Anthropometric criteria for best-identifying children at high risk of mortality: a pooled analysis of twelve cohorts.

OBJECTIVE: To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme implications. DESIGN: A multiple cohort individual data meta-analysis of mortality risk (within 6 months of measurement) by anthropometric case definitions. Sensitivity, specificity, informedness and inclusivity in predicting mortality, face validity and compatibility with current standards and practice were assessed and operational consequences were modelled. SETTING: Community-based cohort studies in twelve low-income countries between 1977 and 2013 in settings where treatment of wasting was not widespread. PARTICIPANTS: Children aged 6 to 59 months. RESULTS: Of the twelve anthropometric case definitions examined, four (weight-for-age Z-score (WAZ) <-2), (mid-upper arm circumference (MUAC) <125 mm), (MUAC < 115 mm or WAZ < -3) and (WAZ < -3) had the highest informedness in predicting mortality. A combined case definition (MUAC < 115 mm or WAZ < -3) was better at predicting deaths associated with weight-for-height Z-score <-3 and concurrent wasting and stunting (WaSt) than the single WAZ < -3 case definition. After the assessment of all criteria, the combined case definition performed best. The simulated workload for programmes admitting based on MUAC < 115 mm or WAZ < -3, when adjusted with a proxy for required intensity and/or duration of treatment, was 1·87 times larger than programmes admitting on MUAC < 115 mm alone. CONCLUSIONS: A combined case definition detects nearly all deaths associated with severe anthropometric deficits suggesting that therapeutic feeding programmes may achieve higher impact (prevent mortality and improve coverage) by using it. There remain operational questions to examine further before wide-scale adoption can be recommended.

Time to recovery from severe acute malnutrition and its predictors among under five children admitted to therapeutic feeding units of general and referral hospitals in Tigray, Ethiopia, 2020: a prospective cohort study.

BACKGROUND: Across the globe, an estimated 16 million children under the age of 5 are affected by severe acute malnutrition. Children with severe acute malnutrition are nine times more likely to die than well-nourished children. In Ethiopia, 7% of children under five are wasted, and 1% of these are severely wasted. A prolonged hospital stay increases the incidence of hospital-acquired infections. The aim of this study was to assess the time to recovery and its predictors among children 6-59 months old with severe acute malnutrition admitted to therapeutic feeding units of selected general and referral hospitals in Tigray, Ethiopia. METHODS: A prospective cohort study design was conducted among children aged 6-59 months admitted with severe acute malnutrition in selected hospitals in Tigray that have therapeutic feeding units. The data were cleaned, coded, entered into Epi-data Manager, and exported to STATA 14 for analysis. RESULT: Among 232 children followed in the study, 176 have recovered from severe acute malnutrition with a recovery rate of 54 per 1000 person-days observation and the median time to recovery was 16 days with an inter-quartile range of 8. In a multivariable Cox Regression, feeding plumpy nut [AHR 0.49 (95% CI 0.2717216-0.8893736)] and failing to gain 5 gr/kg/day for three successive days after feeding freely on F-100 [AHR 3.58 (95% CI 1.78837-7.160047)] were found to have an association with time to recovery. CONCLUSION: Despite the median time to recovery is shorter than what has been reported in a few studies, we can conclude that this could not let children avoid any possible hospital-acquired infections. The impact of staying in a hospital may also extend to the mother/caregiver in terms of the infection that they may acquire or the costs imposed on them.

Improving screening for malnourished children at high risk of death: a study of children aged 6-59 months in rural Senegal.

OBJECTIVE: To investigate whether children with concurrent wasting and stunting require therapeutic feeding and to better understand whether multiple diagnostic criteria are needed to identify children with a high risk of death and in need of treatment. DESIGN: Community-based cohort study, following 5751 children through time. Each child was visited up to four times at 6-month intervals. Anthropometric measurements were taken at each visit. Survival was monitored using a demographic surveillance system operating in the study villages. SETTING: Niakhar, a rural area of the Fatick region of central Senegal.ParticipantsChildren aged 6-59 months living in thirty villages in the study area. RESULTS: Weight-for-age Z-score (WAZ) and mid-upper arm circumference (MUAC) were independently associated with near-term mortality. The lowest WAZ threshold that, in combination with MUAC, detected all deaths associated with severe wasting or concurrent wasting and stunting was WAZ <-2·8. Performance for detecting deaths was best when only WAZ and MUAC were used. Additional criteria did not improve performance. Risk ratios for near-term death in children identified using WAZ and MUAC suggest that children identified by WAZ <-2·8 but with MUAC≥115 mm may require lower-intensity treatment than children identified using MUAC <115 mm. CONCLUSIONS: A combination of MUAC and WAZ detected all near-term deaths associated with severe anthropometric deficits including concurrent wasting and stunting. Therapeutic feeding programmes may achieve higher impact if WAZ and MUAC admission criteria are used.

Active and adaptive case finding to estimate therapeutic program coverage for severe acute malnutrition: a capture-recapture study.

BACKGROUND: Coverage is an important indicator to assess both the performance and effectiveness of public health programs. Recommended methods for coverage estimation for the treatment of severe acute malnutrition (SAM) can involve active and adaptive case finding (AACF), an informant-driven sampling procedure, for the identification of cases. However, as this procedure can yield a non-representative sample, exhaustive or near exhaustive case identification is needed for valid coverage estimation with AACF. Important uncertainty remains as to whether an adequate level of exhaustivity for valid coverage estimation can be ensured by AACF. METHODS: We assessed the sensitivity of AACF and a census method using a capture-recapture design in northwestern Nigeria. Program coverage was estimated for each case finding procedure. RESULTS: The sensitivity of AACF was 69.5% (95% CI: 59.8, 79.2) and 91.9% (95% CI: 85.1, 98.8) with census case finding. Program coverage was estimated to be 40.3% (95% CI 28.6, 52.0) using AACF, compared to 34.9% (95% CI 24.7, 45.2) using the census. Depending on the distribution of coverage among missed cases, AACF sensitivity of at least ≥70% was generally required for coverage estimation to remain within ±10% of the census estimate. CONCLUSION: Given the impact incomplete case finding and low sensitivity can have on coverage estimation in potentially non-representative samples, adequate attention and resources should be committed to ensure exhaustive or near exhaustive case finding. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT03140904. Registered on May 3, 2017.

Estimating program coverage in the treatment of severe acute malnutrition: a comparative analysis of the validity and operational feasibility of two methods.

BACKGROUND: Many health programs can assess coverage using standardized cluster survey methods, but estimating the coverage of nutrition programs presents a special challenge due to low disease prevalence. Used since 2012, the Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) employs both qualitative and quantitative methods to identify key barriers to access and estimate coverage of therapeutic feeding programs. While the tool has been increasingly used in programs, the validity of certain methodological elements has been the subject of debate. METHODS: We conducted a study comparing a SQUEAC conjugate Bayesian analysis to a two-stage cluster survey estimating the coverage of a therapeutic feeding program in Niger in 2016. RESULTS: We found that the coverage estimate from the conjugate Bayesian analysis was sensitive to the prior estimation. With the exception of prior estimates produced by an external support team, all prior estimates resulted in a conflict with the likelihood result, excluding interpretation of the final coverage estimate. Allowing for increased uncertainty around the prior estimate did not materially affect conclusions. CONCLUSION: SQUEAC is a demanding analytical method requiring both qualitative and quantitative data collection and synthesis to identify program barriers and estimate coverage. If the necessary technical capacity is not available to objectively specify an accurate prior for a conjugate Bayesian analysis, alternatives, such as a two-stage cluster survey or a larger likelihood survey, may be considered to ensure valid coverage estimation. TRIAL REGISTRATION: NCT03280082 . Retrospectively registered on September 12, 2017.

Point-of-use water treatment improves recovery rates among children with severe acute malnutrition in Pakistan: results from a site-randomized trial.

OBJECTIVE: To evaluate effectiveness of point-of-use water treatment in improving treatment of children affected by severe acute malnutrition (SAM). DESIGN: Programme sites were randomized to one of four intervention arms: (i) standard SAM treatment; (ii) SAM treatment plus flocculent/disinfectant water treatment; (iii) SAM treatment plus chlorine disinfectant; or (iv) SAM treatment plus ceramic water filter. Outcome measures were calculated based on participant status upon exit or after 120d of enrolment, whichever came first. Child anthropometric data were collected during weekly monitoring at programme sites. Child caregivers were interviewed at enrolment and exit. Use of water treatment products was assessed in a home visit 4-6 weeks after enrolment. SETTING: Dadu District, Sindh Province, Pakistan. SUBJECTS: Children (n 901) aged 6-59 months with SAM and no medical complications. RESULTS: Recovery rates were 16·7-22·2 % higher among children receiving water treatment compared with the control group. The adjusted odds of recovery were approximately twice as high for those receiving water treatment compared with controls. Mean length of stay until recovery was 73 (sd 24·6) d and mean rate of weight gain was 4·7 (sd 3·0) g/kg per d. Differences in recovery rate, length of stay and rate of weight gain between intervention groups were not statistically significant. CONCLUSIONS: Incorporating point-of-use water treatment into outpatient treatment programmes for children with SAM increased nutritional recovery rates. No significant differences in recovery rates were observed between the different intervention groups, indicating that different water treatment approaches were equally effective in improving recovery.

Serum phosphate and magnesium in children recovering from severe acute undernutrition in Ethiopia: an observational study.

BACKGROUND: Children with severe acute malnutrition (SAM) have increased requirements for phosphorus and magnesium during recovery. If requirements are not met, the children may develop refeeding hypophosphatemia and hypomagnesemia. However, little is known about the effect of current therapeutic diets (F-75 and F-100) on serum phosphate (S-phosphate) and magnesium (S-magnesium) in children with SAM. METHODS: Prospective observational study, with measurements of S-phosphate and S-magnesium at admission, prior to rehabilitation phase and at discharge in children aged 6-59 months admitted with SAM to Jimma Hospital, Ethiopia. Due to shortage of F-75, 25 (35 %) children were stabilized with diluted F-100 (75 kcal/100 ml). RESULTS: Of 72 children enrolled, the mean age was 32 ± 14 months, and edema was present in 50 (69 %). At admission, mean S-phosphate was 0.92 ± 0.34 mmol/L, which was low compared to normal values, but increased to 1.38 ± 0.28 mmol/L at discharge, after on average 16 days. Mean S-magnesium, at admission, was 0.95 ± 0.23 mmol/L, and increased to 1.13 ± 0.17 mmol/L at discharge. At discharge, 18 (51 %) children had S-phosphate below the normal range, and 3 (9 %) had S-phosphate above. Most children (83 %) had S-magnesium above normal range for children. Both S-phosphate and S-magnesium at admission were positively associated with serum albumin (S-albumin), but not with anthropometric characteristics or co-diagnoses. Using diluted F-100 for stabilization was not associated with lower S-phosphate or S-magnesium. CONCLUSION: Hypophosphatemia was common among children with SAM at admission, and still subnormal in about half of the children at discharge. This could be problematic for further recovery as phosphorus is needed for catch-up growth and local diets are likely to be low in bioavailable phosphorus. The high S-magnesium levels at discharge does not support that magnesium should be a limiting nutrient for growth in the F-100 diet. Although diluted F-100 (75 kcal/100 mL) is not designed for stabilizing children with SAM, it did not seem to cause lower S-phosphate than in children fed F-75.

Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar.

The treatment of uncomplicated severe acute malnutrition (SAM) requires substantial amounts of ready-to-use therapeutic food (RUTF). In 2009, Action Contre la Faim anticipated a shortfall of RUTF for their nutrition programme in Myanmar. A low-dose RUTF protocol to treat children with uncomplicated SAM was adopted. In this protocol, RUTF was dosed according to beneficiary's body weight, until the child reached a Weight-for-Height z-score of ≥-3 and mid-upper arm circumference ≥110 mm. From this point, the child received a fixed quantity of RUTF per day, independent of body weight until discharge. Specific measures were implemented as part of this low-dose RUTF protocol in order to improve service quality and beneficiary support. We analysed individual records of 3083 children treated from July 2009 to January 2010. Up to 90.2% of children recovered, 2.0% defaulted and 0.9% were classified as non-responders. No deaths were recorded. Among children who recovered, median [IQR] length of stay and weight gain were 42 days [28; 56] and 4.0 g kg(-1) day(-1) [3.0; 5.7], respectively. Multivariable logistic regression showed that children older than 48 months had higher odds of non-response to treatment than younger children (adjusted odds ratio: 3.51, 95% CI: 1.67-7.42). Our results indicate that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM in this setting. This programmatic experience should be validated by randomised studies aiming to test, quantify and attribute the effect of the protocol adaptation and programme improvements presented here.

Effectiveness of milk whey protein-based ready-to-use therapeutic food in treatment of severe acute malnutrition in Malawian under-5 children: a randomised, double-blind, controlled non-inferiority clinical trial.

The cost of ready-to-use therapeutic food (RUTF) used in community-based management of acute malnutrition has been a major obstacle to the scale up of this important child survival strategy. The current standard recipe for RUTF [peanut-based RUTF (P-RUTF)] is made from peanut paste, milk powder, oil, sugar, and minerals and vitamins. Milk powder forms about 30% of the ingredients and may represent over half the cost of the final product. The quality of whey protein concentrates 34% (WPC34) is similar to that of dried skimmed milk (DSM) used in the standard recipe and can be 25-33% cheaper. This blinded, parallel group, randomised, controlled non-inferiority clinical trial tested the effectiveness in treating severe acute malnutrition (SAM) of a new RUTF formulation WPC-RUTF in which WPC34 was used to replace DSM. Average weight gain (non-inferiority margin Δ = -1.2 g kg(-1) day(-1) ) and recovery rate (Δ = -10%) were the primary outcomes, and length of stay (LOS) was the secondary outcome (Δ = +14 days). Both per-protocol (PP) and intention-to-treat (ITT) analyses showed that WPC-RUTF was not inferior to P-RUTF for recovery rate [difference and its 95% confidence interval (CI) of 0.5% (95% CI -2.7, 3.7) in PP analysis and 0.6% (95% CI -5.2, 6.3) in ITT analysis] for average weight gain [0.2 (-0.5; 0.9) for both analyses] and LOS [-1.6 days (95% CI, -4.6, 1.4 days) in PP analysis and -1.9 days (95% CI, -4.6, 0.8 days) for ITT analysis]. In conclusion, whey protein-based RUTF is an effective cheaper alternative to the standard milk-based RUTF for the treatment of SAM.

Rate, risk factors and estimated time to develop attrition after under-five children started moderate acute malnutrition treatment in Gubalafto, North East Ethiopia.

Lost from follow-up, after starting moderate acute malnutrition (MAM) is an ongoing challenge of public health until the admitted children reached the standard weight of a reference child. Thus, the present study aimed to assess the rate and estimated time to attrition after under-five children started treatment for MAM in the Gubalafto district. A facility-based retrospective cohort study was employed among 487 participant children who had been managed targeted therapeutic feeding from 1 June 2018 to 1 May 2021. The overall mean (±sd) age of the participants' children was 22⋅1 (±12⋅6) months. At the end of the study period, 55 (11⋅46 %) under-five children developed attrition from the treatment after starting ready use of therapeutic feeding. After checking all assumptions, a multivariable Cox regression model was used to claim independent predictors for time to attritions. The median time of attrition after starting treatment of MAM was 13 (IQR ±9) weeks, with the overall incidence of attrition rate reported at 6⋅75 children Per Week (95 % CI 5⋅56, 9⋅6). In the final model of multivariable Cox regression, the hazard of attrition was significantly higher for children from rural residence (AHR 1⋅61; 95 % CI 1⋅18, 2⋅18; P = 0⋅001), and caregivers with their dyads did not get nutritional counselling at baseline (AHR 2⋅78; 95 % CI 1⋅34, 5⋅78; P = 0⋅001). The findings of the present study showed that nearly one in every eleven under-five children was attrition (lost to follow-up) in a median time of 13 (IQR ±9) weeks. We strongly recommended for caregivers provisions of diversification of daily nutrition supplementation of their dyads.

Treatment outcome and associated factors for severely malnourished children (1-5 years) admitted to Lacor Hospital and Gulu Regional Referral Hospital in Uganda.

Globally, severe acute malnutrition (SAM) accounts for >1/3-0⋅5 of deaths in children <5 years, and approximately 54 % deaths in developing countries. The minimum international standard set for the management of SAM is a cure rate of at least 75 % and death rate <10 %. The present study was conducted to determine treatment outcome and associated factors among children 1-5 years hospitalised with SAM in Lacor and Gulu Regional Referral Hospital (GRRH) in 2017. A retrospective observational method supplemented with a qualitative inquiry was done. A total of 317 patients' records were reviewed in either hospital; checklist data were analysed using SPSS version 16 with P-values <0⋅05 considered for statistical significance. The case fatality rate (CFR) was 12⋅6 % (GRRH) and 9⋅5 % (Lacor). The average length of stay (LOS) was 14⋅69 d (GRRH) and 14⋅10 d (Lacor). There was statistical significance between Human Immunodeficiency Virus (HIV) status, blood transfusion, type of SAM, treatment provision at admission, antibiotics, mid-upper arm circumference (MUAC), hospital category and treatment outcome. In total, ten key informants were interviewed and they reported the presence of co-infections and severity of SAM complications as having an important bearing on treatment outcome. A significant proportion of patients were discharged not cured 19⋅9 % (Lacor) v. 16⋅4 % (GRRH). The CFR in GRRH was higher than the WHO recommendation. The LOS in both hospitals was within recommended. These results provide a generalisable problem in most African hospitals and could explain the persistently high rates of SAM in Africa.

Recovery rate and determinants of severe acute malnutrition children treatment in Ethiopia: a systematic review and meta-analysis.

BACKGROUND: Severe acute malnutrition affects more than 20 million children. Africa is pointed out as a region where the problem is highly prevalent. There were individual studies on the recovery rate and its determinants among children with severe acute malnutrition in Ethiopia. But, there is no national pooled estimate. Therefore, this systematic review and meta-analysis aimed to estimate the recovery rate and determinants among children with severe acute malnutrition admitted to the therapeutic feeding unit in Ethiopia. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed in this study. Studies were accessed through electronic web-based search from PubMed, Cochrane Library, Google Scholar, and EMBASE. The statistical analysis was conducted using STATA version-11 software. The pooled prevalence was estimated with 95% confidence intervals using a random-effects model. RESULT: A total of 12 studies were included with 2658 participants in the analysis. The overall pooled estimated recovery rate among children with severe acute malnutrition admitted to the inpatient therapeutic feeding unit in Ethiopia was 72.02 % (CI, 64.83, 79.22%). In the subgroup analysis, the highest estimate (80.29%) was observed in studies conducted in Oromia regional state, while 68.63% was observed in studies Southern Nation Nationality of people region 68.63%. Children who had no congestive heart failure were 4.88 times (OR, 4.88; 95% CI, 2.246, 10.586) more likely to recover than their counterparts. CONCLUSION: The recovery rate among severe acute malnourished children on the therapeutic feeding unit in Ethiopia lied within the international minimum sphere. Hence, health care providers shall strengthen the management of severe acute malnutrition and management other co-morbidities like congestive heart failure. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019119124.

Costs and cost-effectiveness of three point-of-use water treatment technologies added to community-based treatment of severe acute malnutrition in Sindh Province, Pakistan.

BACKGROUND: Severe acute malnutrition (SAM) is a major global public health concern. Despite the cost-effectiveness of treatment, ministries of health are often unable to commit the required funds which limits service coverage. OBJECTIVE: A randomised controlled trial was conducted in Sindh Province, Pakistan, to assess whether adding a point of use water treatment to the treatment of SAM without complications improved its cost-effectiveness. Three treatment strategies - chlorine disinfection (Aquatabs); flocculent disinfection (Procter and Gamble Purifier of Water [P&G PoW]) and Ceramic Filters - were compared to a standard SAM treatment protocol. METHODS: An institutional perspective was adopted for costing, considering the direct and indirect costs incurred by the provider. Combining the cost of SAM treatment and water treatment, an average cost per child was calculated for the combined interventions for each arm. The costs of water treatment alone and the incremental cost-effectiveness of each water treatment intervention were also assessed. RESULTS: The incremental cost-effectiveness ratio for Aquatabs was 24 US dollars (USD), making it the most cost-effective strategy. The P&G PoW arm was the next least expensive strategy, costing an additional 149 USD per additional child recovered, though it was also the least effective of the three intervention strategies. The Ceramic Filters intervention was the most costly strategy and achieved a recovery rate lower than the Aquatabs arm and marginally higher than the P&G PoW arm. CONCLUSIONS: This study found that the addition of a chlorine or flocculent disinfection point-of-use drinking water treatment intervention to the treatment of SAM without complications reduced the cost per child recovered compared to standard SAM treatment. To inform the feasibility of future implementation, further research is required to understand the costs of government implementation and the associated costs to the community and beneficiary household of receiving such an intervention in comparison with the existing SAM treatment protocol.

Increase in acute malnutrition in children following the 2014-2015 Ebola outbreak in rural Sierra Leone.

Setting: All health facility and community malnutrition screening programmes in Tonkolili, a rural Ebola-affected district in Sierra Leone. Objectives: Before the Ebola disease outbreak, Sierra Leone had set a goal to reduce the prevalence of severe acute malnutrition (SAM) in children aged <5 years to <0.2%. We compared the number of children screened, diagnosed and treated for malnutrition before, during and after the outbreak (2013-2016). Design: This was a retrospective cross-sectional study. Results: Health facility screening declined from 16 805 children per month pre-outbreak to 13 510 during the outbreak (P = 0.02), and returned to pre-outbreak levels after the outbreak. Community-based screening remained stable during the outbreak, and increased by 30% post-outbreak (P < 0.001). The proportion diagnosed with moderate acute malnutrition using mid-upper arm circumference increased from respectively 3.6% and 5.1% pre-outbreak in the community and health facilities to 8.2% and 7.9% post-outbreak (P < 0.001, P = 0.003). The proportion of children diagnosed with SAM using a weight-for-age ratio at health facilities increased from 1.5% pre-outbreak to 3.5% post-outbreak (P = 0.003). On average, for every four children diagnosed with SAM per month, one child completed SAM treatment. Conclusion: After a decline in screening during the Ebola outbreak, diagnoses of acute malnutrition increased post-outbreak. Nutrition programmes need to be strengthened to pre-empt such effects in the event of future Ebola outbreaks.

Contexte : Tous les programmes de dépistage de la malnutrition par les structures de santé et dans les communautés à Tonkolili, un district rural affecté par Ebola en Sierra Leone.Objectifs : Avant la flambée épidémique d'Ebola, la Sierra Leone avait fixé l'objectif de réduire la prévalence de la malnutrition aigüe grave (MAG) chez les enfants âgés de <5 ans à < 0,2%. Nous avons comparé le nombre d'enfants dépistés, diagnostiqués et traités pour malnutrition avant, pendant et après la flambée épidémique (2013­2016).Schéma : Une étude rétrospective transversale.Résultats : Le dépistage dans les structures de santé a décliné de 16 805 enfants par mois avant Ebola à 13 510 pendant Ebola (P = 0,02), et il est revenu à son niveau d'avant la flambée dans la période post-Ebola. Le dépistage en communauté est resté stable pendant Ebola et a augmenté de 30% post-Ebola (P < 0,001). La proportion d'enfants ayant eu un diagnostic de malnutrition modérée aigüe en fonction du périmètre brachial a augmenté respectivement de 3,6% et de 5,1% avant Ebola en communauté et dans les structures de santé, de 8,2% et de 7,9% après Ebola (P < 0,001 ; P = 0,003). La proportion d'enfants ayant eu un diagnostic de MAG en fonction du poids pour l'âge dans les structures de santé est passée de 1,5% avant Ebola à 3,5% après Ebola (P = 0,003). En moyenne, un enfant a achevé son traitement de MAM sur quatre enfants ayant eu un diagnostic de MAG par mois.Conclusion : Après un déclin dans le dépistage pendant la flambée épidémique d'Ebola, les diagnostics de malnutrition aigüe ont augmenté après Ebola. Un renforcement des programmes de nutrition est nécessaire pour éviter un tel effet lors de futures flambées épidémiques.

Marco de referencia: Todos los programas institucionales y comunitarios de detección de la desnutrición en Tonkolili, un distrito rural de Sierra Leona afectado por el virus del Ébola.Objetivos: Antes del brote epidémico por el virus del Ébola, Sierra Leona se había fijado el objetivo de disminuir a <0,2% la prevalencia de desnutrición aguda grave (SAM) en los niños <5 años de edad. En el presente estudio se comparó el número de niños que participaron en la detección sistemática de la desnutrición, el número de niños diagnosticados y el de niños tratados por desnutrición antes del brote, durante el mismo y después de él (del 2013 al 2016).Método: Fue este un estudio transversal retrospectivo.Resultados: El tamizaje en los establecimientos sanitarios disminuyó de 16 805 niños por mes antes del brote a 13 510 niños por mes durante el mismo (P = 0,02) y la cifra inicial se recuperó después del brote. El tamizaje en la comunidad permaneció estable durante el brote y aumentó un 30% después del mismo (P < 0,001). Al utilizar como medida el perímetro braquial, la proporción de diagnósticos de desnutrición aguda moderada aumentó de 3,6% en la comunidad y 5,1% en los establecimientos antes del brote respectivamente a 8,2% y 7,9% después del mismo (P < 0,001, P = 0,003). Al aplicar los valores del peso para la edad en los establecimientos de salud, la proporción de niños con diagnóstico de SAM pasó del 1,5% antes del brote a 3,5% después del mismo (P = 0,003). En promedio, uno de cada cuatro niños en quienes se diagnosticó SAM cada mes completó su tratamiento.Conclusión: Después de una diminución de la detección sistemática de la desnutrición aguda grave durante el brote epidémico de enfermedad del Ébola, el diagnóstico de desnutrición aguda aumentó después del brote. Es necesario fortalecer los programas de nutrición con el fin de evitar con anticipación estas repercusiones durante los brotes epidémicos en el futuro.

Evaluation of Nutrition Interventions in Children in Conflict Zones: A Narrative Review.

Food and nutrition insecurity becomes increasingly worse in areas affected by armed conflict. Children affected by conflict, or in war-torn settings, face a disproportionate burden of malnutrition and poor health outcomes. As noted by humanitarian response reviews, there is a need for a stronger evidence-based response to humanitarian crises. To achieve this, we systematically searched and evaluated existing nutrition interventions carried out in conflict settings that assessed their impact on children's nutrition status. To evaluate the impact of nutrition interventions on children's nutrition and growth status, we identified published literature through EMBASE, PubMed, and Global Health by using a combination of relevant text words and Medical Subject Heading terms. Studies for this review must have included children (aged ≤18 y), been conducted in conflict or postconflict settings, and assessed a nutrition intervention that measured ≥1 outcome for nutrition status (i.e., stunting, wasting, or underweight). Eleven studies met the inclusion and exclusion criteria for this review. Five different nutrition interventions were identified and showed modest results in decreasing the prevalence of stunting, wasting, underweight, reduction in severe or moderate acute malnutrition or both, mortality, anemia, and diarrhea. Overall, nutrition interventions in conflict settings were associated with improved children's nutrition or growth status. Emergency nutrition programs should continue to follow recent recommendations to expand coverage and access (beyond refugee camps to rural areas) and ensure that aid and nutrition interventions are distributed equitably in all conflict-affected populations.

Changes in plasma phosphate during in-patient treatment of children with severe acute malnutrition: an observational study in Uganda.

BACKGROUND: Children treated for severe acute malnutrition (SAM) are at risk of refeeding hypophosphatemia. Therapeutic diets have only recently become fortified with phosphorus to meet United Nations (UN) specifications, but to our knowledge no studies have investigated the effect. OBJECTIVE: The aim was to assess concentrations and correlates of plasma phosphate (P-phosphate) at admission and during treatment and to identify correlates of changes in P-phosphate. DESIGN: This was a prospective observational study in 6- to 59-mo-old children admitted for treatment of SAM to Mulago Hospital, Uganda. P-phosphate was measured at admission, on the second day of treatment with a therapeutic formula containing 75 kcal/100 mL and 560 mg phosphorus/L (F-75, Nutriset), at the start of the transition to a therapeutic formula containing 100 kcal/100 mL and 579 mg phosphorus/L (F-100; Nutriset), at day 2 of transition, and at discharge. RESULTS: Among 120 children, mean ± SD P-phosphate at admission was 1.04 ± 0.31 mmol/L and increased by 0.43 (95% CI: 0.35, 0.52) mmol/L during the first 2 d and more slowly toward discharge. Most (79%) children experienced their lowest P-phosphate concentration at admission, and none developed severe hypophosphatemia. P-phosphate was lowest in children with edema and with elevated C-reactive protein, and a lower increase was seen with increasing caretaker-reported severity of illness. Partially or fully replacing F-75 with rice porridge (i.e., a local practice to reduce diarrhea) during the first 2 d of stabilization was associated with a 0.34-mmol/L (95% CI: 0.18, 0.50 mmol/L) lower increase in P-phosphate during the same first 2 d. CONCLUSIONS: F-75, which complies with UN specifications and provides 73 mg phosphorus · kg(-1) · d(-1) (130 mL · kg(-1) · d(-1)), seems to prevent refeeding hypophosphatemia in children with SAM. Replacing this formula with rice porridge during the first days of treatment to manage diarrhea may have an adverse effect on P-phosphate concentrations. This study was registered at http://www.isrctn.com as ISRCTN55092738.