Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study.

BACKGROUND: In South Africa, 30.9% of children under five years with Severe Acute Malnutrition (SAM) died in 2018. We aimed to identify factors associated with mortality among children under five years hospitalized with SAM in Limpopo province, South Africa. METHODS: We conducted a cross-sectional study including children under five years admitted with SAM from 2014 to 2018 in public hospitals of Limpopo province. We extracted socio-demographic and clinical data from hospital records. We used logistic regression to identify factors associated with mortality. FINDINGS: We included 956 children, 50.2% (480/956) male and 49.8% (476/956) female. The median age was 13 months (inter quartile range: 9-19 months). The overall SAM mortality over the study period was 25.9% (248/956). The most common complications were diarrhea, 63.8% (610/956), and lower respiratory tract infections (LRTIs), 42.4% (405/956). Factors associated with mortality included herbal medication use (adjusted Odds Ratio (aOR): 2.2, 95% Confidence Interval (CI): 1.4-3.5, p = 0.001), poor appetite (aOR: 2.7, 95% CI: 1.4-5.2, p = 0.003), Mid-upper circumference (MUAC) <11.5 cm (aOR: 3.0, 95% CI: 1.9-4.7, p<0.001), lower respiratory tract infections (LRTIs) (aOR: 1.6, 95% CI: 1.2-2.0, p<0.001), anemia (aOR: 2.5, 95% CI: 1.1-5.3, p = 0.021), hypoglycemia (aOR: 12.4, 95% CI: 7.1-21.8, p<0.001) and human immunodeficiency virus (HIV) infection (aOR: 2.3, 95% CI: 1.6-3.3, p<0.001). INTERPRETATION: Herbal medication use, poor appetite, LRTIs, anemia, hypoglycemia, and HIV infection were associated with mortality among children with SAM. These factors should guide management of children with SAM.

Factors associated with child survival in children admitted to outpatient therapeutic program at public health institutions in Afar Regional State, Ethiopia: a prospective cohort study.

INTRODUCTION: About 20 million children suffer from severe acute malnutrition each year. The World Health Organization recommends the outpatient therapeutic program as a standard treatment protocol for the management of uncomplicated severe acute malnutrition and for children who are transferred from inpatient cares after recovery. This study aimed to assess the treatment outcome of severe acute malnutrition and determinants of survival in children admitted to outpatient therapeutic program at public health institutions, Afar Regional State. METHODS: Institution-based prospective cohort study was conducted on 286 children aged 6-59 months admitted to the outpatient therapeutic program, from April to September 2017, at selected public health institutions in Afar Regional State. For the comparison of time to recovery among the different groups of children on the outpatient therapeutic program, Kaplan-Meir curve was used and significance test for these differences was assessed by the log-rank test. Then, a proportional hazard in the Cox model was used to identify independent predictors of survival. p value < 0.05 was considered significant. RESULTS: Of 286 children, 238 (83.2%; 95% CI (79, 88)), 18 (6.3%), 14 (4.9%), 8 (2.8%), and 8 (2.8%) cases were cured, defaulters, non-responder, died, and transfer to inpatient care, respectively. The overall mean rate of weight gain was 10.5(± 3.45) g/kg/day, and mean length of stay was 44.15(± 8.77) days. The recovery rate of children whose mothers travel less than 2 h to the health institution was about three times (AHR, 2.91; 95% CI (2.18, 3.88)) higher than children whose mothers travel 2 h and above. Compared with children who received vitamin A supplementation, children who lack supplementation were less likely (AHR, 0.39; 95% CI (0.25, 0.59)) to be cured. Moreover, the rate of recovery from outpatient therapeutic program among children who received antibiotics was about 1.4 times (AHR, 1.38; 95% CI (1.01, 1.89)) higher compared with children who did not receive of antibiotics. CONCLUSION: This study showed that nearly eight children in every ten had recovered from severe acute malnutrition. Therefore, considering the distance of health facility from children's residence, improving vitamin A supplementation and antibiotics are vital in improving the rate of recovery. Further research is also required to identify and address barriers to the provision of antibiotics and vitamin A supplementation.

Survival and nutritional status of children with severe acute malnutrition, six months post-discharge from outpatient treatment in Jigawa state, Nigeria.

BACKGROUND: The Outpatient Therapeutic Program (OTP) for treatment brings the management of Severe Acute Malnutrition (SAM) closer to the community. Many lives have been saved through this approach, but little data exists on the outcome of the children after discharge from such programmes. This study was aimed to determine the survival and nutritional status of children at six months after discharge from OTP for SAM. METHODOLOGY: This was a prospective study of children with SAM admitted into 10 OTPs in two local government areas of Jigawa state from June 2016 to July 2016. Home visits at six months after discharge enabled the collection of data on survival and nutritional status. The primary outcome measures were survival and nutritional status (Mid upper arm circumference and weight-for-height z-score). RESULT: Of 494 children with SAM, 410 were discharged and 379 were followed up. Of these, 354, (93.4%) were found alive while 25 (6.6%) died. Among the survivors 333 (94.1%) had MUAC ≥12.5cm and 64 (18.1%) had WHZ<-3. Mortality rates were higher 10 (8.4%) among the 6-11months old. Most deaths 16 (64%) occurred within the first 3months post-discharge. Those who died were significantly more stunted, p = 0.016 and had a smaller head circumference, p = 0.005 on entry to OTP programme. There was improvement from admission to six months follow up in the number of children with complete immunization (27.4% to 35.6%), and a decrease in the number of unimmunized children (34.8% vs 20.6%) at follow-up. CONCLUSION: The study demonstrates good post discharge survival rate and improved nutritional status for SAM patients managed in OTPs. There were, however considerable post discharge mortality, especially in the first three months and lower immunization uptake post discharge. A follow-up programme will improve these indices further.

[Infectious profile and mortality of children aged 0-5 years admitted with severe acute malnutrition: a retrospective cohort study conducted in the Therapeutic Nutritional Center in Bukavu, Republic of Congo]. / Profil infectieux et mortalité des enfants âgés de 0 à 5 ans admis pour malnutrition aiguë sévère: étude de cohorte rétrospective au Centre Nutritionnel et Thérapeutique de Bukavu, République Démocratique du Congo.

INTRODUCTION: Malnutrition is a backdrop on which several infections are grafted. The aim of this study is to determine the most lethal infections, the median length of stay and the median daily weight gain of malnourished children. METHOD: A retrospective cohort study of malnutrition in children aged 0-59 months hospitalized in the Therapeutic Nutritional Center in Bukavu from 1 January 2011 to 31 December 2013. The evaluation of the risk of deaths related to infectious complication was made measuring the relative risk. Mann-Whitney test was used for comparing the medians. Adjusted odd ratios using logistic regression and 95% confidence interval for the risk of mortality were given for each infectious cause. RESULTS: A total of 574 children were included in the study. Five hundred twenty-one (90.8%) children were cured, 10 (1.7%) had discontinued treatment and 43 (7.5%) had died. The median length of stay was 19 (13-26) days and the median daily weight gain was 7 (3-13) g/kg/j. There was a statistically significant association between mortality and sepsis/septic shock (p = 0.0004), meningitis (p = 0.00001) and HIV infection (p = 0.02). CONCLUSION: A better management of acute malnutrition in our region should be based on the establishment of specialized and well equipped units for the treatment of malnutrition associated with severe infections.

Global challenges in acute diarrhea.

PURPOSE OF REVIEW: Childhood diarrhea is the most common cause of morbidity and mortality, especially in the low and middle-income countries. The burden of child mortality because of diarrhea has declined, but still a lot is desired not only to reduce diarrhea-specific mortality but reduce the overall incidence, and hence the morbidity associated with childhood diarrhea. RECENT FINDINGS: A recent Lancet series on diarrhea suggests that amplification of the current interventions can eliminate virtually all preventable diarrhea deaths. A refocused attention and strategy and collective effort from the multilateral entities to promote water sanitation and hygiene, rotavirus vaccination, nutrition, and improved case management can bridge gaps and tackle the existing undue burden of deaths because of diarrhea. SUMMARY: Investment toward preventing and controlling childhood diarrhea should be a priority, especially when the existing solution is plausible for implementation at scale and in underprivileged settings.

Predictors of nutritional recovery time and survival status among children with severe acute malnutrition who have been managed in therapeutic feeding centers, Southern Ethiopia: retrospective cohort study.

BACKGROUND: Malnutrition remains to be one of the most common causes of morbidity and mortality among children in developing countries. The prevalence of wasting in Ethiopia remained about 10 % for the past ten years. Mortality rate of children with severe acute malnutrition treated in inpatient set ups has remained unacceptably high. METHODS: A retrospective cohort study was conducted in Southern Ethiopia. The study population were children with severe acute malnutrition aged from 6 to 59 months who have been managed at Karat and Fasha stabilization centers between September 30, 2013, and Sep. 29, 2014. The total sample size was 420 and pretested questionnaire was used. Kaplan Meier analysis was used to estimate time to nutritional recovery and Cox proportional-hazard regression analysis was carried out to determine independent predictors. RESULTS: Nutritional recovery rate was 3.61 per 100 person day observations. Median nutritional recovery time was 22 and 29 days for edematous malnourished and severely wasted children respectively. The independent predictors of nutritional recovery rate were: stabilization center (AHR = 1.4, 95 % CI: 1.1-1.7), malnutrition status (AHR = 1.8, 95 % CI: 1.3-2.4), weight (AHR = 1.5, 95 % CI: 1.2-1.9), mid- upper arm circumference (AHR = 1.4, 95 % CI: 1.1-1.9), inpatient complications (AHR = 2.2, 95 % CI: 1.4-3.5) and did not lose edema within four days of inpatient treatment (AHR = 2.3, 95 % CI: 1.1-4.8). CONCLUSIONS: The findings of this study confirm the probability of surviving gets slimmer with inpatient complications and staying longer in stabilization centers. So, to prevent complications and enhance recovery rate due emphasis should be given in improving early detection and treatment of severely malnourished children in Ethiopia.

Assessment of Nutritional Status in Children With Cancer and Effectiveness of Oral Nutritional Supplements.

Malnutrition is a common consequence of cancer in children, but the most effective methods of nutrition intervention are under debate. We aimed to evaluate the nutritional status of children diagnosed with cancer, and to investigate the effect of oral nutritional supplements on anthropometric measurements, biochemical parameters, and outcome. A randomized clinical study of 45 newly diagnosed cancer patients was performed. Anthropometric and biochemical data and related factors were assessed at 0, 3, and 6 months after diagnosis. On initial anthropometric assessment, prevalence of malnutrition by weight or height was found to be lower as compared with body mass index (BMI), or weight for height (WFH), or arm anthropometry. Twenty-six of the patients (55%) received oral nutritional supplement. During the second 3 months after diagnosis, there was a statistically significant decrease in number of the patients with WFH <90th percentile and BMI <5th percentile (P = .003 and P = .04, respectively). Infectious complications occurred more frequently in malnourished patients during first 3 months, and survival of children who were malnourished at the 6th month was significantly lower than that of well-nourished children (P = .003). On laboratory assessment, serum prealbumin levels of the all subjects were below normal ranges, but no relation was found for serum prealbumin or albumin levels in patients who were malnourished or not at diagnosis. Nutritional intervention is necessary to promote normal development and increase functional status as a child receives intensive treatment. Protein- and energy-dense oral nutritional supplements are effective for preventing weight loss in malnourished children.

Wasting and stunting--similarities and differences: policy and programmatic implications.

Wasting and stunting are often presented as two separate forms of malnutrition requiring different interventions for prevention and/or treatment. These two forms of malnutrition, however, are closely related and often occur together in the same populations and often in the same children. Wasting and stunting are both associated with increased mortality, especially when both are present in the same child. A better understanding of the pathophysiology of these two different forms of malnutrition is needed to design efficient programs. A greatly reduced muscle mass is characteristic of severe wasting, but there is indirect evidence that it also occurs in stunting. A reduced muscle mass increases the risk of death during infections and also in many other different pathological situations. Reduced muscle mass may represent a common mechanism linking wasting and stunting with increased mortality. This suggests that to decrease malnutrition-related mortality, interventions should aim at preventing both wasting and stunting, which often share common causes. Also, this suggests that treatment interventions should focus on children who are both wasted and stunted and therefore have the greatest deficits in muscle mass, instead of focusing on one or the other form of malnutrition. Interventions should also focus on young infants and children, who have a low muscle mass in relation to body weight to start with. Using mid-upper-arm circumference (MUAC) to select children in need of treatment may represent a simple way to target young wasted and stunted children efficiently in situations where these two conditions are present. Wasting is also associated with decreased fat mass. A decreased fat mass is frequent but inconsistent in stunting. Fat secretes multiple hormones, including leptin, which may have a stimulating effect on the immune system. Depressed immunity resulting from low fat stores may also contribute to the increased mortality observed in wasting. This may represent another common mechanism linking wasting and stunting with increased mortality in situations where stunting is associated with reduced fat mass. Leptin may also have an effect on bone growth. This may explain why wasted children with low fat stores have reduced linear growth when their weight-for-height remains low. It may also explain the frequent association of stunting with previous episodes of wasting. Stunting, however, can occur in the absence of wasting and even in overweight children. Thus, food supplementation should be used with caution in populations where stunting is not associated with wasting and low fat stores.

Metabolomics in nutrition research: biomarkers predicting mortality in children with severe acute malnutrition.

BACKGROUND: Millions of the world's children suffer from malnutrition, which predisposes to death from diarrhea and a variety of infectious diseases. Mortality rates among infants and toddlers remain staggeringly high, in part because the pathogenesis of acute malnutrition and its complications remains poorly understood. OBJECTIVE: We used metabolomic analysis to characterize the metabolic status of Ugandan children with severe acute malnutrition (SAM) and to delineate changes in hormones, metabolites, growth factors, and cytokines during nutritional therapy. We hypothesized that hormonal and metabolic factors measured at presentation would associate with, or predict, subsequent mortality during treatment. METHODS: This was a prospective cohort study of 75 severely malnourished children 6 months to 5 years of age treated as inpatients with F-75 and F-100 and supplemental micronutrients; after discharge, they received ready-to-use therapeutic food (RUTF). This increased the mean weight-for-height z-score (WHZ) from -4.27 to -1.75 SD. Blood samples were obtained at presentation, after 2 weeks of inpatient therapy, and after 4 to 10 weeks of RUTF. Plasma samples were analyzed by tandem mass spectrometry and microassays. RESULTS: At presentation there were high levels of nonesterified fatty acids (NEFA), ketones, and even-chain acylcarnitines, indicating active lipolysis and fatty acid oxidation. In contrast, albumin, amino acids, and C3 carnitine, a by-product of branched-chain amino acids, were low. Levels of insulin, insulin-like growth factor 1 (IGF-1), adiponectin, and leptin were low, while levels of ghrelin, growth hormone, cortisol, interleukin 6 (IL-6), peptide YY (PYY), and glucagon-like peptide 1 (GLP-1) were high. The metabolic and hormonal changes were reversed by formula feeding and RUTF. Biomarkers associated with mortality included HIV, WHZ, and mid-upper-arm circumference (MUAC); the biochemical factor associated most strongly with mortality was low leptin, a marker of adipose reserve and modulator of immune function. CONCLUSIONS: Low leptin predicts mortality in edematous and nonedematous-patients with SAM. Leptin assays might be used to identify malnourished children at highest risk for death.

The importance of nutritional care in HIV-infected children in resource-limited settings.

Renewed efforts to provide proper nutritional care are essential for appropriate pediatric HIV management. Current studies support the use of vitamin A and macronutrients that increase caloric and protein intake. With additional research on key issues such as the needed composition and timing for nutritional supplementation, we can determine the best strategies to support the growth and development of HIV-infected children in resource-limited settings. Malnutrition among children is common in the resource-limited settings where HIV infection is most prevalent. While malnutrition is associated with higher morbidity and mortality for HIV-infected children, there is only limited evidence to guide the use of nutritional support for HIV-infected children. The best studied is vitamin A, which is associated with improved mortality and clinical outcomes. Zinc and multivitamin supplementation have not consistently been associated with clinical benefits. Limited research suggests macronutrient supplementation, which typically uses enriched formulas or foods, improves key anthropometrics for HIV-infected children, but the optimal composition of nutrients for supplementation has not been determined. More research is needed to understand the most efficient and sustainable ways to ensure adequate nutrition in this vulnerable population.

Nationwide implementation of integrated community case management of childhood illness in Rwanda.

BACKGROUND: Between 2008 and 2011, Rwanda introduced integrated community case management (iCCM) of childhood illness nationwide. Community health workers in each of Rwanda's nearly 15,000 villages were trained in iCCM and equipped for empirical diagnosis and treatment of pneumonia, diarrhea, and malaria; for malnutrition surveillance; and for comprehensive reporting and referral services. METHODS: We used data from the Rwanda health management information system (HMIS) to calculate monthly all-cause under-5 mortality rates, health facility use rates, and community-based treatment rates for childhood illness in each district. We then compared a 3-month baseline period prior to iCCM implementation with a seasonally matched comparison period 1 year after iCCM implementation. Finally, we compared the actual changes in all-cause child mortality and health facility use over this time period with the changes that would have been expected based on baseline trends in Rwanda. RESULTS: The number of children receiving community-based treatment for diarrhea and pneumonia increased significantly in the 1-year period after iCCM implementation, from 0.83 cases/1,000 child-months to 3.80 cases/1,000 child-months (P = .01) and 0.25 cases/1,000 child-months to 5.28 cases/1,000 child-months (P<.001), respectively. On average, total under-5 mortality rates declined significantly by 38% (P<.001), and health facility use declined significantly by 15% (P = .006). These decreases were significantly greater than would have been expected based on baseline trends. CONCLUSIONS: This is the first study to demonstrate decreases in both child mortality and health facility use after implementing iCCM of childhood illness at a national level. While our study design does not allow for direct attribution of these changes to implementation of iCCM, these results are in line with those of prior studies conducted at the sub-national level in other low-income countries.

Post-discharge mortality in children with severe malnutrition and pneumonia in Bangladesh.

BACKGROUND: Post-discharge mortality among children with severe illness in resource-limited settings is under-recognized and there are limited data. We evaluated post-discharge mortality in a recently reported cohort of children with severe malnutrition and pneumonia, and identified characteristics associated with an increased risk of death. METHODS: Young children (<5 years of age) with severe malnutrition (WHO criteria) and radiographic pneumonia on admission to Dhaka Hospital of icddr,b over a 15-month period were managed according to standard protocols. Those discharged were followed-up and survival status at 12 weeks post-discharge was determined. Verbal autopsy was requested from families of those that died. RESULTS: Of 405 children hospitalized with severe malnutrition and pneumonia, 369 (median age, 10 months) were discharged alive with a follow-up plan. Of these, 32 (8.7%) died in the community within 3 months of discharge: median 22 (IQR 9-35) days from discharge to death. Most deaths were reportedly associated with acute onset of new respiratory or gastrointestinal symptoms. Those that died following discharge were significantly younger (median 6 [IQR 3,12] months) and more severely malnourished, on admission and on discharge, than those that survived. Bivariate analysis found that severe wasting on admission (OR 3.64, 95% CI 1.66-7.97) and age <12 months (OR 2.54, 95% CI 1.1-8.8) were significantly associated with post-discharge death. Of those that died in the community, none had attended a scheduled follow-up and care-seeking from a traditional healer was more common (p<0.001) compared to those who survived. CONCLUSION AND SIGNIFICANCE: Post-discharge mortality was common in Bangladeshi children following inpatient care for severe malnutrition and pneumonia. The underlying contributing factors require a better understanding to inform the potential of interventions that could improve survival.

Global burden of childhood diarrhea and interventions.

PURPOSE OF REVIEW: Diarrhea is a leading cause of morbidity and mortality among children under 5 years in low-income and middle-income countries. Over the past 2 decades under-five mortality has decreased substantially, but reductions have been uneven and unsatisfactory in resource-poor regions. RECENT FINDINGS: There are known interventions which can prevent diarrhea or manage children who suffer from it. Interventions with proven effectiveness at the prevention level include water, sanitation, and hygiene interventions, breastfeeding, complementary feeding, vitamin A and zinc supplementation, and vaccines for diarrhea (rotavirus and cholera). Oral rehydration solution, zinc treatment, continued feeding, and antibiotic treatment for certain strains of diarrhea (cholera, Shigella, and cryptosporidiosis) are effective strategies for treatment of diarrhea. The recent Lancet series using the 'Lives Saved' tool suggested that if these identified interventions were scaled up to a global coverage to at least 80%, and immunizations to at least 90%; almost all deaths due to diarrhea could be averted. SUMMARY: The current childhood mortality burden highlights the need of a focused global diarrhea action plan. The findings suggest that with proper packaging of interventions and delivery platforms, the burden of childhood diarrhea can be reduced to a greater extent. All that is required is greater attention and steps toward right direction.

Severe acute malnutrition in childhood: hormonal and metabolic status at presentation, response to treatment, and predictors of mortality.

OBJECTIVE: Malnutrition is a major cause of childhood morbidity and mortality. To identify and target those at highest risk, there is a critical need to characterize biomarkers that predict complications prior to and during treatment. METHODS: We used targeted and nontargeted metabolomic analysis to characterize changes in a broad array of hormones, cytokines, growth factors, and metabolites during treatment of severe childhood malnutrition. Children aged 6 months to 5 years were studied at presentation to Mulago Hospital and during inpatient therapy with milk-based formulas and outpatient supplementation with ready-to-use food. We assessed the relationship between baseline hormone and metabolite levels and subsequent mortality. RESULTS: Seventy-seven patients were enrolled in the study; a subset was followed up from inpatient treatment to the outpatient clinic. Inpatient and outpatient therapies increased weight/height z scores and induced striking changes in the levels of fatty acids, amino acids, acylcarnitines, inflammatory cytokines, and various hormones including leptin, insulin, GH, ghrelin, cortisol, IGF-I, glucagon-like peptide-1, and peptide YY. A total of 12.2% of the patients died during hospitalization; the major biochemical factor predicting mortality was a low level of leptin (P = .0002), a marker of adipose tissue reserve and a critical modulator of immune function. CONCLUSIONS: We have used metabolomic analysis to provide a comprehensive hormonal and metabolic profile of severely malnourished children at presentation and during nutritional rehabilitation. Our findings suggest that fatty acid metabolism plays a central role in the adaptation to acute malnutrition and that low levels of the adipose tissue hormone leptin associate with, and may predict, mortality prior to and during treatment.

Effectiveness of personalised, home-based nutritional counselling on infant feeding practices, morbidity and nutritional outcomes among infants in Nairobi slums: study protocol for a cluster randomised controlled trial.

BACKGROUND: Nutrition in the first 1,000 days of life (during pregnancy and the first two years) is critical for child growth and survival. Poor maternal, infant and young child nutrition (MIYCN) practices are widely documented in Kenya, with potential detrimental effects on child growth and survival. This is particularly a problem in slums, where most urban residents live. For example, exclusive breastfeeding for the first six months is only about two per cent. Innovative strategies to reach slum residents are therefore needed. Strategies like the Baby Friendly Hospital Initiative have proven effective in some settings but their effectiveness in resource-limited settings, including slums where many women do not deliver in hospital, is questionable. We propose to test the effectiveness of a home-based intervention on infant feeding practices, nutrition and health outcomes of infants born in two slums in Nairobi, Kenya. METHODS/DESIGN: The study, employing a cluster-randomised study design, will be conducted in two slums in Nairobi: Korogocho and Viwandani where 14 community units (defined by the Government's health care system) will form the unit of randomization. A total of 780 pregnant women and their respective child will be recruited into the study. The mother-child pair will be followed up until the child is one year old. Recruitment will last approximately one year and three months from September 2012 to December 2013. The mothers will receive regular, personalised, home-based counselling by trained Community Health Workers on MIYCN. Regular assessment of knowledge, attitudes and practices on MIYCN will be done, coupled with assessments of nutritional status of the mother-child pairs and diarrhea morbidity for the children. Statistical methods will include analysis of covariance and multinomial logistic regression. Additionally, cost-effectiveness analysis will be done. The study is funded by the Wellcome Trust and will run from March 2012 to February 2015. DISCUSSION: Interventions aimed at promoting optimal breastfeeding and complementary feeding practices are considered to have high impact and could prevent a fifth of the under-five deaths in countries with high mortality rates. This study will inform policy and practice in Kenya and similar settings regarding delivery mechanisms for such high-impact interventions, particularly among urban poor populations. TRIAL REGISTRATION: ISRCTN83692672.

Health economic perspectives of pediatric malnutrition: determinants of innovative progress.

Despite some improvements in recent years, extreme poverty and malnutrition remain a critical concern for developing countries. Malnutrition, and more specifically pediatric malnutrition, is a reality affecting millions of children, particularly in South Asia and Africa. It causes increased mortality and morbidity, decreased physical and intellectual development, poor productivity and a number of negative economic outcomes. Health economics data clearly demonstrate that interventions are effective and efficient, but more data are needed to measure that efficiency. Initiatives to address microdeficiencies have focused on vitamin A, iodine, zinc, iron and folate. Iodine is often used as a best practice example. Two main institutions lead the efforts to address malnutrition throughout the world: the UN with its UN Millennium Development Goal project, and the Copenhagen Consensus. We consider micronutrient deficiencies, particularly in iodine, corresponding interventions, their effects and health economic data. We discuss how developing public/private partnership could boost the effectiveness of interventions by combining the competencies of both sides: credibility, national and international buy-in, experience of public institutions, commercial competencies, high penetration rate, and product knowledge of private industry.

Probiotics and prebiotics for severe acute malnutrition (PRONUT study): a double-blind efficacy randomised controlled trial in Malawi.

BACKGROUND: Severe acute malnutrition affects 13 million children worldwide and causes 1-2 million deaths every year. Our aim was to assess the clinical and nutritional efficacy of a probiotic and prebiotic functional food for the treatment of severe acute malnutrition in a HIV-prevalent setting. METHODS: We recruited 795 Malawian children (age range 5 to 168 months [median 22, IQR 15 to 32]) from July 12, 2006, to March 7, 2007, into a double-blind, randomised, placebo-controlled efficacy trial. For generalisability, all admissions for severe acute malnutrition treatment were eligible for recruitment. After stabilisation with milk feeds, children were randomly assigned to ready-to-use therapeutic food either with (n=399) or without (n=396) Synbiotic2000 Forte. Average prescribed Synbiotic dose was 10(10) colony-forming units or more of lactic acid bacteria per day for the duration of treatment (median 33 days). Primary outcome was nutritional cure (weight-for-height >80% of National Center for Health Statistics median on two consecutive outpatient visits). Secondary outcomes included death, weight gain, time to cure, and prevalence of clinical symptoms (diarrhoea, fever, and respiratory problems). Analysis was on an intention-to-treat basis. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN19364765. FINDINGS: Nutritional cure was similar in both Synbiotic and control groups (53.9% [215 of 399] and 51.3% [203 of 396]; p=0.40). Secondary outcomes were also similar between groups. HIV seropositivity was associated with worse outcomes overall, but did not modify or confound the negative results. Subgroup analyses showed possible trends towards reduced outpatient mortality in the Synbiotic group (p=0.06). INTERPRETATION: In Malawi, Synbiotic2000 Forte did not improve severe acute malnutrition outcomes. The observation of reduced outpatient mortality might be caused by bias, confounding, or chance, but is biologically plausible, has potential for public health impact, and should be explored in future studies. FUNDING: Department for International Development (DfID).

Child nutrition in countries of the Commonwealth of Independent States: time to redirect strategies?

BACKGROUND: Countries in the Commonwealth of Independent States made little progress in child nutrition and mortality between 1990 and 2005. The present paper assesses the nutritional status of children <5 years of age and discusses possible strategies for improvement. METHODS: Data on low birth weight, infant and young child feeding, underweight, overweight and micronutrient deficiencies were compiled from available reports and databases, complemented through questionnaires to UNICEF Country Offices, and analysed by country, age, gender, urban/rural residence, maternal education and wealth quintiles. RESULTS: Exclusive breast-feeding in the first 6 months and continuing breast-feeding up to 2 years fall short of WHO and UNICEF recommendations. Complementary foods are introduced too early and may be poor in protein and micronutrients. Stunting and underweight are prevalent, especially in children aged 12 to 35 months; overweight is even more prevalent. Vitamin A and I deficiencies are still present in some countries, despite current control efforts. Anaemia ranges between 20 % and 40 %. Higher rates of malnutrition are found in rural areas, children of less educated mothers and lower-income families. DISCUSSION: Current public health strategies should be redirected to address: (i) overall protection, promotion and support of infant and young child feeding, in addition to breast-feeding; (ii) overweight, in addition to underweight and stunting; and (iii) malnutrition as a whole, in addition to micronutrient deficiencies. An equity lens should be used in developing policies and plans and implementing and monitoring programmes. Capacity building, cross-sectoral action, improved data collection within adequate legal frameworks and community engagement should be the pillars of redirected strategies.

Acute lower respiratory infections in childhood: opportunities for reducing the global burden through nutritional interventions.

Inadequate nutrition and acute lower respiratory infection (ALRI) are overlapping and interrelated health problems affecting children in developing countries. Based on a critical review of randomized trials of the effect of nutritional interventions on ALRI morbidity and mortality, we concluded that: (1) zinc supplementation in zinc-deficient populations prevents about one-quarter of episodes of ALRI, which may translate into a modest reduction in ALRI mortality; (2) breastfeeding promotion reduces ALRI morbidity; (3) iron supplementation alone does not reduce ALRI incidence; and (4) vitamin A supplementation beyond the neonatal period does not reduce ALRI incidence or mortality. There was insufficient evidence regarding other potentially beneficial nutritional interventions. For strategies with a strong theoretical rationale and probable operational feasibility, rigorous trials with active clinical case-finding and adequate sample sizes should be undertaken. At present, a reduction in the burden of ALRI can be expected from the continued promotion of breastfeeding and scale-up of zinc supplementation or fortification strategies in target populations.