Improving Anemia Assessment in Clinical and Public Health Settings.

We aim to provide a practical approach to assess anemia and its primary causes, both in clinical settings and in the context of public health programs. Anemia remains a global challenge; thus, to achieve goals for anemia reduction and assess progress, standardized approaches are required for the assessment of anemia and its causes. We first provide a brief review of how to assess anemia, based on hemoglobin concentrations and cutoffs that correspond to age, sex, and physiologic status. Next, we discuss how to assess the likely causes of anemia in different settings. The causes of anemia are classified as non-nutritional (for example, because of infection, inflammation, blood loss, or genetic disorders) or nutrition-specific (for example, because of deficiencies of iron, vitamin A, riboflavin, vitamin B12, or folate). There is an important overlap between these 2 categories, such as the increased likelihood of iron deficiency in the context of inflammation. Given the multifaceted nature of anemia etiology, we introduce a framework for anemia assessment based on the "ecology of anemia," which recognizes its many overlapping causes. This conceptual framework is meant to inform what data on anemia causes may need to be collected in population surveys. The framework has a supporting table with information on the diagnostic tests, biomarkers and proposed cutoffs, characteristics, and feasibility of collecting the myriad information that can help elucidate the anemia etiology. We also provide examples of how this framework can be applied to interpret the anemia risk factor data from population-based surveys that can inform decisions about context-specific interventions. Finally, we present research gaps and priorities related to anemia assessment.

Causes and consequences of child growth faltering in low-resource settings.

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers.

BACKGROUND: Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development. OBJECTIVES: We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024). RESULTS: In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11). CONCLUSIONS: Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali.

INTRODUCTION: Moderate acute malnutrition (MAM) causes substantial child morbidity and mortality, accounting for 4.4% of deaths and 6.0% of disability-adjusted life years (DALY) lost among children under 5 each year. There is growing consensus on the need to provide appropriate treatment of MAM, both to reduce associated morbidity and mortality and to halt its progression to severe acute malnutrition. We estimated health outcomes, costs and cost-effectiveness of four dietary supplements for MAM treatment in children 6-35 months of age in Mali. METHODS: We conducted a cluster-randomised MAM treatment trial to describe nutritional outcomes of four dietary supplements for the management of MAM: ready-to-use supplementary foods (RUSF; PlumpySup); a specially formulated corn-soy blend (CSB) containing dehulled soybean flour, maize flour, dried skimmed milk, soy oil and a micronutrient pre-mix (CSB++; Super Cereal Plus); Misola, a locally produced, micronutrient-fortified, cereal-legume blend (MI); and locally milled flour (LMF), a mixture of millet, beans, oil and sugar, with a separate micronutrient powder. We used a decision tree model to estimate long-term outcomes and calculated incremental cost-effectiveness ratios (ICERs) comparing the health and economic outcomes of each strategy. RESULTS: Compared to no MAM treatment, MAM treatment with RUSF, CSB++, MI and LMF reduced the risk of death by 15.4%, 12.7%, 11.9% and 10.3%, respectively. The ICER was US$9821 per death averted (2015 USD) and US$347 per DALY averted for RUSF compared with no MAM treatment. CONCLUSION: MAM treatment with RUSF is cost-effective across a wide range of willingness-to-pay thresholds. TRIAL REGISTRATION: NCT01015950.

Improving maternal folate status to prevent infant neural tube defects: working group conclusions and a framework for action.

As infectious disease control programs achieve increasing success, further reductions in child mortality in low- and middle-income countries (LMICs) will require focused prevention strategies for birth defects and other noninfectious diseases. Neural tube defects (NTDs) can cause early death or lifelong disability. Preventing NTDs provides a feasible, significant opportunity to decrease the toll of birth defects and contribute to further reducing child mortality globally. The Micronutrient Forum convened a technical consultation on Folate Status in Women and Neural Tube Defects Prevention to develop a roadmap to inform and prioritize investments in NTD prevention in LMICs; help guide implementation efforts in terms of the feasibility of interventions and the potential for acceleration; and identify research and knowledge gaps. Here, we describe the impetus for and approach to the consultation and present the conclusions and a framework for developing a roadmap for action to accelerate NTD prevention in LMICs. The framework (1) provides options for action on folate status assessment; (2) outlines a way forward to develop and implement a time-bound global action plan for NTD prevention; and (3) identifies common impediments to NTD prevention, broad strategies to overcome or minimize these impediments, and basic building blocks necessary to accelerate action.

Regional, Socioeconomic, and Dietary Risk Factors for Vitamin B-12 Deficiency Differ from Those for Folate Deficiency in Cameroonian Women and Children.

BACKGROUND: Representative data on folate and vitamin B-12 dietary intake and status in low-income countries are rare, despite the widespread adoption of folic acid fortification. OBJECTIVE: The purpose of this study was to evaluate folate and vitamin B-12 intake, status, and risk factors for deficiency before implementation of a national fortification program in Cameroon. METHODS: A nationally representative cross-sectional cluster survey was conducted in 3 ecologic zones of Cameroon (South, North, and the 2 largest cities, Yaoundé/Douala), and information on dietary intake was collected from 10 households in each of 30 randomly selected clusters per zone. In a subset of women and their 12- to 59-mo-old children (n = 396 pairs), plasma folate and vitamin B-12, as well as breast milk vitamin B-12, were analyzed. RESULTS: Vitamin B-12 and folate dietary intake patterns and plasma concentrations were similar for women and children. In the subsample, 18% and 29% of women and 8% and 30% of children were vitamin B-12 (≤ 221 pmol/L) and folate (< 10 nmol/L) deficient, respectively. Mean dietary folate ranged from 351 µg dietary folate equivalents/d in the North to 246 µg dietary folate equivalents/d in Yaoundé/Douala; plasma folate was negatively associated with socioeconomic status (P = 0.001). Plasma vitamin B-12 deficiency was similar in the South and North, 29% and 40%, respectively, but was only 11% in Yaoundé/Douala, and was positively associated with socioeconomic status. Mean breast milk vitamin B-12 was statistically significantly lower in the North (101 pmol/L) than in the South (296 pmol/L) or Yaoundé/Douala (349 pmol/L). CONCLUSIONS: Folate intake and status are inadequate among women and young children in Yaoundé/Douala, whereas low vitamin B-12 intake and status are more common in poor and rural areas, especially in the North. Different strategies may be needed to control deficiency of these nutrients in different regions of Cameroon.

Measuring the Costs of Vitamin A Interventions: Institutional, Spatial, and Temporal Issues in the Context of Cameroon.

BACKGROUND: To address vitamin A (VA) deficiency, an array of interventions have been developed for increasing VA status among young children. With numerous possible combinations of interventions, however, comes the need to take decisions regarding which intervention or combination of interventions is most cost effective for achieving VA deficiency reduction targets. METHODS: Detailed intervention-specific, "macro-region"-level data in Cameroon are used to generate estimates of the costs associated with delivering VA to children aged 6 to 59 months. RESULTS: In Cameroon, our estimates of costs per effectively-covered child (ie, children at risk of inadequate intake of VA who are exposed to an intervention and who achieve adequate intake) each year (2 rounds of Child Health Days [CHDs]) were US$3.31 for VA supplements. VA fortification of edible oil and bouillon cube was US$2.95 and US$2.41, respectively, per child effectively covered per year, and biofortification of maize was US$5.30 per child effectively covered per year. Combinations of interventions could reduce costs (eg, delivering additional interventions that affect VA status through the CHDs). Spatial differences in costs within Cameroon were also evident, for example, delivering high-dose VA capsules through CHDs leads to a cost of US$0.77 per child reached in the northern regions compared to US$1.40 per child reached in the southern regions. CONCLUSION: The costs associated with alternative VA interventions in Cameroon differ spatially, temporally, and in their cost-effectiveness. Choosing the appropriate combination of interventions can produce a more efficient portfolio of interventions to address VA deficiencies and VA-related deaths.

Use of Optimization Modeling for Selecting National Micronutrient Intervention Strategies: An Example Based on Potential Programs for Control of Vitamin A Deficiency in Cameroon.

Vitamin and mineral (micronutrient [MN]) deficiencies are common in lower income countries, especially among young children and women of reproductive age. These deficiencies are cause for serious concern because of their high prevalence and their associated complications, which include depressed immune function and increased risk and severity of infections, impaired neurocognitive development, and anemia, which together result in elevated mortality and reduced human productive capacity. A broad range of different intervention strategies are available to control MN deficiencies. At present, these interventions are usually implemented at a national scale through different public and private sector entities, often with little coordination. We have developed a set of models based on the estimated ability of different interventions to achieve effective coverage and the necessary financial resources required to deploy these interventions. The models provide a unified and transparent framework for considering different options using the common indicator of effective coverage. More specifically, information on nutritional benefits and costs are analyzed using an economic optimization model to identify the mix of interventions that could be delivered to specific target groups in particular geographic areas to achieve a desired level of effective coverage at lowest cost. Alternatively, these optimization models can be developed to identify the combination of interventions needed to achieve the maximum effective coverage, given specified budgetary limitations. The results of these models can be useful input into policy-making processes. To introduce this analytical approach, the set of papers in this volume addresses the problem of vitamin A deficiency among young children in Cameroon.

Comparison of a Household Consumption and Expenditures Survey with Nationally Representative Food Frequency Questionnaire and 24-hour Dietary Recall Data for Assessing Consumption of Fortifiable Foods by Women and Young Children in Cameroon.

BACKGROUND: Household Consumption and Expenditures Surveys (HCES) are potential sources of data on dietary patterns for planning fortification programs, but they rarely have been compared with individual-level dietary assessment methods. OBJECTIVE: To compare apparent consumption of fortifiable foods estimated from the Third Cameroon Household Survey (ECAM3) with the results of a national dietary survey using food frequency questionnaire (FFQ) and 24-hour recall (24HR) methods among women aged 15 to 49 years and children aged 12 to 59 months. METHODS: We estimated coverage and frequency of consumption in the previous week (ECAM3 and FFQ) and coverage and amount consumed on the previous day (ECAM3 and 24HR) of refined vegetable oil, wheat flour, sugar, and bouillon cubes. RESULTS: Coverage in the past week as measured by the ECAM3 and FFQ, respectively, was 64% vs. 54% for oil, 60% vs. 92% for flour, 69% vs. 78% for sugar, and 85% vs. 96% for bouillon cubes. The different methods identified similar patterns of coverage among subgroups for oil, but patterns for other foods were variable. Frequency of consumption and previous-day coverage were lower with the ECAM3 than with the FFQ and 24HR, likely reflecting infrequent acquisition relative to intake. For women, the mean amounts consumed on the previous day (among consumers) were 43 vs. 29 g of oil, 71 vs. 83 g of flour, 42 vs. 32 g of sugar, and 5.0 vs. 2.4 g of bouillon cubes (ECAM and 24HR, respectively). CONCLUSIONS: HCES provide useful information on patterns of food access but inadequate information on individual consumption amounts to estimate appropriate food fortification levels.

Considerations in developing lipid-based nutrient supplements for prevention of undernutrition: experience from the International Lipid-Based Nutrient Supplements (iLiNS) Project.

The International Lipid-Based Nutrient Supplements (iLiNS) Project began in 2009 with the goal of contributing to the evidence base regarding the potential of lipid-based nutrient supplements (LNS) to prevent undernutrition in vulnerable populations. The first project objective was the development of acceptable LNS products for infants 6-24 months and for pregnant and lactating women, for use in studies in three countries (Burkina Faso, Ghana and Malawi). This paper shares the rationale for a series of decisions in supplement formulation and design, including those related to ration size, ingredients, nutrient content, safety and quality, and packaging. Most iLiNS supplements have a daily ration size of 20 g and are intended for home fortification of local diets. For infants, this ration size is designed to avoid displacement of breast milk and to allow for dietary diversity including any locally available and accessible nutrient-dense foods. Selection of ingredients depends on acceptability of flavour, micronutrient, anti-nutrient and essential fatty acid contents. The nutrient content of LNS designed to prevent undernutrition reflects the likelihood that in many resource-poor settings, diets of the most nutritionally vulnerable individuals (infants, young children, and pregnant and lactating women) are likely to be deficient in multiple micronutrients and, possibly, in essential fatty acids. During ingredient procurement and LNS production, safety and quality control procedures are required to prevent contamination with toxins or pathogens and to ensure that the product remains stable and palatable over time. Packaging design decisions must include consideration of product protection, stability, convenience and portion control.

Comparison of methods to assess adherence to small-quantity lipid-based nutrient supplements (SQ-LNS) and dispersible tablets among young Burkinabé children participating in a community-based intervention trial.

Adherence to supplementation provided during an intervention trial can affect interpretation of study outcomes. We compared different approaches for estimating adherence to small-quantity lipid-based nutrient supplements (SQ-LNS) and dispersible tablets in a randomised clinical trial in Burkina Faso. A total of 2435 children (9-18 months) were randomly assigned to receive daily 20 g SQ-LNS with varying contents of zinc and a dispersible tablet containing 0 or 5 mg zinc. Adherence to SQ-LNS and tablets was assessed for all children through weekly caregiver interviews, and disappearance rate was calculated based on empty and unused packages returned during home visits. Additional adherence data were collected in different randomly selected subgroups of children: 12-h home observations were completed for children 11 and 16 months of age (n = 192) to assess consumption of SQ-LNS and dispersible tablets, and plasma zinc concentration was measured at baseline and 18 months (n = 310). Apparent adherence to SQ-LNS and dispersible tablets differed according to the assessment method used. Average daily caregiver-reported adherence to both SQ-LNS and dispersible tablets was 97 ± 6%. Disappearance rates showed similarly high average weekly adherence (98 ± 4%). In contrast, only 63% and 54% of children at 11 and 16 months, respectively, received SQ-LNS during the 12-h home observation periods, and fewer (32% and 27%) received a tablet. The lack of change in plasma zinc concentration after 9 months of supplementation suggests low adherence to the zinc tablet. Better methods are needed to assess adherence in community-based supplementation trials.

Comparison of the estimated cost-effectiveness of preventive and therapeutic zinc supplementation strategies for reducing child morbidity and mortality in sub-Saharan Africa.

BACKGROUND: Zinc supplementation of young children in lower-income countries reduces morbidity from diarrhea and pneumonia and all-cause mortality, but the most cost-effective approach for distributing zinc supplements is unknown. OBJECTIVE: To examine the potential impact of four possible strategies for delivering zinc supplements on disease prevention and deaths averted among children 6 to 59 months of age in sub-Saharan Africa. METHODS: We analyzed different zinc supplementation strategies to assess their likely impact on morbidity and mortality of preschool children in sub-Saharan Africa and to estimate their possible costs. RESULTS: Preventive zinc supplementation reduces diarrhea incidence by 27% among children 12 to 59 months of age, pneumonia incidence by 21% among children 6 to 59 months of age, and all-cause mortality by 18% among children 12 to 59 months of age. The likely average total program costs of zinc supplementation programs were estimated from the outlays of existing service delivery platforms, such as child health days, community-based nutrition programs, and clinic-based treatment of diarrhea, assuming different levels of coverage and target age ranges of children. CONCLUSIONS: We found that the average total costs per life saved ranged from approximately US$462 to US$3,111, and the most cost-effective interventions were weekly or intermittent preventive zinc supplementation, because of the possibility of high coverage and fewer supplements required. Empirical data from zinc supplementation programs will be needed to confirm these estimates.

Results of Fortification Rapid Assessment Tool (FRAT) surveys in sub-Saharan Africa and suggestions for future modifications of the survey instrument.

BACKGROUND: Food fortification has been increasingly recognized as a promising approach to prevent micronutrient deficiencies. The Fortification Rapid Assessment Tool (FRAT) was developed to assist public health program managers to acquire the information needed to implement an effective mass food fortification program. Multiple countries have conducted FRAT surveys, but information on results and experiences with the FRAT tool has been available only at the national level. OBJECTIVE: To summarize the findings of the FRAT surveys previously conducted in sub-Saharan Africa. METHODS: Surveys from 12 sub-Saharan African countries (Burkina Faso, Cameroon, Congo, Guinea, Malawi, Mali, Mauritania, Mozambique, Niger, Rwanda, Senegal, Uganda) were identified. Information on consumption patterns for wheat flour, vegetable oil, sugar, and bouillon cubes was reviewed and summarized. RESULTS: Most surveys found that a moderate to high proportion of women reported consuming wheat flour (48% to 93%), vegetable oil (44% to 98%), sugar (55% to 99%), and bouillon cubes (79% to 99%) in the past 7 days, although consumption was more common and more frequent in urban areas than in rural areas. Similarly, the reported amounts consumed during the previous 24 hours were generally higher in urban settings. CONCLUSIONS: The FRAT instrument has been successfully used in multiple countries, and the results obtained have helped in planning national food fortification programs. However, the recommended sampling scheme may need to be reconsidered, and the guidelines should be revised to clarify important aspects of fieldworker training, implementation, data analysis and interpretation, and reporting of the results.

Very low adequacy of micronutrient intakes by young children and women in rural Bangladesh is primarily explained by low food intake and limited diversity.

Documentation of micronutrient intake inadequacies among developing country populations is important for planning interventions to control micronutrient deficiencies. The objective of this study was to quantify micronutrient intakes by young children and their primary female caregivers in rural Bangladesh. We measured 24-h dietary intakes on 2 nonconsecutive days in a representative sample of 480 children (ages 24-48 mo) and women in 2 subdistricts of northern Bangladesh by using 12-h weighed food records and subsequent 12-h recall in homes. We calculated the probability of adequacy (PA) of usual intakes of 11 micronutrients and an overall mean PA, and evaluated dietary diversity by counting the total number of 9 food groups consumed. The overall adequacy of micronutrient intakes was compared to dietary diversity scores using correlation and multivariate regression analyses. The overall mean prevalence of adequacy of micronutrient intakes for children was 43% and for women was 26%. For children, the prevalence of adequate intakes for each of the 11 micronutrients ranged from a mean of 0 for calcium to 95% for vitamin B-6 and was <50% for iron, calcium, riboflavin, folate, and vitamin B-12. For women, mean or median adequacy was <50% for all nutrients except vitamin B-6 and niacin and was <1% for calcium, vitamin A, riboflavin, folate, and vitamin B-12. The mean PA (MPA) was correlated with energy intake and dietary diversity, and multivariate models including these variables explained 71-76% of the variance in MPA. The degree of micronutrient inadequacy among young children and women in rural Bangladesh is alarming and is primarily explained by diets low in energy and little diversity of foods.

Consumption of potentially fortifiable foods by women and young children varies by ecological zone and socio-economic status in Cameroon.

In preparation for a proposed large-scale food fortification program in Cameroon, we completed a nationally representative, cross-sectional, cluster survey to assess the consumption patterns of four potentially fortifiable foods (refined vegetable oil, wheat flour, sugar, and bouillon cube) by women and children. Thirty clusters were randomly chosen in each of three ecologic zones (south, north, and large cities) and 10 households (HH) per cluster were selected, each with a child 12-59 mo old and a primary female caregiver 15-49 y old (total 1002 HH). Blood samples were collected and food consumption was assessed by FFQ and 24-h dietary recall. Anemia (39% of women, 58% of children) and deficiencies of iron (15-32%, 21-70%), zinc (77%, 70%), vitamin A (22%, 35%), and vitamin B-12 (28%, 27%) were common, especially in the north and among HH with lower socio-economic status (SES). Oil was consumed by 54% of HH, whereas >75% of HH consumed wheat flour, sugar, and bouillon cube. For most foods, coverage was lower among HH with lower SES. On average, oil, wheat flour, and sugar were consumed once per day and bouillon cube was consumed twice per day. Median intakes of oil, wheat flour, sugar, and bouillon cube (among consumers) were 19.8, 79.4, 30.0, and 1.9 g/d for women and 12.0, 49.4, 19.4, and 0.9 g/d for children, respectively. Food consumption patterns of high risk population subgroups must be considered, along with technical feasibility and cost, for the selection of appropriate vehicles for food fortification.

Acceptability of zinc-fortified, lipid-based nutrient supplements (LNS) prepared for young children in Burkina Faso.

Micronutrient deficiencies are a public health concern among young children in low-income countries, and novel strategies are needed to improve the nutritional status of children at risk. One promising approach is the use of lipid-based nutrient supplements (LNS), which can be added to complementary food at the time of consumption. The optimal amount of zinc to include in LNS is uncertain, and concerns have been expressed about possible adverse effects of zinc on sensory characteristics of LNS. We conducted a series of acceptability studies of LNS containing either 0 or 10 mg of zinc per daily 20 g LNS dose among Burkinabe children 9-15 months old and their mothers. These acceptability studies included observations of children's consumption, maternal and child sensory reaction to the products using a 5-unit hedonic scale, a triangle test for detection of differences and a review of maternal reports of their child-feeding experiences during a 2-week home-feeding trial. The LNS products were well appreciated by the mothers and children during the sensory trials and the 2-week home-feeding trial. The addition of 10 mg zinc to LNS did not affect the consumed proportion of the offered porridge-LNS-mixture (P = 0.43). Results of the triangle test with mothers confirmed that there was no detectable difference between products containing 0 or 10 mg zinc per 20 g LNS dose. Most importantly, interviews and focus groups following the 2-week home-feeding trial indicated good acceptability of the products by mothers and their children.

Setting priorities in global child health research investments: assessment of principles and practice.

This article reviews theoretical and practical approaches for setting priorities in global child health research investments. It also provides an overview of previous attempts to develop appropriate tools and methodologies to define priorities in health research investments. A brief review of the most important theoretical concepts that should govern priority setting processes is undertaken, showing how different perspectives, such as medical, economical, legal, ethical, social, political, rational, philosophical, stakeholder driven, and others will necessarily conflict each other in determining priorities. We specially address present research agenda in global child health today and how it relates to United Nation's (UN) Millennium Development Goal 4, which is to reduce child mortality by two-thirds between 1990 and 2015. The outcomes of these former approaches are evaluated and their benefits and shortcomings presented. The case for a new methodology for setting priorities in health research investments is presented, as proposed by Child Health and Nutrition Research Initiative, and a need for its implementation in global child health is outlined. A transdisciplinary approach is needed to address all the perspectives from which investments into health research can be seen as priorities. This prioritization requires a process that is transparent, systematic, and that would take into account many perspectives and build on advantages of previous approaches.

Comparison of isotope dilution with bioimpedance spectroscopy and anthropometry for assessment of body composition in asymptomatic HIV-infected and HIV-uninfected breastfeeding mothers.

BACKGROUND: The effect of breastfeeding on the nutrition of HIV-infected (HIV+) mothers is unknown. Simple, valid methods are needed for body-composition assessment of HIV+ women. OBJECTIVE: We compared the ability of bioimpedance spectroscopy (BIS) and anthropometry with that of isotope dilution (2H2O) to measure fat-free mass (FFM) and fat mass (FM) in HIV+ and HIV-uninfected (HIV-) breastfeeding South African mothers. DESIGN: Total body water (TBW) content of 68 lactating mothers (20 HIV+, 48 HIV-) was measured 10 wk after delivery by using BIS and 2H2O to measure FFM and FM. Anthropometric measurements included body mass index (BMI; in kg/m2), midupper arm circumference (MUAC), and 4 skinfold thicknesses. RESULTS: TBW, FFM, and FM measurements determined by BIS were correlated with 2H2O measurements in HIV+ (r = 0.664, 0.621, and 0.872, respectively; P < 0.01) and HIV- (r = 0.876, 0.868, and 0.932, respectively; P < 0.001) mothers. TBW measured by BIS was greater than that measured by the 2H2O method in both HIV+ (1.8 L) and HIV- (1.5 L) women; FM or FFM did not differ significantly by method. BMI, MUAC, and all skinfold-thickness measurements correlated strongly (r > 0.62, P < 0.001) with FM measured by 2H2O in both groups. BMI and MUAC correlated (r > 0.64, P < 0.001) with FFM in HIV- mothers but not in HIV+ mothers. CONCLUSIONS: In HIV+ and HIV- breastfeeding mothers, BIS provides an estimate of body composition comparable to that obtained with the 2H2O method. BMI and MUAC are useful in predicting FM in both groups but are not valid measures of FFM in HIV+ mothers.

Low nutrient intakes among infants in rural Bangladesh are attributable to low intake and micronutrient density of complementary foods.

We assessed the adequacy of nutrient intakes of 135 rural Bangladeshi breast-fed infants 6-12 mo of age and examined nutritional trade-offs due to possible displacement of breast milk by complementary foods. Observers completed 12-h daytime measurements of breast milk and complementary food intakes; data for the previous 12 h were obtained from maternal recall, yielding estimates of total 24-h intakes. On average, infants were mildly wasted (mean +/- SD weight-for-length Z-score = -0.92 +/- 0.88) and moderately stunted (length-for-age Z-score = -1.49 +/- 0.96). Total energy intakes at 6-8 and 9-12 mo were 88 and 86% of absolute energy requirements (kJ/d), 106 and 105% of requirements per kg body weight, and 97 and 94% of requirements per kg median weight-for-length, respectively. Breast milk contributed 78% of energy intake at 6-8 mo and 75% at 9-12 mo. Mean meal frequency and energy density of complementary foods were generally consistent with recommendations, but only small amounts of food were offered. Nevertheless, only 72% of the food energy offered was consumed. Total energy intake was positively correlated with meal frequency, quantity consumed per meal, and energy intake from breast milk, but not with energy density of complementary foods. Energy intake from complementary foods was inversely related to energy intake from breast milk. The diets fell short of recommended intakes for numerous vitamins and minerals. We conclude that although greater intakes of complementary foods were associated with higher total energy intake, micronutrient intake remained low due to the low micronutrient density of the complementary foods consumed and the partial displacement of breast milk.