Incorrect Feeding Practices, Dietary Diversity Determinants and Nutritional Status in Children Aged 6-23 Months: An Observational Study in Rural Angola.

BACKGROUND: More than a quarter of children who are affected by severe acute undernutrition reside in Sub-Saharan Africa. Incorrect feeding practices have a negative impact on a child's health in both the short and the long term, and the interval from conception to two years is the most critical for the development of undernutrition-related complications. These first 1000 days of life also represent an "opportunity window" for early interventions, hence, having a clear insight into dietary habits and the determinants of diet quality is fundamental to improving nutritional counseling practices. OBJECTIVES: To investigate incorrect feeding practices, dietary diversity determinants and nutritional status in children aged 6-23 months. METHODS: Prospective quali-quantitative observational study conducted at the Missionary Catholic Hospital of Chiulo (Angola) from March to April 2023. RESULTS: Of 250 children, global acute malnutrition affected 25.2% and was associated with starting complementary feeding at <4 months of age (p = 0.007) and not achieving the minimum meal frequency (p < 0.0001). Minimum dietary diversity was found in 11.2%, minimum meal frequency was experienced by 72.8%, and the minimum acceptable diet was found in 11.2% of participants. The minimum dietary diversity was reached only by households with access to food from five or more major food groups (p = 0.007) or the money to buy food from five or more major food groups (p = 0.008) and was higher in households where the householder had a higher educational level (p = 0.002). Regarding the determinants linked to family traditions and beliefs, the main religion-associated beliefs concerned the impurity of pork (n = 25) and fish (n = 8), while eggs (n = 19) and cow milk (n = 8) were the main food types that were deemed harmful for children. CONCLUSIONS: Although some factors (economic and religious) may be difficult to overcome, other factors linked to erroneous beliefs (dangerous foods) or incorrect feeding practices (early weaning and an incorrect frequency of meals) can be targeted, to improve the effectiveness of nutritional counseling practices.

Adherence to WHO guidelines on severe pneumonia management in children and its impact on outcome: an observational study at Jinka General Hospital in Ethiopia.

Introduction: Poor adherence to guidelines during empirical antibiotic prescription in low-income countries could increase antimicrobial resistance without improving outcomes. Revised World Health Organization (WHO) guidelines published in 2014 on childhood (2-59 months) pneumonia re-defined the classification of severe pneumonia and changed the first-line treatment. The adherence to WHO guidelines in southern Ethiopia at the hospital level is unknown. We sought to determine the adherence to WHO guidelines on severe pneumonia first-line treatment in children in an Ethiopian referral hospital and assess the impact of non-adherence on patient outcomes. Methods: An observational study was conducted on all children (2-59 months) clinically diagnosed with severe pneumonia and admitted to the Pediatric Ward of Jinka Hospital from 1 June 2021 to 31 May 2022. Exclusion criteria included a known HIV infection, ongoing antibiotic treatment before the event not related to acute pneumonia, or any other severe bacterial infection, confirmed or suspected. Adherence to guidelines was defined as first-line treatment with ampicillin or benzylpenicillin and gentamicin at the recommended dose. We compared the patients treated adherently vs. non-adherently. For categorical variables, the chi-square or Fisher's exact test was used, while for continuous variables, the Mann-Whitney U-test was used. Multivariate logistic regression was used to evaluate the association between adherence and demographic and clinical characteristics. Results: During the observational period, 266 patients were registered as having severe pneumonia with an age between 2 and 59 months. After excluding 114 patients due to missing charts or other exclusion criteria, a total of 152 patients were included in the analysis. Of these, 78 (51%) were girls with a median age of 10 months (IQR 7-14). Overall, 75 (49%) patients received therapy according to the WHO guidelines. Compared to patients treated adherently to the guidelines, patients not treated adherently had similar outcomes [median length of stay of 3 (IQR 3-5) and 4 (IQR 3-6) days], median duration of oxygen therapy of 2 (IQR 1-3) for both the groups, and self-discharge rates of 5% and 6.5%, respectively). Conclusion: Adherence to the revised WHO guideline was limited and not associated with outcomes. Efforts should focus on reducing the gap between theory and practice.

Rewarming rate of hypothermic neonates in a low-resource setting: a retrospective single-center study.

Background: Hypothermic neonates need to be promptly rewarmed but there is no strong evidence to support a rapid or a slow pace of rewarming. This study aimed to investigate the rewarming rate and its associations with clinical outcomes in hypothermic neonates born in a low-resource setting. Methods: This retrospective study evaluated the rewarming rate of hypothermic inborn neonates admitted to the Special Care Unit of Tosamaganga Hospital (Tanzania) in 2019-2020. The rewarming rate was calculated as the difference between the first normothermic value (36.5-37.5°C) and the admission temperature, divided by the time elapsed. Neurodevelopmental status at 1 month of age was assessed using the Hammersmith Neonatal Neurological Examination. Results: Median rewarming rate was 0.22°C/h (IQR: 0.11-0.41) in 344/382 (90%) hypothermic inborn infants, and was inversely correlated to admission temperature (correlation coefficient -0.36, p < 0.001). Rewarming rate was not associated with hypoglycemia (p = 0.16), late onset sepsis (p = 0.10), jaundice (p = 0.85), respiratory distress (p = 0.83), seizures (p = 0.34), length of hospital stay (p = 0.22) or mortality (p = 0.17). In 102/307 survivors who returned at follow-up visit at 1 month of age, rewarming rate was not associated with a potential correlate of cerebral palsy risk. Conclusions: Our findings did not show any significant association between rewarming rate and mortality, selected complications or abnormal neurologic exam suggestive of cerebral palsy. However, further prospective studies with strong methodological approach are required to provide conclusive evidence on this topic.

Influence of a quality improvement intervention on rehabilitation outcomes of children (6-24 months) with acute malnutrition: a retrospective study in rural Angola.

BACKGROUND: Defaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate. METHODS: Retrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6-24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate. RESULTS: The intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil. CONCLUSIONS: The present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.

Impact of Quality Improvement Bundle on Neonatal Mortality in a District Hospital in Tanzania.

BACKGROUND: The poor quality of care received by mothers and neonates in many limited-resource countries represents a main determinant of newborn mortality. Small and sick hospitalized newborns are the highest-risk population, and they should be one of the prime beneficiaries of quality-of-care interventions. This study aimed to evaluate the impact on neonatal mortality of quality improvement interventions which were implemented at Tosamaganga Council Designated Hospital, Iringa, Tanzania, between 2016 and 2020. METHODS: A retrospective comparison between pre- and post-intervention periods was performed using the chi-square test and Fisher's exact test. Effect sizes were reported as odds ratios with 95% confidence intervals. RESULTS: The analysis included 5742 neonates admitted to the Special Care Unit (2952 in the pre-intervention period and 2790 in the post-intervention period). A decrease in mortality among infants with birth weight between 1500 and 2499 g (overall: odds ratio 0.49, 95% confidence interval 0.27-0.87; inborn: odds ratio 0.50, 95% confidence interval 0.27-0.93) was found. The analysis of cause-specific mortality showed a decrease in mortality for asphyxia (odds ratio 0.33, 95% confidence interval 0.12-0.87) among inborn infants with birth weight between 1500 and 2499 g. CONCLUSIONS: A quality improvement intervention was associated with decreased mortality among infants with birth weight between 1500 and 2499 g. Further efforts are needed to improve prognosis in very-low-birth-weight infants.

Comparison of alternative gestational age assessment methods in a low resource setting: a retrospective study.

BACKGROUND: Accurate gestational age (GA) determination allows correct management of high-risk, complicated or post-date pregnancies and prevention or anticipation of prematurity related complications. Ultrasound measurement in the first trimester is the gold standard for GA determination. In low- and middle-income countries elevated costs, lack of skills and poor maternal access to health service limit the availability of prenatal ultrasonography, making it necessary to use alternative methods. This study compared three methods of GA determination: Last Normal Menstrual Period recall (LNMP), New Ballard Score (NBS) and New Ballard Score corrected for Birth Weight (NBS + BW) with the locally available standard (Ultrasound measurement in the third trimester) in a low-resource setting (Tosamaganga Council Designated Hospital, Iringa, Tanzania). METHODS: All data were retrospectively collected from hospital charts. Comparisons were performed using Bland Altman method. RESULTS: The analysis included 70 mother-newborn pairs. Median gestational age was 38 weeks (IQR 37-39) according to US. The mean difference between LNMP vs. US was 2.1 weeks (95% agreement limits - 3.5 to 7.7 weeks); NBS vs. US was 0.2 weeks (95% agreement limits - 3.7 to 4.1 weeks); NBS + BW vs. US was 1.2 weeks (95% agreement limits - 1.8 to 4.2 weeks). CONCLUSIONS: In our setting, NBS + BW was the least biased method for GA determination as compared with the locally available standard. However, wide agreement bands suggested low accuracy for all three alternative methods. New evidence in the use of second/third trimester ultrasound suggests concentrating efforts and resources in further validating and implementing the use of late pregnancy biometry for gestational age dating in low and middle-income countries.

Training on the Silverman and Andersen score improved how special care unit nurses assessed neonatal respiratory distress in a low-resource setting.

AIM: Identifying the severity of neonatal respiratory distress (RD) is essential, so that resources can be appropriately allocated. We assessed the ability of nurses to grade neonatal RD in a low-resource setting before and after they were trained to use a dedicated scoring tool. METHODS: The study was conducted in the Special Care Unit of St Luke Wolisso Hospital, Ethiopia. Ten nurses reviewed nine local video recordings and graded neonatal RD without a standardised method, which was current practice, and then after they were trained to use the Silverman and Andersen score. The data were analysed using the McNemar test and Cohen's kappa. RESULTS: Training increased the identification of mild RD from 63% to 93% (p = 0.008) and moderate RD from 40% to 73% (p = 0.03). Severe RD was 93% before and 90% after training (p = 0.99). Overall, the agreement improved from kappa 0.59 to 0.84, mainly by reducing the overestimation of milder degrees of RD. CONCLUSION: Being trained on how to use the Silverman and Andersen score improved the ability of nurses to identify mild and moderate neonatal RD. This improvement has the potential to optimise the use of equipment, staff and time.

Relationship between Admission Temperature and Risk of Cerebral Palsy in Infants Admitted to Special Care Unit in a Low Resource Setting: A Retrospective Single-Center Study.

BACKGROUND: Deviations from normothermia affect early mortality and morbidity, but the impact on neurodevelopment of the survivors is unclear. We aimed to investigate the relationship between neonatal temperature at admission and the risk of cerebral palsy (CP) at one month of age in a low-resource setting. METHODS: This retrospective study included all inborn neonates admitted to the Special Care Unit of Tosamaganga Hospital (Tanzania) between 1 January 2019 and 31 December 2020. The neurological examination at one month of age was performed using the Hammersmith method. The relationship between the admission temperature and the risk of CP was investigated using logistic regression models, with temperature modeled as the non-linear term. RESULTS: High/moderate risk of CP was found in 40/119 (33.6%) of the neonates at one month of age. A non-linear relationship between the admission temperature and moderate/high risk of CP at one month of age was found. The lowest probability of moderate/high risk of CP was estimated at admission temperatures of between 35 and 36 °C, with increasing probability when departing from such temperatures. CONCLUSIONS: In a low-resource setting, we found a U-shaped relationship between the admission temperature and the risk of CP at one month of life. Expanding the analysis of the follow-up data to 12-24 months of age would be desirable in order to confirm and strengthen such findings.

Analysis of risk and prognostic factors in a population of pediatric patients hospitalized for acute malnutrition at the Chiulo hospital, Angola.

BACKGROUND: Malnutrition is a multifactorial pathology in which genetic, epigenetic, cultural, environmental, socio-economic factors interact with each other. The impact that this disease has on the health of children worldwide is dramatic. Severe acute malnutrition in particular is a disease affecting nearly 20 million preschool children worldwide, most of them in Africa and South East Asia. OBJECTIVES: This work aims to investigate potential prognostic factors in the clinical evolution of acute malnutrition and potential risk factors for the development of the disease. METHODS: Our study was carried out at the "Hospital da Missão Catolica do Chiulo", in Angola, where the NGO Doctors with Africa CUAMM has been operating since 2000. In the first part of the study we analyzed the characteristics and clinical evolution of 163 patients hospitalized for acute malnutrition at the UEN (Unidade Especial de Nutrição) of the Chiulo Hospital over a period of 6 months, in order to identify potential prognostic factors of the disease. The second part of our study was carried out by administering a questionnaire to a group of caregivers of malnourished children and to a group of caregivers of non-malnourished children admitted to Pediatrics for other causes, with the aim of identifying potential risk factors for the development of malnutrition. RESULTS AND CONCLUSIONS: The analysis of prognostic factors revealed that the most relevant are the WHZ (weight for height z-score) at the time of admission, the presence of Stunting and the presence of other pathologies or clinical conditions associated with severe acute malnutrition. The analysis of risk factors has shown that not only food shortages, but also errors in the timing of the suspension of breastfeeding and the timing of the introduction of complementary foods play an important role. Equally important were some family risk factors, including the size of the family unit and the presence of deceased children. It also emerged that the lack of knowledge of what a child needs to grow up healthy often affects the development of malnutrition. It follows that a useful and low-cost tool for preventing child malnutrition would be large-scale nutrition education campaigns.

Nutritional education during rehabilitation of children 6-24 months with acute malnutrition, under unavailability of therapeutic/supplementary foods: a retrospective study in rural Angola.

BACKGROUND: Dietary counseling can play an important role in managing child malnutrition but is often inadequate or absent. Moreover, little emphasis is given to the usefulness of local available foods in the rehabilitation of malnourished children. This study aimed to evaluate the adherence and effectiveness of nutritional education during rehabilitation of children (6-24 months) with acute malnutrition, in a setting of unavailability of therapeutic/supplementary foods. METHODS: Retrospective observational study on the adherence to dietary counseling and the impact on growth in children 6-24 months who were referred for acute malnutrition at the Catholic Mission Hospital of Chiulo (Angola) from August 2018 to January 2019. Main outcome measures were change in dietary habits and growth gain. RESULTS: Sixty-four out of 120 children returned at first follow-up visit (default rate 47%). A change in dietary habits was reported in 32/64 (50%) children. Changing dietary habits was associated with an improved change in weight gain (MD 9.3 g/kg/day, 95%CI 4.2 to 14.3; p = 0.0005) and in weight/height ratio (MD 1.1 SD, 95%CI 0.7 to 1.4; p < 0.0001). CONCLUSIONS: A change in dietary habits after discharge was noted in only half of the patients who returned at first follow up visit, but it provided some advantages in term of weight gain and weight/height ratio. Further studies are needed to identify children at risk of low adherence to follow-up visits and low compliance to the nutritional recommendations, in order to increase the effectiveness of rehabilitation programs.

Nutritional Intake Influences Zinc Levels in Preterm Newborns: An Observational Study.

(1) Background: Zinc is a key element for protein synthesis in preterm newborns. Early aggressive nutrition, promoting protein synthesis, may increase zinc consumption; (2) Methods: We performed a prospective observational study, to assess the relationship between early macronutrients intake and serum zinc levels, in preterm newborns with Gestational Age (GA) of 24-35 weeks, consecutively observed in Neonatal Intensive Care Unit (NICU). (3) Results: We enrolled 130 newborns (GA 31.5 ± 2.8). A significant negative correlation between serum zinc level at 28 days of life and energy (r -0.587, p < 0.001) and protein intake (r -0.556, p < 0.001) in the first week of life was observed. Linear regression analysis showed that zinc levels depended on energy (ß -0.650; p < 0.001) and protein (ß -0.669; p < 0.001) intake given through parenteral nutrition (PN) in the first week of life; (4) Conclusions: zinc status of preterm neonates was influenced by early protein and energy intake. An additional zinc supplementation should be considered when high protein and energy intake are received by preterm newborns in the first week of life.

Neonatal tactile stimulation at birth in a low-resource setting.

BACKGROUND: Stimulation is the most common intervention during neonatal resuscitation at birth, but scarce information is available on the actual methods, timing and efficacy of this basic step. To evaluate the occurrence, patterns and response to tactile stimulation at birth in a low-resource setting. METHODS: We reviewed 150 video recordings of neonatal resuscitation at Beira Central Hospital (Beira, Mozambique). Timing, method, duration and response to tactile stimulation were evaluated. RESULTS: One hundred two out of 150 neonates (68.0%) received stimulation, while the remaining 48 (32.0%) received positive pressure ventilation and/or chest compressions directly. Overall, 546 stimulation episodes (median 4 episodes per subject, IQR 2-7) were performed. Median time to the first stimulation episode was 134 s (IQR 53-251); 29 neonates (28.4%) received stimulation within the first minute after birth. Multiple techniques of stimulation were administered in 66 neonates (64.7%), while recommended techniques (rubbing the back or flicking the soles of the feet) only in 9 (8.8%). Median duration of stimulation was 17 s (IQR 9-33). Only 9 neonates (8.8%) responded to stimulation. CONCLUSIONS: In a low-resource setting, stimulation of newly born infants at birth is underperformed. Adherence to international guidelines is low, resulting in delayed initiation, inadequate technique, prolonged duration and low response to stimulation. Back rubs may provide some benefits, but large prospective studies comparing different methods of stimulation are required.

Factors That Negatively Affect the Prognosis of Pediatric Community-Acquired Pneumonia in District Hospital in Tanzania.

Community-acquired pneumonia (CAP) is still the most important cause of death in countries with scarce resources. All children (33 months ± 35 DS) discharged from the Pediatric Unit of Itigi Hospital, Tanzania, with a diagnosis of CAP from August 2014 to April 2015 were enrolled. Clinical data were gathered. Dried blood spot (DBS) samples for quantitative real-time polymerase chain reaction (PCR) for bacterial detection were collected in all 100 children included. Twenty-four percent of patients were identified with severe CAP and 11% died. Surprisingly, 54% of patients were admitted with a wrong diagnosis, which increased complications, the need for antibiotics and chest X-rays, and the length of hospitalization. Comorbidity, found in 32% of children, significantly increased severity, complications, deaths, need for chest X-rays, and oxygen therapy. Malnourished children (29%) required more antibiotics. Microbiologically, Streptococcus pneumonia (S. p.), Haemophilus influenza type b (Hib) and Staphylococcus aureus (S. a.) were the bacteria more frequently isolated. Seventy-five percent of patients had mono-infection. Etiology was not correlated with severity, complications, deaths, oxygen demand, or duration of hospitalization. Our study highlights that difficult diagnoses and comorbidities negatively affect clinical evolution. S. p. and Hib still play a large role; thus, implementation of current vaccine strategies is needed. DBS is a simple and efficient diagnostic method for bacterial identification in countries with scarce resources.

Zinc in Early Life: A Key Element in the Fetus and Preterm Neonate.

Zinc is a key element for growth and development. In this narrative review, we focus on the role of dietary zinc in early life (including embryo, fetus and preterm neonate), analyzing consequences of zinc deficiency and adequacy of current recommendations on dietary zinc. We performed a systematic search of articles on the role of zinc in early life. We selected and analyzed 81 studies. Results of this analysis showed that preservation of zinc balance is of critical importance for the avoidance of possible consequences of low zinc levels on pre- and post-natal life. Insufficient quantities of zinc during embryogenesis may influence the final phenotype of all organs. Maternal zinc restriction during pregnancy influences fetal growth, while adequate zinc supplementation during pregnancy may result in a reduction of the risk of preterm birth. Preterm neonates are at particular risk to develop zinc deficiency due to a combination of different factors: (i) low body stores due to reduced time for placental transfer of zinc; (ii) increased endogenous losses; and (iii) marginal intake. Early diagnosis of zinc deficiency, through the measurement of serum zinc concentrations, may be essential to avoid severe prenatal and postnatal consequences in these patients. Typical clinical manifestations of zinc deficiency are growth impairment and dermatitis. Increasing data suggest that moderate zinc deficiency may have significant subclinical effects, increasing the risk of several complications typical of preterm neonates (i.e., necrotizing enterocolitis, chronic lung disease, and retinopathy), and that current recommended intakes should be revised to meet zinc requirements of extremely preterm neonates. Future studies evaluating the adequacy of current recommendations are advocated.

Drugs and newborn.

Most drugs used in paediatrics and even more in neonatology have never been specifically studied and to prescribe neonatal therapy simple adapting from adults therapy could lead to severe adverse events. Moreover the many operational steps, that the use of drugs demands, often lead health-care professional to make mistakes. Many studies show that the use of computer technology can be effective in reducing clinical errors; following this route the Neonatal Therapy Work Group of the Italian Society of Neonatology has created an interactive software that will help the health-care professional in the newborn's therapy management.