Anthropometric deficits and the associated risk of death by age and sex in children aged 6-59 months: A meta-analysis.

Risk of death from undernutrition is thought to be higher in younger than in older children, but evidence is mixed. Research also demonstrates sex differences whereby boys have a higher prevalence of undernutrition than girls. This analysis described mortality risk associated with anthropometric deficits (wasting, underweight and stunting) in children 6-59 months by age and sex. We categorised children into younger (6-23 months) and older (24-59 months) age groups. Age and sex variations in near-term (within 6 months) mortality risk, associated with individual anthropometric deficits were assessed in a secondary analysis of multi-country cohort data. A random effects meta-analysis was performed. Data from seven low-or-middle-income-countries collected between 1977 and 2013 were analysed. One thousand twenty deaths were recorded for children with anthropometric deficits. Pooled meta-analysis estimates showed no differences by age in absolute mortality risk for wasting (RR 1.08, p = 0.826 for MUAC < 125 mm; RR 1.35, p = 0.272 for WHZ < -2). For underweight and stunting, absolute risk of death was higher in younger (RR 2.57, p < 0.001) compared with older children (RR 2.83, p < 0.001). For all deficits, there were no differences in mortality risk for girls compared with boys. There were no differences in the risk of mortality between younger and older wasted children, supporting continued inclusion of all children under-five in wasting treatment programmes. The risk of mortality associated with underweight and stunting was higher among younger children, suggesting that prevention programmes might be justified in focusing on younger children where resources are limited. There were no sex differences by age in mortality risk for all deficits.

Impact evaluation of different cash-based intervention modalities on child and maternal nutritional status in Sindh Province, Pakistan, at 6 mo and at 1 y: A cluster randomised controlled trial.

BACKGROUND: Cash-based interventions (CBIs), offer an interesting opportunity to prevent increases in wasting in humanitarian aid settings. However, questions remain as to the impact of CBIs on nutritional status and, therefore, how to incorporate them into emergency programmes to maximise their success in terms of improved nutritional outcomes. This study evaluated the effects of three different CBI modalities on nutritional outcomes in children under 5 y of age at 6 mo and at 1 y. METHODS AND FINDINGS: We conducted a four-arm parallel longitudinal cluster randomised controlled trial in 114 villages in Dadu District, Pakistan. The study included poor and very poor households (n = 2,496) with one or more children aged 6-48 mo (n = 3,584) at baseline. All four arms had equal access to an Action Against Hunger-supported programme. The three intervention arms were as follows: standard cash (SC), a cash transfer of 1,500 Pakistani rupees (PKR) (approximately US$14; 1 PKR = US$0.009543); double cash (DC), a cash transfer of 3,000 PKR; or a fresh food voucher (FFV) of 1,500 PKR; the cash or voucher amount was given every month over six consecutive months. The control group (CG) received no specific cash-related interventions. The median total household income for the study sample was 8,075 PKR (approximately US$77) at baseline. We hypothesized that, compared to the CG in each case, FFVs would be more effective than SC, and that DC would be more effective than SC-both at 6 mo and at 1 y-for reducing the risk of child wasting. Primary outcomes of interest were prevalence of being wasted (weight-for-height z-score [WHZ] < -2) and mean WHZ at 6 mo and at 1 y. The odds of a child being wasted were significantly lower in the DC arm after 6 mo (odds ratio [OR] = 0.52; 95% CI 0.29, 0.92; p = 0.02) compared to the CG. Mean WHZ significantly improved in both the FFV and DC arms at 6 mo (FFV: z-score = 0.16; 95% CI 0.05, 0.26; p = 0.004; DC: z-score = 0.11; 95% CI 0.00, 0.21; p = 0.05) compared to the CG. Significant differences on the primary outcome were seen only at 6 mo. All three intervention groups showed similar significantly lower odds of being stunted (height-for-age z-score [HAZ] < -2) at 6 mo (DC: OR = 0.39; 95% CI 0.24, 0.64; p < 0.001; FFV: OR = 0.41; 95% CI 0.25, 0.67; p < 0.001; SC: OR = 0.36; 95% CI 0.22, 0.59; p < 0.001) and at 1 y (DC: OR = 0.53; 95% CI 0.35, 0.82; p = 0.004; FFV: OR = 0.48; 95% CI 0.31, 0.73; p = 0.001; SC: OR = 0.54; 95% CI 0.36, 0.81; p = 0.003) compared to the CG. Significant improvements in height-for-age outcomes were also seen for severe stunting (HAZ < -3) and mean HAZ. An unintended outcome was observed in the FFV arm: a negative intervention effect on mean haemoglobin (Hb) status (-2.6 g/l; 95% CI -4.5, -0.8; p = 0.005). Limitations of this study included the inability to mask participants or data collectors to the different interventions, the potentially restrictive nature of the FFVs, not being able to measure a threshold effect for the two different cash amounts or compare the different quantities of food consumed, and data collection challenges given the difficult environment in which this study was set. CONCLUSIONS: In this setting, the amount of cash given was important. The larger cash transfer had the greatest effect on wasting, but only at 6 mo. Impacts at both 6 mo and at 1 y were seen for height-based growth variables regardless of the intervention modality, indicating a trend toward nutrition resilience. Purchasing restrictions applied to food-based voucher transfers could have unintended effects, and their use needs to be carefully planned to avoid this. TRIAL REGISTRATION: ISRCTN registry ISRCTN10761532.

The role of unconditional cash transfers during a nutritional emergency in Maradi region, Niger: a pre-post intervention observational study.

OBJECTIVE: To assess the effect of an unconditional cash transfer (CT) implemented as part of an emergency response to food insecurity during a declared state of emergency. DESIGN: Pre-post intervention observational study involving two rounds of data collection, i.e. baseline (April 2012) and final survey (September 2012), on the same cohort of 'poor' and 'very poor' households enrolled by Save the Children in an unconditional CT programme. SETTING: Aguié district, Maradi, Niger. SUBJECTS: Households with a non-acutely malnourished child aged 6-36 months (n 412). RESULTS: The study showed that the living standards of 'poor' and 'very poor' households improved, as indicated by a reduction in poverty-related indicators and an improvement in household food security. Anthropometric outcomes for children aged 6-36 months improved significantly, despite a decline in child health and women's well-being and autonomy. Risk factors for becoming acutely malnourished post-intervention were being from a very poor household at baseline, starting the lean season with low weight-for-height Z-score (WHZ <-1) and the presence of co-morbidity. CONCLUSIONS: The results of the study are consistent with the published evidence regarding the general impact of CT and suggest it is plausible that giving cash during an emergency can help safeguard living standards of the very poor and poor. While improvements in childhood nutrition status were seen it is not possible to attribute these to the CT programme. However, knowledge of the risk factors for acute malnutrition in a particular setting can be used to influence the design of future CT interventions for which a controlled trial would be recommended if feasible.

The REFANI Pakistan study--a cluster randomised controlled trial of the effectiveness and cost-effectiveness of cash-based transfer programmes on child nutrition status: study protocol.

BACKGROUND: Cash-based transfer programmes are an emerging strategy in the prevention of wasting in children, especially targeted at vulnerable households during periods of food insecurity or during emergencies. However, the evidence surrounding the use of either cash or voucher transfer programmes in the humanitarian context and on nutritional outcomes is elusive. More evidence is needed not only to inform the global community of practice on best practices in humanitarian settings, but also to help strengthen national mitigation responses. METHODS/DESIGN: The Research for Food Assistance on Nutrition Impact Pakistan study (REFANI-P) sets out to evaluate the impact of three cash-based interventions on nutritional outcomes in children aged less than five years from poor and very poor households in Dadu District. This four-arm parallel cluster randomised controlled trial is set among Action Against Hunger (ACF) programme villages in Dadu District, Sindh Province. Mothers are the target recipients of either seasonal unconditional cash transfers or fresh food vouchers. A comparison group receives 'standard care' provided by the ACF programme to which all groups have the same access. The primary outcomes are prevalence of wasting and mean weight-for-height Z-score (WHZ) in children. Impact will be assessed at 6 months and at 1 year from baseline. Using a theory-based approach we will determine 'how' the different interventions work by looking at the processes involved and the impact pathways following the theory of change developed for this context. Quantitative and qualitative data are collected on morbidity, health seeking, hygiene and nutrition behaviours, dietary diversity, haemoglobin concentration, women's empowerment, household food security and expenditures and social capital. The direct and indirect costs of each intervention borne by the implementing organisation and their partners as well as by beneficiaries and their communities are also assessed. DISCUSSION: The results of this trial will provide robust evidence to help increase knowledge about the predictability of how different modalities of cash-based transfer work best to reduce the risk of child wasting during a season where food insecurity is at its highest. Evidence on costing and cost-effectiveness will further aid decisions on choice of modality in terms of effectiveness and sustainability. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10761532 . Registered 26 March 2015.

Prevention of acute malnutrition: distribution of special nutritious foods and cash, and addressing underlying causes--what to recommend when, where, for whom, and how.

Acute malnutrition is associated with increased morbidity and mortality risk. When episodes are prolonged or frequent, acute malnutrition is also associated with poor growth and development, which contributes to stunting Nutrition-specific and nutrition-sensitive strategies to prevent undernutrition during the first 1,000 days from conception to 24 months of age can reduce the risks of wasting, stunting, and micronutrient deficiencies. Under circumstances that exacerbate the underlying causes of undernutrition and increase the incidence of wasting, such as food insecurity related to lean seasons or emergencies, or increased incidence of illness, such as diarrhea or measles, additional efforts are required to prevent and treat wasting. Special nutritious foods directly meet the increased nutrient requirements of children at risk for wasting; assistance to vulnerable households, in the form of cash or food, enables households to better meet the food, health, and other needs of household members and may increase resilience; water, sanitation, and hygiene (WASH) and health interventions help prevent and address illness and hence reduce wasting risk. The contributions of specific interventions to reducing the incidence of wasting are difficult to assess under emergency conditions, due to ethical constraints and to the fact that multiple strategies are implemented at the same time. However, pragmatic studies under real-life circumstances, using different designs, e.g., including a group receiving "best possible" treatment, can provide evidence about what works, to what extent, at what cost, and under which circumstances. Programs should address the most important causes in given contexts, be feasible to implement at scale, and assess implementation, coverage, and outcomes.

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.

An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia.

OBJECTIVE: To determine which interventions can reduce linear growth retardation (stunting) in children aged 6-36 months over a 5-year period in a food-insecure population in Ethiopia. DESIGN: We used data collected through an operations research project run by Save the Children UK: the Child Caring Practices (CCP) project. Eleven neighbouring villages were purposefully selected to receive one of four interventions: (i) health; (iii) nutrition education; (iii) water, sanitation and hygiene (WASH); or (iv) integrated comprising all interventions. A comparison group of three villages did not receive any interventions. Cross-sectional surveys were conducted at baseline (2004) and for impact evaluation (2009) using the same quantitative and qualitative tools. The primary outcome was stunted growth in children aged 6-36 months measured as height (or length)-for-age Z-scores (mean and prevalence). Secondary outcomes were knowledge of health seeking, infant and young child feeding and preventive practices. SETTING: Amhara, Ethiopia. SUBJECTS: Children aged 6-36 months. RESULTS: The WASH intervention group was the only group to show a significant increase in mean height-for-age Z-score (+0·33, P = 0·02), with a 12·1 % decrease in the prevalence of stunting, compared with the baseline group. This group also showed significant improvements in mothers' knowledge of causes of diarrhoea and hygiene practices. The other intervention groups saw non-significant impacts for childhood stunting but improvements in knowledge relating to specific intervention education messages given. CONCLUSIONS: The study suggests that an improvement in hygiene practices had a significant impact on stunting levels. However, there may be alternative explanations for this and further evidence is required.

Effects on child growth of a reduction in the general food distribution ration and provision of small-quantity lipid-based nutrient supplements in refugee camps in eastern Chad.

BACKGROUND: We used the United Nations High Commissioner for Refugees Standardised Expanded Nutrition Survey data to evaluate the effect of a change in food ration on child growth in refugee camps in eastern Chad. METHODS: We compared trends of wasting and stunting prevalence over time and the association between the coexistence of being both stunted and wasted using Pearson's χ2 test. We analysed the effect of an approximate 50% reduction in the general food distribution, with the introduction of a 20 g daily ration of small quantity lipid-based nutrient supplements given to all children aged 6-23 months, on child growth. This was done using interrupted time-series analysis to observe differences in levels and trends in mean height-for-age z-score (HAZ) and weight-for-height z-score (WHZ) over time and by age group (6-24 months and 24-59 months). RESULTS: Overall the prevalence of stunting and wasting decreased significantly over time. The odds of being both stunted and wasted was 1.38 higher than having one or the other condition separately (p<0.001, 95% CI=1.29 to 1.47). Trends in mean HAZ and WHZ before and after a ration change in 2014 indicate that growth had either slowed down or worsened. In the period following the ration change, children 24-59 months saw a significant decrease in mean HAZ of 0.04 per year (p=0.02, 95% CI=-0.07 to -0.01) and for the younger age group, there was a significant decrease in mean WHZ of 0.06 per year (p=0.03, 95% CI=-0.12 to -0.01). CONCLUSIONS: The dual burden of stunting and wasting is a considerable challenge in refugee camp settings. Changes to the food distribution had adverse effects on child growth for both age groups. Broadening the scope of interventions aimed at children in camps is essential when tackling malnutrition with increased efforts essential during periods of wider food assistance shortages.

Prevention of child wasting: Results of a Child Health & Nutrition Research Initiative (CHNRI) prioritisation exercise.

BACKGROUND: An estimated 49.5 million children under five years of age are wasted. There is a lack of robust studies on effective interventions to prevent wasting. The aim of this study was to identify and prioritise the main outstanding research questions in relation to wasting prevention to inform future research agendas. METHOD: A research prioritisation exercise was conducted following the Child Health and Nutrition Research Initiative method. Identified research gaps were compiled from multiple sources, categorised into themes and streamlined into forty research questions by an expert group. A survey was then widely circulated to assess research questions according to four criteria. An overall research priority score was calculated to rank questions. FINDINGS: The prioritised questions have a strong focus on interventions. The importance of the early stages of life in determining later experiences of wasting was highlighted. Other important themes included the identification of at-risk infants and young children early in the progression of wasting and the roles of existing interventions and the health system in prevention. DISCUSSION: These results indicate consensus to support more research on the pathways to wasting encompassing the in-utero environment, on the early period of infancy and on the process of wasting and its early identification. They also reinforce how little is known about impactful interventions for the prevention of wasting. CONCLUSION: This exercise provides a five-year investment case for research that could most effectively improve on-the-ground programmes to prevent child wasting and inform supportive policy change.

Perceptions of heatwave risks to health: interview-based study of older people in London and Norwich, UK.

BACKGROUND: Most projections of climate change suggest an increased frequency of heatwaves in England over coming decades; older people are at particular risk. This could result in substantial mortality and morbidity. OBJECTIVE: To determine elderly people's knowledge and perceptions of heat-related risks to health, and of protective behaviours. METHODS: Semi-structured interviews: 73 men and women, 72-94 years, living in their own homes in London and Norwich, UK. RESULTS: Few respondents considered themselves either old or at risk from the effects of heat, even though many had some form of relevant chronic illness; they did recognize that some medical conditions might increase risks in others. Most reported that they had taken appropriate steps to reduce the effects of heat. Some respondents considered it appropriate for the government to take responsibility for protecting vulnerable people, but many thought state intervention was unnecessary, intrusive and unlikely to be effective. Respondents were more positive about the value of appropriately disseminated advice and solutions by communities themselves. CONCLUSION: The Heatwave Plan should consider giving greater emphasis to a population-based information strategy, using innovative information dissemination methods to increase awareness of vulnerability to heat among the elderly and to ensure clarity about behaviour modification measures.