malnutrition (CSM)] have a high risk of dying. The biological processes underlying their mortality are poorly understood. In this case-control study nested within a multicenter randomized controlled trial among children with CSM in Kenya and Malawi, we found that blood metabolomic and proteomic profiles robustly differentiated children who died (n = 92) from those who survived (n = 92). Fatalities were characterized by increased energetic substrates (tricarboxylic acid cycle metabolites), microbial metabolites (e.g., propionate and isobutyrate), acute phase proteins (e.g., calprotectin and C-reactive protein), and inflammatory markers (e.g., interleukin-8 and tumor necrosis factor-α). These perturbations indicated disruptions in mitochondria-related bioenergetic pathways and sepsis-like responses. This study identified specific biomolecular disturbances associated with CSM mortality, revealing that systemic inflammation and bioenergetic deficits are targetable pathophysiological processes for improving survival of this vulnerable population.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - James M. Njunge
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Celine Bourdon
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Bonface M. Gichuki
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Dorothy Lee
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | | | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Laura Mwalekwa
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, Netherlands
- Department of Pediatrics, the College of Medicine, University of Malawi, Blantyre, Malawi
| | - James A. Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert HJ Bandsma
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Department of Pediatrics, the College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Biomedical Sciences, the College of Medicine, University of Malawi, Blantyre, Malawi
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Wen B, Brals D, Bourdon C, Erdman L, Ngari M, Chimwezi E, Potani I, Thitiri J, Mwalekwa L, Berkley JA, Bandsma RHJ, Voskuijl W. Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs. BMC Med 2021; 19:222. [PMID: 34538239 PMCID: PMC8451091 DOI: 10.1186/s12916-021-02074-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite adherence to WHO guidelines, inpatient mortality among sick children admitted to hospital with complicated severe acute malnutrition (SAM) remains unacceptably high. Several studies have examined risk factors present at admission for mortality. However, risks may evolve during admission with medical and nutritional treatment or deterioration. Currently, no specific guidance exists for assessing daily treatment response. This study aimed to determine the prognostic value of monitoring clinical signs on a daily basis for assessing mortality risk during hospitalization in children with SAM. METHODS This is a secondary analysis of data from a randomized trial (NCT02246296) among 843 hospitalized children with SAM. Daily clinical signs were prospectively collected during ward rounds. Multivariable extended Cox regression using backward feature selection was performed to identify daily clinical warning signs (CWS) associated with time to death within the first 21 days of hospitalization. Predictive models were subsequently developed, and their prognostic performance evaluated using Harrell's concordance index (C-index) and time-dependent area under the curve (tAUC). RESULTS Inpatient case fatality ratio was 16.3% (n=127). The presence of the following CWS during daily assessment were found to be independent predictors of inpatient mortality: symptomatic hypoglycemia, reduced consciousness, chest indrawing, not able to complete feeds, nutritional edema, diarrhea, and fever. Daily risk scores computed using these 7 CWS together with MUAC<10.5cm at admission as additional CWS predict survival outcome of children with SAM with a C-index of 0.81 (95% CI 0.77-0.86). Moreover, counting signs among the top 5 CWS (reduced consciousness, symptomatic hypoglycemia, chest indrawing, not able to complete foods, and MUAC<10.5cm) provided a simpler tool with similar prognostic performance (C-index of 0.79; 95% CI 0.74-0.84). Having 1 or 2 of these CWS on any day during hospitalization was associated with a 3 or 11-fold increased mortality risk compared with no signs, respectively. CONCLUSIONS This study provides evidence for structured monitoring of daily CWS as recommended clinical practice as it improves prediction of inpatient mortality among sick children with complicated SAM. We propose a simple counting-tool to guide healthcare workers to assess treatment response for these children. TRIAL REGISTRATION NCT02246296.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Daniella Brals
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Celine Bourdon
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Lauren Erdman
- Genetics and Genome Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Emmanuel Chimwezi
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Isabel Potani
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Laura Mwalekwa
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Coast General Hospital, Mombasa, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Biomedical Sciences, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wieger Voskuijl
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands. .,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya. .,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi. .,Amsterdam Center for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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5
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Gonzales GB, Lelijveld N, Bourdon C, Chimwezi E, Nyirenda MJ, Wells JC, Kerac M, Bandsma RHJ. Childhood Malnutrition and Association of Lean Mass with Metabolome and Hormone Profile in Later Life. Nutrients 2020; 12:E3593. [PMID: 33238545 PMCID: PMC7700560 DOI: 10.3390/nu12113593] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 11/17/2022] Open
Abstract
This study aimed to determine the associations of targeted metabolomics and hormone profiles data with lean mass index (LMI), which were estimated using bioelectrical impedance, in survivors of child severe malnutrition (SM) (n = 69) and controls (n = 77) in Malawi 7 years after being treated. Linear associations between individual metabolite or hormone and LMI were determined, including their interaction with nutrition status 7 years prior. Path analysis was performed to determine structural associations. Lastly, predictive models for LMI were developed using the metabolome and hormone profile by elastic net regularized regression (EN). Metabolites including several lipids, amino acids, and hormones were individually associated (p < 0.05 after false discovery rate correction) with LMI. However, plasma FGF21 (Control: β = -0.02, p = 0.59; Case: β = -0.14, p < 0.001) and tryptophan (Control: β = 0.15, p = 0.26; Case: β = 0.70, p < 0.001) were associated with LMI among cases but not among controls (both interaction p-values < 0.01). Moreover, path analysis revealed that tryptophan mediates the association between child SM and LMI. EN revealed that most predictors of LMI differed between groups, further indicating altered metabolic mechanisms driving lean mass accretion among SM survivors later in life.
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Affiliation(s)
- Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University, 6708 WE Wageningen, The Netherlands
- Laboratory of Gastroenterology, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | | | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (C.B.); (R.H.J.B.)
- The Childhood Acute Illness & Nutrition Network, Nairobi 43640-00100, Kenya
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S, Canada
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi;
| | | | - Jonathan C. Wells
- Childhood Nutrition Research Centre, Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
| | - Robert H. J. Bandsma
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; (C.B.); (R.H.J.B.)
- The Childhood Acute Illness & Nutrition Network, Nairobi 43640-00100, Kenya
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S, Canada
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6
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Bourdon C, Bartels RH, Chimwezi E, Kool J, Chidzalo K, Perot L, Brals D, Bandsma RHJ, Boele van Hensbroek M, Voskuijl WP. The clinical use of longitudinal bio-electrical impedance vector analysis in assessing stabilization of children with severe acute malnutrition. Clin Nutr 2020; 40:2078-2090. [PMID: 33097306 DOI: 10.1016/j.clnu.2020.09.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Severe Acute Malnutrition (SAM) in children is determined using anthropometry. However, bio-electrical impedance (BI) analysis could improve the estimation of altered body composition linked to edema and/or loss of lean body mass in children with SAM. We aimed to assess: 1) the changes in BI parameters during clinical stabilization and 2) whether BI parameters add prognostic value for clinical outcome beyond the use of anthropometry. METHODS This prospective observational study enrolled children, aged 6-60 months, that were admitted at Queen Elizabeth Central Hospital in Blantyre, Malawi, for complicated SAM (i.e., having either severe wasting or edematous SAM with a complicating illness). Height, weight, mid-upper arm circumference (MUAC), and BI were measured on admission and after clinical stabilization. BI measures were derived from height-adjusted indices of resistance (R/H), reactance (Xc/H), and phase angle (PA) and considered to reflect body fluids and soft tissue in BI vector analysis (BIVA). RESULTS We studied 183 children with SAM (55% edematous; age 23.0 ± 12.0 months; 54% male) and 42 community participants (age 20.1 ± 12.3 months; male 62%). Compared to community participants, the BIVA of children with edematous SAM were short with low PA and positioned low on the hydration axis which reflects severe fluid retention. In contrast, children with severe wasting had elongated vectors with a PA that was higher than children with edematous SAM but lower than community participants. Their BIVA position fell within the top right quadrant linked to leanness and dehydration. BIVA from severely wasted and edematous SAM patients differed between groups and from community children both at admission and after stabilization (p < 0.001). Vector position shifted during treatment only in children with edematous SAM (p < 0.001) and showed a upward translation suggestive of fluid loss. While PA was lower in children with SAM, PA did not contribute more than anthropometry alone towards explaining mortality, length of stay, or time-to-discharge or time-to-mortality. The variability and heterogeneity in BI measures was high and their overall added predictive value for prognosis of individual children was low. CONCLUSIONS BIVA did not add prognostic value over using anthropometry alone to predict clinical outcome. Several implementation challenges need to be optimized. Thus, in low-resource settings, the routine use of BI in the management of pediatric malnutrition is questionable without improved implementation.
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Affiliation(s)
- Céline Bourdon
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Rosalie H Bartels
- Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Emmanuel Chimwezi
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jacintha Kool
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Katherine Chidzalo
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lyric Perot
- Woodrow Wilson School of Public and International Affairs, Princeton University, NJ, USA
| | - Daniella Brals
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | - Robert H J Bandsma
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Wieger P Voskuijl
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi; Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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7
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Lelijveld N, Groce N, Patel S, Nnensa T, Chimwezi E, Gladstone M, Mallewa M, Wells J, Seal A, Kerac M. Long-term outcomes for children with disability and severe acute malnutrition in Malawi. BMJ Glob Health 2020; 5:bmjgh-2020-002613. [PMID: 33028697 PMCID: PMC7542612 DOI: 10.1136/bmjgh-2020-002613] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Severe acute malnutrition (SAM) and disability are major global health issues. Although they can cause and influence each other, data on their co-existence are sparse. We aimed to describe the prevalence and patterns of disability among a cohort of children with SAM. Methods A longitudinal cohort study in Malawi followed SAM survivors up to 7 years postdischarge. Clinical and anthropometric profiles were compared with sibling and community controls. Disability at original admission was identified clinically; at 7-year follow-up a standardised screening tool called ‘the Washington Group Questionnaire’ was used. Results 60/938 (6.4%) of admissions to SAM treatment had clinically obvious disability at admission. Post-treatment mortality was high, with only 11/60 (18%) surviving till 7-year follow-up. SAM children with a disability at admission had 6.99 (95% CI 3.49 to 14.02; p<0.001) greater risk of dying compared with children without disability. They were also older, less likely to be HIV positive or have oedema and more severely malnourished. Long-term survivors were more stunted, had less catch-up growth, smaller head circumference, weaker hand grip strength and poorer school achievement than non-disabled survivors. The Washington Group Questionnaire confirmed disability in all who had been identified clinically, and identified many who had not been previously flagged. Conclusion Disability is common among children affected by SAM. Those with disability-associated SAM have greatly increased risk of dying even if they survive the initial episode of malnutrition. Survivors have poorer growth, physical strength and school achievement. To enable all children to survive and thrive post-SAM, it is vital to focus more on those with disabilities. SAM treatment programmes should consider using not just clinical assessment but structured assessments to better identify at-risk individuals as well as understand the population of children for which they are developing services.
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Affiliation(s)
- Natasha Lelijveld
- Institute for Global Health, University College London, London, UK .,Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Nora Groce
- Department of Epidemiology and Health Care, UCL International Disability Research Centre, London, UK
| | - Seema Patel
- Department of Epidemiology and Health Care, UCL International Disability Research Centre, London, UK
| | - Theresa Nnensa
- Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Emmanuel Chimwezi
- Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi
| | - Melissa Gladstone
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Macpherson Mallewa
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Southern Region, Malawi
| | - Jonathan Wells
- Childhood Nutrition Research Centre, Institute of Child Health, University, London, UK
| | - Andrew Seal
- Institute for Global Health, University College London, London, UK
| | - Marko Kerac
- Clinical Research Programme, Malawi-Liverpool Wellcome Trust, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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8
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Wen B, Bourdon C, Gonzales G, Lee D, Njunge J, Ngari M, Chimwezi E, Thitiri J, Mwalekwa L, Voskuijl W, Berkley J, Bandsma R. Metabolomic Profiles Associated with Mortality of Children with Complicated Severe Malnutrition: A Nested Case-Control Study. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa053_126] [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: 11/15/2022] Open
Abstract
Abstract
Objectives
Children hospitalized with complicated severe malnutrition (CSM) have unacceptably high mortality rates despite receiving standard nutritional and medical treatment. The underlying pathology of the poor prognosis is not well understood. Growing evidence indicates presence of metabolic dysfunction in CSM. Yet, it is unclear whether and how metabolic dysfunction contributes the poor prognosis. This study aimed to identify metabolic signatures and pathways associated with CSM mortality.
Methods
A case-control study was performed on CSM patients enrolled to a multicenter (one Malawi and two Kenya hospitals) randomized control trial (NCT02246296). A total of 90 death cases and 90 discharged controls that were propensity score matched by age, HIV and mid-upper arm circumferences were included in the study. Targeted metabolomics was performed on their serum samples collected at admission and on day 3 of hospitalization. In particular, 206 metabolites, including amino acids, acylcarnitines, lipids and organic acids were quantified by LC-MS/MS.
Results
Discriminant analysis (PLS-DA) showed that metabolomic signatures at admission could differentiate cases from controls, with a cross-validated classification error rate of 21.8%. An increase of homovanillic, isobutyric and propionic acids, and decrease of lipids lysoPC a C18:2, lysoPC a C20:4, PC ae C42:2, SM C26:0, and SM C26:1 were the top 8 significant features characterizing the admission metabolomes of cases. Notably, cases with higher levels of isobutyrate, a microbial fermentation product, had significantly shorter survival time, implying a role of gut integrity in mortality. Pathway analysis revealed that metabolites of the tricarboxylic acid (TCA) cycle pathway differentiated cases from controls. Analysis of day 3 samples showed metabolic differences in response to treatment, especially in the recovery rate of lipids, between cases and controls.
Conclusions
CSM non-survivors have metabolomes distinct from survivors indicating perturbations in mitochondrial function and nutrition utilization. Perturbed metabolites identified shed light on biological mechanisms of mortality and may serve as targets of nutritional or therapeutic interventions to improve CSM survival.
Funding Sources
Bill and Melinda Gates Foundation, Thrasher Research Fund, and RESTRACOMP Graduate Scholarship.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto
| | - Celine Bourdon
- Translational Medicine Program, The Hospital for Sick Children, Canada
| | | | - Dorothy Lee
- Translational Medicine Program, The Hospital for Sick Children, Canada
| | - James Njunge
- The Childhood Acute Illness & Nutrition Network (CHAIN), Kenya
| | - Moses Ngari
- KEMRI-Wellcome Trust Research Programme, Kenya
| | | | | | | | - Wieger Voskuijl
- Global Child Health Group, Emma Children's Hospital, University of Amsterdam, The Netherlands
| | | | - Robert Bandsma
- Translational Medicine Program, The Hospital for Sick Children, Canada
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9
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Bourdon C, Lelijveld N, Thompson D, Dalvi PS, Gonzales GB, Wang D, Alipour M, Wine E, Chimwezi E, Wells JC, Kerac M, Bandsma R, Nyirenda MJ. Metabolomics in plasma of Malawian children 7 years after surviving severe acute malnutrition: "ChroSAM" a cohort study. EBioMedicine 2019; 45:464-472. [PMID: 31255658 PMCID: PMC6642285 DOI: 10.1016/j.ebiom.2019.06.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND More children are now surviving severe acute malnutrition (SAM), but evidence suggests that early-life malnutrition is associated with increased risk of long-term cardio-metabolic disorders. To better understand potential mechanisms, we studied the metabolite profiles of children seven years after treatment for SAM. METHODS We followed-up children (n = 352) treated for SAM in 2006-2007, at Queen Elizabeth Central Hospital, in Malawi. Using nuclear magnetic resonance spectroscopy, tandem mass spectrometry and enzyme-linked immunosorbent assay, we measured circulating metabolites in fasting blood in a subset of SAM survivors (n = 69, 9·6 ± 1·6 years), siblings (n = 44, 10·5 ± 2·7 years), and age and sex-matched community controls (n = 37, 9·4 ± 1·8 years). Data were analysed using univariate and sparse partial least square (sPLS) methods. Differences associated with SAM survival, oedema status, and anthropometry were tested, adjusting for age, sex, HIV, and wealth index. FINDINGS Based on 194 measured metabolites, the profiles of SAM survivors were similar to those of siblings and community controls. IGF1, creatinine, and FGF21, had loading values >0·3 and ranked stably in the top 10 distinguishing metabolites, but did not differ between SAM survivors and controls with univariate analysis. Current stunting was associated with IGF1 (β = 15·2, SE = 3·5, partial R2 = 12%, p < 0·0001) and this relationship could be influenced by early childhood SAM (β = 17·4, SE = 7·7, partial R2 = 2·8%, p = 0·025). No metabolites were associated with oedema status, duration of hospital stay, anthropometry measured during hospitalization, nor with changes in anthropometry since hospitalization. INTERPRETATION In this group of survivors, SAM was not associated with longer-term global metabolic changes 7 years after treatment. However, SAM may influence the relationship between current stunting and IGF1. Further risk markers for NCDs in SAM survivors may only be revealed by direct metabolic challenge or later in life.
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Affiliation(s)
- Celine Bourdon
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Canada
| | - Natasha Lelijveld
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Institute for Global Health, University College London, London, UK.
| | - Debbie Thompson
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
| | - Prasad S Dalvi
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; Morosky College of Health Professions and Sciences, Gannon University, Erie, PA, USA
| | - Gerard Bryan Gonzales
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; Gastroenterology, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium; VIB Inflammation Research Centre, Ghent, Belgium
| | - Dominic Wang
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - Misagh Alipour
- Division of Pediatric Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | - Eytan Wine
- Division of Pediatric Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Institute of Child Health, University College London, London, UK
| | - Marko Kerac
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Robert Bandsma
- Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Canada; Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi; Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University Medical Center Groningen, Groningen, the Netherlands; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Moffat J Nyirenda
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; MRC / UVRI Uganda Research Unit, Entebbe, Uganda
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10
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Bandsma RHJ, Voskuijl W, Chimwezi E, Fegan G, Briend A, Thitiri J, Ngari M, Mwalekwa L, Bandika V, Ali R, Hamid F, Owor B, Mturi N, Potani I, Allubha B, Muller Kobold AC, Bartels RH, Versloot CJ, Feenstra M, van den Brink DA, van Rheenen PF, Kerac M, Bourdon C, Berkley JA. A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial. PLoS Med 2019; 16:e1002747. [PMID: 30807589 PMCID: PMC6390989 DOI: 10.1371/journal.pmed.1002747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 01/18/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Children with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase. METHODS AND FINDINGS In a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2-5 days), which was similar between randomized groups (0.23 [95% CI -0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite. CONCLUSIONS Empirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM. TRIAL REGISTRATION ClinicalTrials.gov NCT02246296.
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Affiliation(s)
- Robert H. J. Bandsma
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutrition Sciences, University of Toronto, Toronto, Canada
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - Wieger Voskuijl
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Emmanuel Chimwezi
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Greg Fegan
- Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
- University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
| | | | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Victor Bandika
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Rehema Ali
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Fauzat Hamid
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Betty Owor
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Isabel Potani
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Benjamin Allubha
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Anneke C. Muller Kobold
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - Rosalie H. Bartels
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Christian J. Versloot
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marjon Feenstra
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Deborah A. van den Brink
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Patrick F. van Rheenen
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marko Kerac
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - James A. Berkley
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
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11
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Lelijveld N, Kerac M, Seal A, Chimwezi E, Wells JC, Heyderman RS, Nyirenda MJ, Stocks J, Kirkby J. Long-term effects of severe acute malnutrition on lung function in Malawian children: a cohort study. Eur Respir J 2017; 49:49/4/1601301. [PMID: 28381429 PMCID: PMC5540677 DOI: 10.1183/13993003.01301-2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [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] [Received: 07/01/2016] [Accepted: 12/03/2016] [Indexed: 12/31/2022]
Abstract
Early nutritional insults may increase risk of adult lung disease. We aimed to quantify the impact of severe acute malnutrition (SAM) on spirometric outcomes 7 years post-treatment and explore predictors of impaired lung function. Spirometry and pulse oximetry were assessed in 237 Malawian children (median age: 9.3 years) who had been treated for SAM and compared with sibling and age/sex-matched community controls. Spirometry results were expressed as z-scores based on Global Lung Function Initiative reference data for the African–American population. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were low in all groups (mean FEV1 z-score: −0.47 for cases, −0.48 for siblings, −0.34 for community controls; mean FVC z-score: −0.32, −0.38, and −0.15 respectively). There were no differences in spirometric or oximetry outcomes between SAM survivors and controls. Leg length was shorter in SAM survivors but inter-group sitting heights were similar. HIV positive status or female sex was associated with poorer FEV1, by 0.55 and 0.31 z-scores, respectively. SAM in early childhood was not associated with subsequent reduced lung function compared to local controls. Preservation of sitting height and compromised leg length suggest “thrifty” or “lung-sparing” growth. Female sex and HIV positive status were identified as potentially high-risk groups. Despite stunting, survivors of acute malnutrition do not have worse lung function than controlshttp://ow.ly/2nvH308LroU
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Affiliation(s)
- Natasha Lelijveld
- Institute for Global Health, University College London, London, UK .,Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Marko Kerac
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Leonard Cheshire Disability and Inclusive Development Centre, Dept of Epidemiology and Child Health, University College London, London, UK
| | - Andrew Seal
- Institute for Global Health, University College London, London, UK
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, UCL Great Ormond Street, Institute of Child Health, University College London, London, UK
| | - Robert S Heyderman
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Division of Infection and Immunity, University College London, London, UK
| | - Moffat J Nyirenda
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Stocks
- Respiratory, Critical Care and Anaesthesia section in III, UCL Great Ormond Street, Institute of Child Health, University College London, London, UK
| | - Jane Kirkby
- Respiratory, Critical Care and Anaesthesia section in III, UCL Great Ormond Street, Institute of Child Health, University College London, London, UK
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12
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Lelijveld N, Seal A, Wells JC, Kirkby J, Opondo C, Chimwezi E, Bunn J, Bandsma R, Heyderman RS, Nyirenda MJ, Kerac M. Chronic disease outcomes after severe acute malnutrition in Malawian children (ChroSAM): a cohort study. Lancet Glob Health 2016; 4:e654-62. [PMID: 27470174 PMCID: PMC4985564 DOI: 10.1016/s2214-109x(16)30133-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 05/17/2016] [Accepted: 06/09/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tackling severe acute malnutrition (SAM) is a global health priority. Heightened risk of non-communicable diseases (NCD) in children exposed to SAM at around 2 years of age is plausible in view of previously described consequences of other early nutritional insults. By applying developmental origins of health and disease (DOHaD) theory to this group, we aimed to explore the long-term effects of SAM. METHODS We followed up 352 Malawian children (median age 9·3 years) who were still alive following SAM inpatient treatment between July 12, 2006, and March 7, 2007, (median age 24 months) and compared them with 217 sibling controls and 184 age-and-sex matched community controls. Our outcomes of interest were anthropometry, body composition, lung function, physical capacity (hand grip, step test, and physical activity), and blood markers of NCD risk. For comparisons of all outcomes, we used multivariable linear regression, adjusted for age, sex, HIV status, and socioeconomic status. We also adjusted for puberty in the body composition regression model. FINDINGS Compared with controls, children who had survived SAM had lower height-for-age Z scores (adjusted difference vs community controls 0·4, 95% CI 0·6 to 0·2, p=0·001; adjusted difference vs sibling controls 0·2, 0·0 to 0·4, p=0·04), although they showed evidence of catch-up growth. These children also had shorter leg length (adjusted difference vs community controls 2·0 cm, 1·0 to 3·0, p<0·0001; adjusted difference vs sibling controls 1·4 cm, 0·5 to 2·3, p=0·002), smaller mid-upper arm circumference (adjusted difference vs community controls 5·6 mm, 1·9 to 9·4, p=0·001; adjusted difference vs sibling controls 5·7 mm, 2·3 to 9·1, p=0·02), calf circumference (adjusted difference vs community controls 0·49 cm, 0·1 to 0·9, p=0·01; adjusted difference vs sibling controls 0·62 cm, 0·2 to 1·0, p=0·001), and hip circumference (adjusted difference vs community controls 1·56 cm, 0·5 to 2·7, p=0·01; adjusted difference vs sibling controls 1·83 cm, 0·8 to 2·8, p<0·0001), and less lean mass (adjusted difference vs community controls -24·5, -43 to -5·5, p=0·01; adjusted difference vs sibling controls -11·5, -29 to -6, p=0·19) than did either sibling or community controls. Survivors of SAM had functional deficits consisting of weaker hand grip (adjusted difference vs community controls -1·7 kg, 95% CI -2·4 to -0·9, p<0·0001; adjusted difference vs sibling controls 1·01 kg, 0·3 to 1·7, p=0·005,)) and fewer minutes completed of an exercise test (sibling odds ratio [OR] 1·59, 95% CI 1·0 to 2·5, p=0·04; community OR 1·59, 95% CI 1·0 to 2·5, p=0·05). We did not detect significant differences between cases and controls in terms of lung function, lipid profile, glucose tolerance, glycated haemoglobin A1c, salivary cortisol, sitting height, and head circumference. INTERPRETATION Our results suggest that SAM has long-term adverse effects. Survivors show patterns of so-called thrifty growth, which is associated with future cardiovascular and metabolic disease. The evidence of catch-up growth and largely preserved cardiometabolic and pulmonary functions suggest the potential for near-full rehabilitation. Future follow-up should try to establish the effects of puberty and later dietary or social transitions on these parameters, as well as explore how best to optimise recovery and quality of life for survivors. FUNDING The Wellcome Trust.
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Affiliation(s)
- Natasha Lelijveld
- Institute for Global Health, University College London, London, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Andrew Seal
- Institute for Global Health, University College London, London, UK
| | - Jonathan C Wells
- Childhood Nutrition Research Centre, Institute of Child Health, University College London, London, UK
| | - Jane Kirkby
- Respiratory, Critical Care & Anaesthesia section in IIIP, Institute of Child Health, University College London, London, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Emmanuel Chimwezi
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - James Bunn
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Robert Bandsma
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robert S Heyderman
- Division of Infection & Immunity, University College London, London, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Moffat J Nyirenda
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Marko Kerac
- Leonard Cheshire Disability & Inclusive Development Centre, Department of Epidemiology & Child Health, University College London, London, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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