Assessment of vitamin B12 and folate status and their determinants in children aged 6-59 months with severe acute malnutrition admitted to a tertiary-care centre in North India.

BACKGROUND: Vitamin B12 and folate are essential micronutrients, a deficiency of which causes anaemia, poor growth and an increased risk of infections, along with irreversible neurological damage to the developing brain in children. METHODS: A hospital-based prospective observational study was conducted in 100 children with severe acute malnutrition (SAM) aged 6-59 months admitted to a tertiary-care facility in northern India from July 2021 to June 2022. A structured proforma was used to record socio-demographic information, a detailed clinical history, results of general and systemic physical examination and a detailed anthropometric assessment. Serum folate and vitamin B12 were estimated by electrochemiluminescence. RESULTS: The mean age of the children was 24.18 months, and 64.0% were aged 6-12 months. The male-to-female ratio was 1.08:1. Anaemia was present in 87.0% of the children, and it was severe in 35% of them. There was serum vitamin B12 and folate deficiency in 61.0% and 19.0%, respectively. A deficiency of vitamin B12 was significantly associated with delayed developmental milestones in all domains, a mid-upper-arm circumference of <11.5 cm, severe anaemia, a low platelet count and folate deficiency, and a folate deficiency was significantly associated with older age, delayed developmental milestones in all domains, severe anaemia, a low platelet count and vitamin B12 deficiency. CONCLUSION: Vitamin B12 deficiency is highly prevalent in children aged 6-59 months with SAM, but the prevalence of folate deficiency is much lower. Apart from iron and folic acid supplementation, government programmes should consider vitamin B12 supplementation for children aged 6-59 months.

Pattern of intestinal parasitic infections in children with malnutrition in Somalia.

Objectives: Children living in conflict zones plagued with adverse climatic conditions often suffer from acute malnutrition. Being coinfected with intestinal parasites could worsen the prognosis if adequate interventions are not promptly instituted. We determined the pattern of intestinal parasitic infections (IPIs) in children with acute malnutrition in the Bay and Banadir regions of Somalia. Methods: A hospital-based cross-sectional study was conducted from August to October 2023 in 222 children with acute malnutrition aged 6-59 months, using a structured questionnaire and stool examination by a trained laboratorian. The prevalence of IPI was estimated and the pattern of IPI was explored. The relationship between the presence of IPI and demographic characteristics was examined with multiple logistic regression at a 95% level of confidence. Results: The mean age was 20.4 ± 12.3 months, 125 (56.3%) were females, and 41.9% were internally displaced. The prevalence of IPI was 82.9% (95% confidence interval: 77.4-87.3), Of the infected, 73.9% (136 of 184) had single parasitic infection and 23.4% (43 of 184) had double parasitic infections. Ascaris lumbricoides (46.6%), Giardia lamblia (22.1%), and Entamoeba histolytica (17.6%) were the most common parasites identified. The age of 13-36 months (adjusted odds ratio: 1.13, P = 0.02) and eating once a day (adjusted odds ratio: 1.13, P = 0.06) were associated with being infected with intestinal parasites. Conclusions: The prevalence of intestinal parasitic infection was high in children with malnutrition in the Bay and Banadir regions. Deworming should be extended to all children with malnutrition. Food, sanitation, and water provision initiatives should be improved at the community level.

Clinical and biochemical responses to treatment of uncomplicated severe acute malnutrition: a multicenter observational cohort from the OptiDiag study.

BACKGROUND: Severe acute malnutrition (SAM) can be diagnosed using weight-for-height Z-score (WHZ) and/or mid-upper arm circumference (MUAC). Although some favor using MUAC alone, valuing its presumed ability to identify children at greatest need for nutritional care, the functional severity and physiological responses to treatment in children with varying deficits in WHZ and MUAC remain inadequately characterized. OBJECTIVE: We aimed to compare clinical and biochemical responses to treatment in children with 1) both low MUAC and low WHZ, 2) low MUAC-only, and 3) low WHZ-only. METHODS: A multicenter, observational cohort study was conducted in children aged 6-59 mo with nonedematous, uncomplicated SAM in Bangladesh, Burkina Faso, and Liberia. Anthropometric measurements and critical indicators were collected 3 times during treatment; metrics included clinical status, nutritional status, viability, and serum leptin, a biomarker of mortality risk in SAM. RESULTS: Children with combined MUAC and WHZ deficits had greater increases in leptin levels during treatment than those with low MUAC alone, showing a 34.4% greater increase on the second visit (95% confidence interval [CI]: 7.6%, 43.6%; P = 0.02) and a 34.3% greater increase on the third visit (95% CI: 13.2%, 50.3%; P = 0.01). Similarly, weight gain velocity was higher by 1.56 g/kg/d in the combined deficit group (95% CI: 0.38, 2.75; P = 0.03) compared with children with low MUAC-only. Children with combined deficits had higher rates of iron deficiency and wasting while those with low WHZ alone and combined deficits had higher rates of tachypnea and pneumonia during treatment. CONCLUSIONS: Given the comparable treatment responses of children with low WHZ alone and those with low MUAC alone, and the greater vulnerability at admission and during treatment in those with combined deficits, our findings support retaining WHZ as an independent diagnostic and admission criterion of SAM, alongside MUAC. This trial was registered at www. CLINICALTRIALS: gov/study/NCT03400930 as NCT03400930.

Investigating the Effects of Dietary Supplementation and High-Intensity Motor Learning on Nutritional Status, Body Composition, and Muscle Strength in Children with Moderate Thinness in Southwest Ethiopia: A Cluster-Randomized Controlled Trial.

BACKGROUND: In Ethiopia, moderate thinness (MT) is a persistent issue among children. Yet, evidence on the effects of dietary supplementation and motor skills training in these children is limited. OBJECTIVE: This study aimed to assess the effect of Ready-to-Use Supplementary Food (RUSF), whether or not combined with high-intensity motor learning (HiML), on weight, height, body composition, and muscle strength in children 5-7 years old with MT living in Jimma Town, Ethiopia. METHODS: A cluster-randomized controlled trial was carried out among 69 children (aged 5-7) with MT assigned to receive RUSF (n = 23), RUSF + HiML (n = 25), or no intervention (control group, n = 21). A multivariable Generalized Estimating Equations model was used and the level of significance was set at alpha < 0.05. RESULTS: At baseline, there were no significant differences in the outcome measurements between the RUSF, RUSF + HiML, and control groups. However, after 12 weeks of intervention, there were significant mean differences in differences (DIDs) between the RUSF group and the control arm, with DIDs of 1.50 kg for weight (p < 0.001), 20.63 newton (N) for elbow flexor (p < 0.001), 11.00 N for quadriceps (p = 0.023), 18.95 N for gastrocnemius sup flexor of the leg (p < 0.001), and 1.03 kg for fat-free mass (p = 0.022). Similarly, the mean difference in differences was higher in the RUSF + HiML group by 1.62 kg for weight (p < 0.001), 2.80 kg for grip strength (p < 0.001), 15.93 for elbow flexor (p < 0.001), 16.73 for quadriceps (p < 0.001), 9.75 for gastrocnemius sup flexor of the leg (p = 0.005), and 2.20 kg for fat-free mass (p < 0.001) compared the control arm. CONCLUSION: RUSF alone was effective, but combining it with HiML had a synergistic effect. Compared to the control group, the RUSF and RUSF + HiML interventions improved the body composition, height, weight, and muscle strength of the studied moderately thin children. The findings of this study suggest the potential that treating moderately thin children with RUSF and combining it with HiML has for reducing the negative effects of malnutrition in Ethiopia. Future research should explore these interventions in a larger community-based study. This trial has been registered at the Pan African Clinical Trials Registry (PACTR) under trial number PACTR202305718679999.

Performance of Mid-Upper Arm Circumference (MUAC) in Detection of Severe Acute Malnutrition (SAM), in Young Infants Aged 1 to 6 Months.

Infants are more vulnerable to malnutrition as compared with older children. Prevalence of severe wasting in Indian infants under 6 months of age (U6M) is 14.8% (National Family Health Survey 4, 2015-2016). Weight for length z-score (WLZ) and mid-upper arm circumference (MUAC) are 2 anthropometric parameters for detecting severe acute malnutrition (SAM) in children aged 6 months to 5 years. But in infants U6M, currently no accepted MUAC criteria are present for SAM. Calculating WLZ is practically difficult and cumbersome as compared with measuring MUAC. We tried to find out whether MUAC can be used in detecting SAM in infants aged 1 to 6 months also. The area under ROC curve was computed to evaluate the accuracy of MUAC in detecting SAM (taking WLZ as reference test). Level of accuracy was found out to be "good." Optimal MUAC cut-off with best diagnostic accuracy was identified as ≤11.5 cm, using the highest Youden index of 0.55.

Effects of Formula-100 therapeutic milk and Bregas Nutriroll ready-to-use therapeutic food on Indonesian children with severe acute malnutrition: A randomized controlled trial study.

Severe acute malnutrition (SAM) is a global health concern that affects children and leads to delayed growth. The aim of this study was to compare the impact of F100 milk and Bregas Nutriroll, a local ready-to-use therapeutic food (RUTF), on SAM children. An unmasked, non-blinded, two-group, and simple randomized controlled trial was conducted. Indonesian children aged 12-59 months with SAM were randomly assigned to receive either F100 milk or Bregas Nutriroll. After eight weeks, the increase in the mean weight gain in both groups was assessed. The Bregas Nutriroll group (n=19) had a mean weight gain of 1.07±0.09 kg, while the F100 group (n=17) had a mean weight gain of 1.05±0.11 kg. The Bregas Nutriroll group had a slightly higher gain of mid-upper arm circumference (MUAC) than the F100 group (0.62±0.34 cm vs 0.50±0.37 cm). The gain of children's height of the Bregas Nutriroll group was 0.96±0.42 cm, while the F100 group was shorter at a mean of 0.81±0.44 cm. Statistically significant differences (p<0.001) in nutritional status were observed based on weight, MUAC, and height/length after F100 and Bregas Nutriroll interventions. The intervention with F100 increased hemoglobin (Hb) levels of 0.71±1.25 mg/dL, while the Bregas Nutriroll intervention led to an increase of 0.11±1.39 mg/dL. In conclusion, our study showed that community-based treatment with F100 milk or Bregas Nutriroll resulted in nutritional status in children with SAM. These findings suggested that both treatments could be effective in treating SAM in improving nutritional status and child health outcomes.

A Study of the Prevalence of Anemia in Children With Severe Acute Malnutrition at a Pediatric Tertiary Care Hospital in South India.

Introduction In developing countries such as India, severe acute malnutrition (SAM) has been a cause for great concern in the pediatric population. SAM is associated with significant morbidity and mortality in children less than 60 months of age and leaves them vulnerable to diseases due to a decrease in immunological response. Children with SAM are prone to infections, and due to nutritional deficiency, many have anemia which may be a direct or indirect cause of morbidity and mortality. They are affected by frequent respiratory and gastrointestinal infections. Methodology A cross-sectional study was conducted for a period of two months, from December 1, 2023, to January 31, 2024, in children with SAM aged less than 60 months. A detailed history and demographic profile were taken and recorded in a predesigned proforma. Anthropometric measurements of the study subjects were recorded, and lab investigations included complete blood picture, serum iron, serum ferritin, serum folate, and serum vitamin B12 levels. The prevalence and severity of anemia were determined by assessing the hemoglobin levels. The data collected was analyzed in Excel sheets (Microsoft Corporation, Redmond, Washington, United States) and the results were depicted in the form of graphs. Results A total of 300 children were included in the study of which 22 children were aged less than six months and 278 children were in the age group of 6-60 months. The overall gender distribution was 124 (41.4%) males and 176 (58.6%) females. In the age group of <6 months, of the 22 children, six (27.27%) were females while 16 (72.72%) were male. In the age group of 6-60 months, of the 278 children, 170 (61%) were females while 108 (39%) were males. Of the total 300 children, 232 (77.3%) were found to be anemic, of which 54 (23.2%) had mild anemia, 162 (69.8%) had moderate anemia, and 16 (6.89%) had severe anemia. Low serum iron levels were detected in 134 (44.6%) with iron deficiency being more common in females; below-normal ferritin levels were seen in 153 (51%) cases. Folate levels were found to be deficient in 97 (32.3%) children while vitamin B12 levels were deficient in 186 (62%). Conclusion Anemia is a common occurrence in children with SAM. Prevention of anemia starts from the womb by improvement of maternal nutrition and iron, and folic acid supplementation during pregnancy. Exclusive breastfeeding up to six months of age and further continuation of breastfeeding coupled with initiation of home-available complementary feeding from the age of six months onwards go a long way in maintaining healthy nutrition status in children in the vulnerable age group of less than 60 months. Healthcare professionals should utilize the well-baby and well-child visits to educate the parents and primary caretakers regarding the feeding practices to prevent, detect, and treat anemia, which will help reduce the morbidity and mortality in children with SAM.

Implementing a pragmatic randomised controlled trial in a humanitarian setting: lessons learned from the TISA trial.

INTRODUCTION: High-quality evidence is crucial for guiding effective humanitarian responses, yet conducting rigorous research, particularly randomised controlled trials, in humanitarian crises remains challenging. The TISA ("traitement intégré de la sous-nutrition aiguë") trial aimed to evaluate the impact of a Water, Sanitation and Hygiene (WASH) intervention on the standard national treatment of uncomplicated Severe Acute Malnutrition (SAM) in children aged 6-59 months. Implemented in two northern Senegalese regions from December 22, 2021, to February 20, 2023, the trial faced numerous challenges, which this paper explores along with the lessons learned. METHODS: The study utilised trial documentation, including field reports, meeting minutes, training plans, operational monitoring data and funding proposals, to retrace the trial timeline, identify challenges and outline implemented solutions. Contributions from all TISA key staff-current and former, field-based and headquarters-were essential for collecting and interpreting information. Challenges were categorised as internal (within the TISA consortium) or external (broader contextual issues). RESULTS: The TISA trial, executed by a consortium of academic, operational, and community stakeholders, enrolled over 2000 children with uncomplicated SAM across 86 treatment posts in a 28,000 km2 area. The control group received standard outpatient SAM care, while the intervention group also received a WASH kit and hygiene promotion. Initially planned to start in April 2019 for 12 months, the trial faced a 30-month delay and was extended to 27 months due to challenges like the COVID-19 pandemic, national strikes, health system integration issues and weather-related disruptions. Internal challenges included logistics, staffing, data management, funding and aligning diverse stakeholder priorities. DISCUSSION AND CONCLUSION: Despite these obstacles, the trial concluded successfully, underscoring the importance of tailored monitoring, open communication, transparency and community involvement. Producing high-quality evidence in humanitarian contexts demands extensive preparation and strong coordination among local and international researchers, practitioners, communities, decision-makers and funders from the study's inception. TRIAL REGISTRATION: Clinicaltrials.gov NCT04667767 .

Determinants of severe acute malnutrition among under-five children in Ethiopia: analysis using data from the 2016 Ethiopia Demographic and Health Survey.

Objective: Malnutrition is a silent killer that is under-reported, under-addressed, and, as a result, emphasized. This study aimed to identify the determinants of severe acute malnutrition (SAM) among under-five children in Ethiopia. Methods: Cross-sectional data from the 2016 Ethiopian Demographic and Health Survey (EDHS) were used. A total of 6,170 under-five children were included in the current analysis. The data were cleaned and analyzed using STATA 14. An adjusted odds ratio (AOR) and their 95% confidence intervals (CIs) were calculated to determine the association between factors and outcomes. A p-value of less than 0.05 was considered significant in multivariable logistic regression. Results: A multivariable logistic regression revealed that under-five children with the age of children in months 6-11 (AOR = 1.52, 95% CI: 1.25, 1.86), 12-23 (AOR = 1.98, 95% CI: 1.65, 2.37), and 24-59 months (AOR = 1.71, 95% CI: 1.40, 2.08), birth order between fourth and fifth (AOR = 1.24, 95% CI: 1.01, 1.54), having fever (AOR = 1.31, 95% CI: 1.09, 1.58), anemic children (AOR = 1.21, 95% CI: 1.07, 1.36), age of mothers in years 25-34 (AOR = 0.60, 95% CI: 0.51, 0.72) and 35-49 (AOR = 0.49, 95% CI: 0.39, 0.63), antenatal care (ANC) visits (AOR = 0.83, 95% CI: 0.71, 0.92), rural residence (AOR = 2.98, 95% CI: 2.54, 3.49), and solid fuels users (AOR = 2.46, 95% CI: 1.86, 3.26) were significant predictors. Conclusion: Older age of children, those with higher birth order, those having fever, anemic children, those living in rural areas, and solid fuel users were more likely to suffer from SAM, while older mothers and those having ANC visits had reduced SAM as significant predictors.

Factors associated with non-response and nutrional status of non-responders at 6-month post-discharge: a cohort study nested in a MUAC-based nutrition programme for acutely malnourished children in Mirriah, Niger.

Background: In the treatment of acute malnutrition (AM), non-response is considered a treatment failure for not meeting recovery criteria within a therapeutic window of 12-16 weeks, but this category of children is misunderstood. As current research emphasizes ways to simplify and optimize treatment protocols, non-response emerges as a new issue to enhance program efficiency. Methods: A prospective cohort study was conducted from 2019 to 2020 at two health centres in Mirriah, Niger among children aged 6-59 months with uncomplicated AM treated under the Optimising treatment for Acute MAlnutrition (OptiMA) protocol. Children who did not meet recovery criteria by 12 weeks (mid-upper arm circumference (MUAC) ≥125 mm without oedema for two consecutive weeks) were classified as non-responders. Non-responders received a home visit six-months post-discharge. Logistic regression was used to analyze factors associated with non-responders compared with children who recovered. Results: Of the 1,112 children enrolled, 909 recovered and 139 were non-responders, of which 127 (80.6%) had significant MUAC gain (mean: +9.6 mm, sd = 5.1) at discharge. Girls (adjusted hazard ratio (aHR) = 2.07, 95% CI 1.33-3.25), children <12 months of age (aHr = 4.23, 95% CI 2.02-9.67), those with a MUAC <115 mm (aHR = 11.1, 95% CI 7.23-17.4) or severe stunting (aHR = 2.5, 1.38-4.83) at admission and a negative or flat MUAC trajectory between admission and week 4 (aHR = 4.66, 95% CI 2.54-9.13) were more likely to be non-responders. The nutritional status of non-responders had generally improved 6 months after discharge, but only 40% had achieved MUAC ≥125 mm. Conclusion: Non-responders are not a homogeneous group; while most children ultimately show significant nutritional improvement, rapid hospital referral is crucial for those not gaining MUAC early in treatment. As efforts to expand MUAC-based programming progress, adapting exit criterion and/or providing additional food supplementation with smaller daily ration for children with risk factors discussed here may help improve programme efficiency without adding to the cost of treatment.

Prevalence of Acute Bacterial Infections and Their Antibiotic Sensitivity Pattern in Children With Severe Acute Malnutrition From a Tertiary Care Hospital of Odisha.

Background and objective Malnutrition remains a significant cause of childhood morbidity and mortality worldwide. Severe acute malnutrition (SAM) profoundly affects immune development, physiological functions, and metabolic processes, increasing susceptibility to infections. This study aimed to investigate the prevalence of acute bacterial infections and their antibiotic sensitivity patterns among SAM children admitted to a tertiary care hospital. Methodology This prospective observational study was conducted at the pediatric department of Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar, Odisha, from November 2020 to October 2023. The study included 95 children aged 6-59 months meeting WHO criteria for SAM. Participants underwent comprehensive demographic assessments, clinical evaluations, and relevant laboratory tests, including blood and urine cultures with sensitivity testing. Results The study found that 82.1% of children had weight-for-height below -3 standard deviations, and 84.21% had mid-upper arm circumference below 115 mm, confirming SAM diagnosis. The most prevalent infections were acute gastroenteritis (47.3%), respiratory tract infections (46.3%), bacteremia (27.4%), and urinary tract infections (26.3%). Positive urine cultures were observed in 25 cases (26.3%), predominantly among females (68%). Escherichia coli (40%) and Klebsiella pneumoniae (24%) were the most common organisms isolated from urine, with high sensitivity to gentamicin (76%) and meropenem (72%). Blood cultures were positive in 26 cases (27.36%), with Staphylococcus aureus ​​​​​​(30.76%) and Klebsiella pneumoniae (23%) being predominant. Blood isolates showed significant sensitivity to vancomycin (73%), meropenem (69.2%), and linezolid (65.3%).  Conclusion Acute gastroenteritis, respiratory tract infections, bacteremia, and urinary tract infections are prevalent among SAM children. Staphylococcus aureus was frequently isolated from blood cultures, while Escherichia coli were predominant in urine cultures. High sensitivity of urinary isolates to gentamicin and meropenem, and of blood isolates to vancomycin, meropenem, and linezolid, highlights effective antibiotic choices. These findings emphasize the importance of tailored antimicrobial therapy based on local sensitivity patterns to improve clinical outcomes in SAM children.

Prevalence of Iron Deficiency Anemia and Iron Deficiency Without Anemia Among Moderate and Severely Acute Malnourished Children.

BACKGROUND: Iron deficiency remains one of the globally recognized leading causes of morbidity and mortality in children, among developing countries like India as compared to the Western world. OBJECTIVE: To estimate the prevalence of iron deficiency anemia (IDA) and iron deficiency without anemia (IDWA) among malnourished children. METHODS: This cross-sectional study was conducted in the Department Of Pediatrics, Tertiary Care Hospital, Western Rajasthan. Demographic data and serum samples were collected and analyzed. Hematological and biochemical values were determined for 300 children aged 6 months to 59 months. RESULTS: A total of 93.9% of severe acute malnutrition (SAM) children and 83.24% of moderate acute malnutrition (MAM) children had anemia as per WHO definition, with moderate anemia (47.66%) being the predominant type of anemia. About 64% of children showed iron deficiency with a prevalence of IDA and IDWA being 94.27% and 5.72%, respectively. The mean values of serum ferritin, serum iron, serum total iron binding capacity (TIBC), and transferrin saturation in children with IDWA were 8.34±2.85, 17.43±7.57, 454.09±40.76, and 4.09±1.44, respectively. CONCLUSION: The proportion of anemic children in both SAM and MAM groups was very high. Our study shows that more than 60% of the MAM and SAM children were iron deficient. We recommend future measures for the prevention and control of anemia, including increased coverage of nutritional supplementation, fortification programs, and supplement iron in this sub-group (IDWA) to take care of their symptoms due to iron deficiency even before the development of overt IDA.

Time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda, East Hararghe Zone, Eastern Ethiopia.

Background: Acute malnutrition is a major global public health problem, particularly in low-and middle-income countries. A targeted supplementary feeding program is an approach recommended to address moderate acute malnutrition in food-insecure settings. Preventing and treating moderate acute malnutrition requires identifying factors shown to affect the treatment outcome and duration of stay on treatment. This study aimed to determine the time to recovery from moderate acute malnutrition and its predictors among children aged 6-59 months in Fedis Woreda East Hararghe Zone, Eastern Ethiopia, from January 1 to December 31, 2022. Methods: A facility-based retrospective cohort study was conducted on 567 children with moderate acute malnutrition in Fedis Woreda, East Hararghe Zone, eastern Ethiopia. A multi-stage sampling technique was employed, and data was collected using a structured checklist. Data were extracted from randomly selected records after obtaining ethical clearance. Data were cleaned, coded, entered into EpiData 4.6, and analyzed using STATA/SE version 14. Descriptive statistics and analytic analysis schemes, including bivariable and multivariable Cox proportional hazards models, were conducted, and finally, statistical significance was considered at p < 0.05. Results: The overall median time to recovery was 16 weeks. The major predicting factors for time to recovery among children aged 6-59 months were admission with a mid-upper arm circumference of 12.1-12.4 centimeters (AHR = 1.02, 95% CI: 1.01-1.19), access to transportation to facilities (AHR = 0.62, 95% CI: 0.36-0.81), children using specialized nutritious foods (RUSF; AHR = 1.96, 95% CI: 1.36-3.11), and children who had diarrhea (AHR = 0.4, 95% CI: 0.31-0.71). Conclusion: The study found a median recovery time of 16 weeks for children with targeted supplementary feeding. Significant predictors included admission with a MUAC of 12.1-12.4 centimeters, transportation access, RUSF use, and the presence of diarrhea. These findings highlighted the importance of these factors in determining and improving recovery from moderate-acute malnutrition.

The relationship between energy provided and growth during severe wasting treatment.

Treatment of severe acute malnutrition aims at producing quick catch-up growth in children to decrease their short-term mortality risk. The extent to which catch-up growth is influenced by the amount of energy provided is unclear. This study assessed whether energy provided at admission is associated with catch-up ponderal growth among children with mid-upper arm circumference (MUAC) < 115 mm at admission. We conducted a secondary data analysis an operational cohort in Mali. The children were treated with a simplified protocol providing 1000 kcal/day of therapeutic food until MUAC ≥ 115 mm was achieved for two consecutive weeks and 500 kcal/day thereafter until discharge with MUAC ≥ 125 mm for two consecutive weeks. Linear mixed-effects regression models were fitted to assess the relationship between energy provided at admission (kcal/kg/day) with weight gain velocity (g/kg/day) (primary outcome), change in MUAC -for-age z-score and change in weight-for-age z-score. Unadjusted models and models adjusted for sex, age, seasonality and MUAC at admission were fitted. Both models included the study site as a random effect. A 10 kcal/kg/day increase in energy provided at admission was associated with increments in all outcomes; for weight gain velocity, the mean (95% CI) increment was 0.340 [0.326, 0.354] g/kg/day and 0.466 [0.446, 0.485] g/kg/day in the unadjusted and adjusted analysis, respectively. A positive relationship exists between energy provided at admission and catch-up ponderal growth in children with MUAC < 115 mm treated using a simplified protocol. Determining the ideal weight gain rate remains essential for assessing the benefits and risks of increased energy intake during treatment.

Development of tuberculosis treatment decision algorithms in children below 5 years hospitalised with severe acute malnutrition in Zambia and Uganda: a prospective diagnostic cohort study.

Background: In children with severe acute malnutrition (SAM) tuberculosis is common, challenging to diagnose, and often fatal. We developed tuberculosis treatment decision algorithms (TDAs) for children under the age of 5 years with SAM. Methods: In this prospective diagnostic study, we enrolled and followed up children aged <60 months hospitalised with SAM at three tertiary hospitals in Zambia and Uganda from 4 November 2019 to 20 June 2022. We included children aged 2-59 months with SAM as defined by WHO and hospitalised following the WHO clinical criteria. We excluded children with current or history of antituberculosis treatment within the preceding 3 months. They underwent tuberculosis symptom screening, clinical assessment, chest X-ray, abdominal ultrasound, Xpert MTB/RIF Ultra (Ultra) and culture on respiratory and stool samples with 6 months follow-up. Tuberculosis was retrospectively defined using the 2015 standard case definition for childhood tuberculosis. We used logistic regression to develop diagnostic prediction models for a one-step diagnosis and a two-step screening and diagnostic approaches. We derived scores from models using WHO-recommended thresholds for sensitivity and proposed TDAs. This study is registered with ClinicalTrials.gov, NCT04240990. Findings: Of 1906 children hospitalised with SAM during the study period, 1230 were screened, 1152 were eligible and 603 were enrolled. Of the 603 children enrolled-median age 15 (inter-quartile range (IQR): 11-20) months and 65 (11.0%) living with HIV-114 (18.9%) were diagnosed with tuberculosis, including 51 (8.5%) with microbiological confirmation and 104 (17.2%) initiated treatment at a median of 6(IQR: 2-10) days after inclusion. 108 children were retrospectively classified as having tuberculosis resulting in a prevalence of 17.9% (95% confidence intervals (CI): 15.1; 21.2). 75 (69.4%) children with tuberculosis reported cough of any duration, 32 (29.6%) cough ≥2 weeks and 11 (10.2%) tuberculosis contact history. 535 children had complete data and were included in the diagnostic prediction model. The one-step diagnostic model had 15 predictors, including Ultra, clinical, radiographic, and abdominal features, an area under the receiving operating curve (AUROC) of 0.910, and derived TDA sensitivity of 86.14% (95% CI: 78.07-91.56) and specificity of 80.88% (95% CI: 76.91-84.30). The two-step model had AUROCs of 0.750 and 0.912 for screening and diagnosis, respectively, and derived combined TDA sensitivity of 79.21% (95% CI: 70.30-85.98) and a specificity of 83.64% (95% CI: 79.87-86.82). Interpretation: Tuberculosis prevalence was high among hospitalised children with SAM, with atypical clinical features. TDAs achieved satisfactory diagnostic accuracy and could be used to improve diagnosis in this vulnerable group. Funding: Unitaid.

The Economic Burden of Severe Acute Malnutrition with Complications: A Cost Analysis for Inpatient Children Aged 6 to 59 Months in Northern Senegal.

Severe acute malnutrition (SAM) is a high-fatality condition that affected 13.7 million children under five years of age worldwide in 2022, with complicated cases requiring extensive inpatient stay with an accompanying caregiver. Our objective was to assess the costs of inpatient treatment for complicated SAM in children aged 6 to 59 months in Northern Senegal and identify cost predictors. We performed a retrospective cost analysis, including 140 children hospitalized from January to December 2020 in five SAM inpatient treatment facilities. We adopted a societal perspective, including direct medical and non-medical costs and indirect costs. We extracted patients' sociodemographic and clinical data from medical records and conducted semi-structured interviews with healthcare staff to capture information on time allocation and care management. A multivariable generalized linear model with gamma family and a log link was used to investigate the factors associated with direct costs. Costs are expressed in 2020 international USD using purchasing power parity. Mean length of stay was 5.3 (SD = 3.2) days and diarrhoea was the cause of the admission in 55.7% of cases. Mean total cost was USD 431.9 (SD = 203.9), with personnel being the largest cost item (33% of the total). Households' out-of-pocket expenses represented 45.3% of total costs and amounted to USD 195.6 (SD = 103.6). Costs were significantly associated with gender (20.3% lower in boys), diarrhoea (27% increase), anaemia (49.4% increase), inpatient death (44.9% decrease), and type of facility (26% higher in hospitals vs. health centre). Our study highlights the financial burden of complicated SAM in Senegal in particular for families. This underscores the need for tailored prevention and social policies to protect families from the disease's financial burden and improve treatment adherence, both in Senegal and similar contexts.

Treatment of moderate acute malnutrition through community health volunteers is a cost-effective intervention: Evidence from a resource-limited setting.

Treatment outcomes for acute malnutrition can be improved by integrating treatment into community case management (iCCM). However, little is known about the cost-effectiveness of this integrated nutrition intervention. The present study investigates the cost-effectiveness of treating moderate acute malnutrition (MAM) through community health volunteer (CHV) and integrating it with routine iCCM. A cost-effectiveness model compared the costs and effects of CHV sites plus health facility-based treatment (intervention) with the routine health facility-based treatment strategy alone (control). The costing assessments combined both provider and patient costs. The cost per DALY averted was the primary metric for the comparison, on which sensitivity analysis was performed. Additionally, the integrated strategy's relative value for money was evaluated using the most recent country-specific gross domestic product threshold metrics. The intervention dominated the health facility-based strategy alone on all computed cost-effectiveness outcomes. MAM treatment by CHVs plus health facilities was estimated to yield a cost per death and DALY averted of US$ 8743 and US$ 397, respectively, as opposed to US$ 13,846 and US$ 637 in the control group. The findings also showed that the intervention group spent less per child treated and recovered than the control group: US$ 214 versus US$ 270 and US$ 306 versus US$ 485, respectively. Compared with facility-based treatment, treating MAM by CHVs and health facilities was a cost-effective intervention. Additional gains could be achieved if more children with MAM are enrolled and treated.

Effectiveness of acute malnutrition treatment with a simplified, combined protocol in Central African Republic: An observational cohort study.

A simplified, combined protocol admitting children with a mid-upper-arm circumference (MUAC) of <125 mm or oedema to malnutrition treatment with ready-to-use therapeutic food (RUTF) uses two sachets of RUTF per day of those with MUAC < 115 mm and/or oedema and one sachet of RUTF per day for those with MUAC 115-<125 mm. This treatment previously demonstrated noninferior programmatic outcomes compared with standard treatment and high recovery in a routine setting. We aimed to observe the protocol's effectiveness in a routine setting at scale, in two health districts of the Central African Republic through an observational cohort study. The pilot enrolled children for 1 year in consortium by the Ministry of Health and nongovernmental partners. A total of 7909 children were admitted to the simplified, combined treatment. Treatment resulted in an 81.2% overall recovery, with a mean length of stay (LOS) of 38.7 days and a mean RUTF consumption of 43.4 sachets per child treated. Among children admitted with MUAC < 115 mm or oedema, 67.9% recovered with a mean LOS of 48.1 days and consumed an average of 70.9 RUTF sachets. Programme performance differed between the two districts, with an overall defaulting rate of 31.1% in the Kouango-Grimari health district, compared to 8.2% in Kemo. Response to treatment by children admitted with severe acute malnutrition (SAM) by MUAC and SAM by oedema was similar. The simplified, combined protocol resulted in a satisfactory overall recovery and low RUTF consumption per child treated, with further need to understand defaulting in the context.

Survival Analysis of Patients with Severe Acute Malnutrition Admitted at the In-patient Therapeutic Care of the Bicol Regional Training and Teaching Hospital.

Background: Severe acute malnutrition (SAM) in children under five years remains a major global health concern. It carries a burden to the overall health of a child, contributes to mortality, and adds financial strain to the family and the hospital. The Philippine Integrated Management of Acute Malnutrition was established to address acute malnutrition in Filipino children. Objective: This study aimed to determine the factors affecting survival of patients admitted at Bicol Regional Training and Teaching Hospital (BRTTH) In-patient Therapeutic Care (ITC). Methods: This is a retrospective cohort study design utilizing survival analysis. Accrual period was from January 1, 2018 to December 31, 2018. Follow-up ended on March 31, 2019. There were 154 admissions and excluded 17 missing charts. Survival analysis was done utilizing STATA 14. Results: The prevalence of SAM requiring ITC admission was 3.0 percent. Majority belonged to 6-59 months of age (63%), with equal predilection for both sexes (1:1) and 71% came from the home province, Albay. Most of patients' caretakers had middle educational attainment. Sixty-eight percent (68%) were new patients, 16% readmitted, 15% transferred from the Out-patient Therapeutic Care (OTC) and <1% relapsed. The top three most common complications and co-morbidities include: pneumonia, low electrolytes, and fever. Sixty-three percent (63%) of patients at the ITC had a desirable treatment outcome, of which, 8% were cured and 55% transferred to OTC. Undesirable outcomes accounted for 37% of the cases which included non-cured, defaulter, and died at 12%, 8%, and 17%, respectively. The risk of dying was higher in SAM patients with parents having middle and low educational attainment as compared to those with high educational attainment (2-5 folds to 100-200 folds). SAM patients presenting with hypovolemic shock were likely to die by 1.5-19 times (1.5-19x) as compared to those without. SAM patients with malignancy were more likely to die 4-44 folds as compared to patients without malignancy. Conclusion and Recommendations: Educational attainment of parents, malignancy, and hypovolemic shock were significant predictors of mortality. We recommend prompt intervention by educating families, strengthen policies targeting socio-economic determinants, capacitate medical staff, refine current clinical practice guidelines and treatment pathways to reduce the number of children who die from severe acute malnutrition.

Predictors of time to recovery from uncomplicated severe acute malnutrition among children in eastern Ethiopia.

Background: Managing severe acute malnutrition (SAM) involves an outpatient therapeutic program (OTP), targeting more than 80% of SAM children where the quality of primary healthcare remains poor. Treatment success and recovery from SAM remain poor and could be affected by many factors, where such evidence is limited in East Hararghe. This study assessed the predictors of time to recovery from SAM in eastern Ethiopia. Methods: A retrospective cohort study was conducted on 402 records of SAM children under 5 years of age enrolled on OTP at 12 health posts retrieved from 2020 to 2021. We used the Kaplan-Meir estimate along with the p-value of the log-rank test and the survival curve to compare the time to recovery across categories. A multivariable Cox proportional hazard model was fitted to identify predictors of time to recovery from SAM. A p-value below 0.05 was used to declare statistical significance. Results: A total of 402 records were reviewed, and the cure rate from SAM was 89.6% [95% confidence interval (CI), 87-93]. Moreover, a death rate of 0.7%, a default rate of 9.5%, and a non-responder rate of 0.2% were obtained with a median length of stay of 7 weeks. The median time to recovery was significantly shorter for children from shorter distances from OTP sites with edema, amoxicillin, (p < 0.05). Edema at admission [adjusted hazard ratio (AHR) = 1.74; 95% CI: 1.33-2.29], without diarrhea (AHR = 1.51; 95% CI: 1.18-1.94), taking amoxicillin (AHR = 1.55; 95% CI: 1.19-2.02), shorter travel time to the OTP site (AHR = 1.44; 95% CI: 1.13-1.85), breastfeeding (AHR = 1.60; 95% CI: 1.27-2.02), adequacy of ready-to-use therapeutic food (RUTF) (AHR = 1.22; 95% CI: 0.90-1.65), and new admission (AHR = 1.62; 95% CI: 0.84-3.10) were important predictors of recovery from SAM. Conclusion: Recovery from SAM was found to be acceptable in comparison with the Sphere Standards and is predicted by edema, diarrhea, distance from the OTP site, amoxicillin, and RUTF adequacy. These allow for focused interventions that address the identified factors for better recovery from SAM.