A New Murine Undernutrition Model Based on Complementary Feeding of Undernourished Children Causes Damage to the Morphofunctional Intestinal Epithelium Barrier.

BACKGROUND: Complementary feeding is critical in establishing undernutrition. However, experimental undernourished diets do not represent the amount of nutrients in the complementary diets of undernourished children. OBJECTIVES: To develop, validate, and evaluate the impact of a new murine model of undernutrition on the intestinal epithelium, based on the complementary diet of undernourished children from 7 countries with low-socioeconomic power belonging to the Malnutrition-Enteric Diseases (MAL-ED) cohort study. METHODS: We used the difference in the percentage of energy, macronutrients, fiber and zinc in the complementary diet of children without undernutrition compared with stunting (height-for-age Z-score < -2) for the MAL-ED diet formulation. Subsequently, C57BL/6 mice were fed a control diet (AIN-93M diet) or MAL-ED diet for 28 d. Weight was measured daily; body composition was measured every 7 d; lactulose:mannitol ratio (LM) and morphometry were evaluated on days 7 and 28; the cotransport test and analysis of intestinal transporters and tight junctions were performed on day 7. RESULTS: The MAL-ED diet presented -8.03% energy, -37.46% protein, -24.20% lipid, -10.83% zinc, +5.93% carbohydrate, and +45.17% fiber compared with the control diet. This diet rapidly reduced weight gain and compromised body growth and energy reserves during the chronic period (P < 0.05). In the intestinal epithelial barrier, this diet caused an increase in the LM (P < 0.001) and reduced (P < 0.001) the villous area associated with an increase in FAT/CD36 in the acute period and increased (P < 0.001) mannitol excretion in the chronic period. CONCLUSIONS: The MAL-ED diet induced undernutrition in mice, resulting in acute damage to the integrity of the intestinal epithelial barrier and a subsequent increase in the intestinal area during the chronic period. This study introduces the first murine model of undernutrition for the complementary feeding phase, based on data from undernourished children in 7 different countries.

How Can Nutrition Research Better Reflect the Relationship Between Wasting and Stunting in Children? Learnings from the Wasting and Stunting Project.

Childhood wasting and stunting affect large numbers of children globally. Both are important risk factors for illness and death yet, despite the fact that these conditions can share common risk factors and are often seen in the same child, they are commonly portrayed as relatively distinct manifestations of undernutrition. In 2014, the Wasting and Stunting project was launched by the Emergency Nutrition Network. Its aim was to better understand the complex relationship and associations between wasting and stunting and examine whether current separations that were apparent in approaches to policy, financing, and programs were justified or useful. Based on the project's work, this article aims to bring a wasting and stunting lens to how research is designed and financed in order for the nutrition community to better understand, prevent, and treat child undernutrition. Discussion of lessons learnt focuses on the synergy and temporal relationships between children's weight loss and linear growth faltering, the proximal and distal factors that drive diverse forms of undernutrition, and identifying and targeting people most at risk. Supporting progress in all these areas requires research collaborations across interest groups that highlight the value of research that moves beyond a focus on single forms of undernutrition, and ensures that there is equal attention given to wasting as to other forms of malnutrition, wherever it is present.

Association between water, sanitation and hygiene (WASH) and child undernutrition in Ethiopia: a hierarchical approach.

BACKGROUND: Undernutrition is a significant public health challenge and one of the leading causes of child mortality in a wide range of developing countries, including Ethiopia. Poor access to water, sanitation, and hygiene (WASH) facilities commonly contributes to child growth failure. There is a paucity of information on the interrelationship between WASH and child undernutrition (stunting and wasting). This study aimed to assess the association between WASH and undernutrition among under-five-year-old children in Ethiopia. METHODS: A secondary data analysis was undertaken based on the Ethiopian Demographic and Health Surveys (EDHS) conducted from 2000 to 2016. A total of 33,763 recent live births extracted from the EDHS reports were included in the current analysis. Multilevel logistic regression models were used to investigate the association between WASH and child undernutrition. Relevant factors from EDHS data were identified after extensive literature review. RESULTS: The overall prevalences of stunting and wasting were 47.29% [95% CI: (46.75, 47.82%)] and 10.98% [95% CI: (10.65, 11.32%)], respectively. Children from households having unimproved toilet facilities [AOR: 1.20, 95% CI: (1.05,1.39)], practicing open defecation [AOR: 1.29, 95% CI: (1.11,1.51)], and living in households with dirt floors [AOR: 1.32, 95% CI: (1.12,1.57)] were associated with higher odds of being stunted. Children from households having unimproved drinking water sources were significantly less likely to be wasted [AOR: 0.85, 95% CI: (0.76,0.95)] and stunted [AOR: 0.91, 95% CI: (0.83, 0.99)]. We found no statistical differences between improved sanitation, safe disposal of a child's stool, or improved household flooring and child wasting. CONCLUSION: The present study confirms that the quality of access to sanitation and housing conditions affects child linear growth indicators. Besides, household sources of drinking water did not predict the occurrence of either wasting or stunting. Further longitudinal and interventional studies are needed to determine whether individual and joint access to WASH facilities was strongly associated with child stunting and wasting.

Prevalence and predictive factors of undernutrition and low bone mineral density in children with chronic pancreatitis.

BACKGROUND: Malnutrition and bone disease are common in adults with chronic pancreatitis (CP). We studied the nutritional status and bone mineral density (BMD) of children with CP and the factors predicting them. METHODS: CP children were prospectively evaluated with a detailed questionnaire, anthropometry, 25-hydroxy vitamin D, fecal elastase and BMD [total body less head (TBLH), spine and hip] by dual energy x-ray absorptiometry. Body mass index (BMI) Z score of -1 to -1.9, -2 to -2.9 and <-3 was taken as mild, moderate and severe malnutrition respectively. Low BMD and osteoporosis were defined as per International Society for Clinical Densitometry. RESULTS: 83 children (46 boys, 14[4.3-21]years) with CP were enrolled. Majority had Cambridge IV (51,62.2%) or III (15,18.3%) changes. 34(41%) had undernutrition (mild-37.3%, moderate-2.4%, severe-1.2%). Overweight and obesity were present in 3.6% and 1.2% cases. BMI had a significant correlation with haemoglobin, serum albumin, percentage body fat and BMD. A majority had low fecal elastase (69 [84.1%], <100 µg/g) and vitamin D deficiency (70[84.3%],<20 ng/ml). 9 cases had a history of fractures. 14/75(18.6%) cases had low TBLH-BMD and this group had a lower BMI (-1.3[-1.9 to 0.34] vs 0.8 [-2.1 to 5.50; p = 0.03) than patients with normal BMD. There was no difference in age, disease duration, vitamin D, fecal elastase and Cambridge grade between normal and low BMD. CONCLUSIONS: 41% CP children have undernutrition with a majority having mild undernutrition. Nearly 20% have low BMD, with osteoporosis in none. Subjects with low BMI have lower BMD and percentage body fat.

Early management of hypokalaemia in severely malnourished children under five could help to reduce deaths in developing countries.

AIM: This study evaluated the factors associated with hypokalaemia and their outcomes, in severely malnourished children under 5 years of age. METHODS: We focused on 407 severely malnourished children under five who were admitted to the Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh, from April 2011 to June 2012. The cases were 139 with hypokalaemia, and the comparisons were 268 without hypokalaemia. RESULTS: Cases were older than the comparisons, with a poor socio-economic status and a higher death rate of 12% vs 7%. They were more likely to present with a history of measles, diarrhoea, lethargy, lower pulse rates, hyponatraemia, metabolic acidosis, hypocalcaemia, hypomagnesaemia, higher height or length, severe underweight, severe wasting and leucocytosis on admission. At discharge, cases had lower potassium levels and a higher proportion had persistent hypokalaemia. Cases received longer treatment with ampicillin and micronutrients. After adjusting for confounders, hypokalaemia was independently associated with poor socio-economic status, diarrhoea, lower pulse rates, hypocalcaemia, metabolic acidosis and leucocytosis. CONCLUSION: Identifying simple clinical signs, like diarrhoea and lower pulse rates, and laboratory parameters, such as hypocalcaemia and metabolic acidosis, may enable the early management of hypokalaemia in severely malnourished children under 5 years. This could reduce morbidity and mortality.

A 2-month intervention study of preventive clothing against mosquito bites among malnourished and well-nourished children under 5 years of age living on the Atlantic Ocean Coast of Lagos, Southwest Nigeria.

BACKGROUND: Malnutrition is appreciated as a global leading paediatric burden that indirectly or directly contributes to child mortality. In children, malnutrition has profound effects on health and development; and has been associated with poor outcomes in paediatric diseases. However, it is not clear if malnourished children are at an increased risk of having malaria. This study was conducted to evaluate the risk of malaria infection in children with malnutrition. METHODS: The study design was pre-post. A protective clothing against mosquitoes (pCAM) was given to 102 under-five children in two coastal communities, after screening for malaria parasitaemia. The children's weight, height and body temperature were measured at recruitment. Blood was also taken at recruitment and monthly for malaria parasitaemia, haemoglobin concentration and random blood sugar. The parents/care-givers were visited daily for 1 month only, after recruitment, to ensure that the children wore the pCAM daily from 5 pm and the children were followed up monthly for 2 months. RESULTS: Of the 102 study participants, 60 (24 males and 36 females) were rapid diagnostic test (RDT)-positive at recruitment, indicating 58.8% prevalence of malaria parasitaemia. The prevalence of malnutrition and of stunting were 32.3% (33/102) and 54.9% (56/102), respectively, while 7.8% (8/108) children were wasted. Twenty (60.6%) of the malnourished children and 30 (53.6%) of those stunted were RDT-positive at recruitment. At the first post-intervention screening, only 7 (31.8%) of the malnourished and 13 (28.9%) of those stunted were RDT-positive. Malnourished and stunted children were 2.57 times and 2.31 times more likely to be malaria infected (OR = 2.57, 95% CI 0.97, 6.79; OR = 2.31, 95% CI 1.01, 5.26 respectively). Malnourished females were 2.72 times more likely to be RDT-positive compared to malnourished males (OR = 2.72, 95% CI 0.54, 11.61) and stunted females were 1.73 times more likely to the positive for malaria parasites than stunted males (OR 1.73, 95% CI 0.59, 5.03). The prevalence of anaemia at recruitment decreased from 82.4 to 69.6% after intervention. The mean haemoglobin concentration (g/dl) at recruitment was significantly lower (P < 0.05) than that at 1st and 2nd post-intervention measurements (9.6 ± 1.4, t = - 3.17, P-value = 0.0009 and 10.2 ± 1.3, t = - 2.64, P-value = 0.004, respectively). Mean random blood sugar (mg/dl) of females (91.8 ± 12.7) was significantly lower (t = 2.83, P-value = 0.003) than that of males (98.5 ± 11.2). CONCLUSION: Results from this study suggest a higher risk of malaria infection among malnourished and lower risks among stunted and wasted children. Females were at a higher risk of malnutrition, stunting and wasting than males. Protective clothing against malaria seemed to reduce malaria infection and improve anaemia status.

Co-infection of malaria and HIV infection in severely undernourished children in the Democratic Republic of the Congo: a cross-sectional study.

PURPOSE: This study aims to determine the prevalence of malaria and HIV seropositivity among children with undernutrition in the Democratic Republic of the Congo. METHODS: A cross-sectional study of undernourished children aged between 12 and 60 months in Kalembe-Lembe hospital was carried out. Blood samples were collected for the analyses of malaria parasite, haemoglobin and haematocrit levels. HIV serostatus was determined with rapid HIV antibody tests and enzyme-linked immunosorbent assay. Logistic regression analyses were used to identify clinical predictors of HIV seropositivity. RESULTS: Of 225 children, 88.9% had malaria; the parasite loads were 16 000 para per µL (38.0%); 24 400 para per µL (56.8%), P < 0.001 and malaria and associated HIV infection accounted for 29.2%. In children aged >12 months, HIV seroprevalence was 29.3%; 86.0% had undernutrition and malaria, 6.8% had undernutrition and HIV and 4.3% had undernutrition, HIV and malaria (P < 0.001). The occurrence of at least three or more symptoms was highly specific (96.4-100.0%) for HIV seropositivity (P < 0.05). The overall mortality rate was 18.4%, higher in children with malaria and HIV (39.6% vs 12.2%, P < 0.001) and those with lower weight gain (4.3 vs 7.5 g kg-1 day-1, P < 0.001). CONCLUSIONS: There was high prevalence of malaria and HIV and mortality among severely undernourished children with malaria and HIV.

Whole-blood PUFA and associations with markers of nutritional and health status in acutely malnourished children in Cambodia.

OBJECTIVE: To measure fatty acid composition, particularly whole-blood PUFA content, in acutely malnourished children and identify associations with markers of nutritional and health status. DESIGN: PUFA were assessed in dried blood spots obtained from a cross-sectional study. Nutritional and health status were assessed by anthropometry, haemoglobinopathies, inflammation and blood counts. SETTING: Cambodia. PARTICIPANTS: The study was conducted with 174 children aged 0·5-18 years with acute malnutrition. RESULTS: Among total fatty acids (FA), the relative percentage of total PUFA was 20 % FA, with 14 % of the children having very low PUFA (mead acid (MA):arachidonic acid (AA) >0·02, n-6 docosapentaenoic acid:DHA >0·2 and total n-6:n-3 PUFA >10·5). Wasting was not associated with any PUFA. Stunting and low height were consistently positively associated with total PUFA and positively with n-6 PUFA. Height was positively associated with n-3 long-chain PUFA (LCPUFA). The presence of haemoglobinopathies or inflammation was positively associated with MA:AA, but not total PUFA. Elevated blood platelet counts were positively correlated with linoleic acid and appeared to be influenced by anaemia (P = 0·010) and inflammation (P = 0·002). Monocyte counts were high during inflammation (P = 0·052) and correlated positively with n-6 LCPUFA and n-3 LCPUFA. CONCLUSIONS: Children with acute malnutrition or stunting had low PUFA, while elevated platelets and monocytes were associated with high PUFA. In acutely malnourished children, inflammation could lead to elevated blood cell counts resulting in increased whole-blood PUFA which does not reflect dietary intake or nutritional status.

Randomised trial showed that rapid rehydration of severely malnourished children with dehydrating diarrhoea was as safe and effective as slow rehydration.

AIM: This study evaluated the effectiveness and safety of rapid and slow rehydration in children aged 6-60 months with dehydrating diarrhoea and severe malnutrition. METHODS: A randomised controlled trial was conducted from July 2011 to March 2014 at the International Centre for Diarrhoeal Disease Research Bangladesh. We included children with weight for age and, or, weight for length Z-scores of less than -3 or with bipedal oedema and acute diarrhoea with severe dehydration. The children received intravenous fluid at different rates: 105 rapidly over six hours and 103 slowly over the 12 hours recommended by the World Health Organization. RESULTS: All the children were successfully rehydrated. The admittance weights were similar for the slow and rapid groups: 8.4 kg and 8.3 kg. After 24 hours, the mean percentage weight gain was 8.5% and 9.0%, respectively. This confirmed that most of the children had been suffering from severe dehydration on admission. The respective proportions of children who received unscheduled intravenous fluid were 18% and 17%. None developed fluid overload or heart failure and most recovered normal renal function after rehydration. CONCLUSION: Rapid rehydration saved time, was as safe as slow rehydration and was a better option for dehydrating diarrhoea and severe malnutrition.

Contextual Factors and Spatial Patterns of Childhood Malnutrition in Provinces of Burkina Faso.

BACKGROUND: Approximately 45% of all children's deaths are associated with malnutrition, and sub-Saharan Africa is hardest hit by this phenomenon. However, information on geographical variations of malnutrition in developing countries is limited. This study examined the geographical distribution and community characteristics associated with child malnutrition in Burkina Faso. DESIGN: Data from the 2011 Burkina Faso Demographic Health Survey were analyzed. A general Kriging interpolation method was used to generate spatial malnutrition patterns. The global Moran's I test was used to identify significant malnutrition spatial patterns. Generalized estimating equations (GEEs) were fitted to examine the association between community level factors and malnutrition. RESULTS: Average rates of stunting and wasting in the communities were 32.48% and 15.05%, respectively. Stunting hotspots were observed in the eastern and northeastern parts of Burkina Faso (i.e. Oudolan, Séno and Yagha, among others), while high rates of wasting were observed in the north-central part. The GEE results revealed lower stunting rates in communities with a higher percentage of households with improved sanitation. Communities with higher rates of professionally assisted births were associated with low wasting rates, while communities with higher rates of households with a low wealth index reported higher rates of wasting. CONCLUSIONS: Spatial statistical models of malnutrition prevalence are useful for indicating hotspots over wide areas and hence, for guiding intervention strategies. This study revealed significant geographical patterns and community factors associated with childhood malnutrition. These factors should be considered in future programs aimed at reducing malnutrition in Burkina Faso.

Anthropometric measurements to identify undernutrition in children with cerebral palsy.

AIM: To evaluate the diagnostic performance of anthropometric indicators to identify undernutrition in children with cerebral palsy (CP). METHOD: The present study was a monocentric retrospective analysis of prospectively collected data among children and adolescents with CP participating in a rehabilitation program. Undernutrition was defined as a z-score for dual-energy X-ray absorptiometry (DXA) determined body fat percentage less or equal to -2.0. The cut-off values for body mass index (BMI) of the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC), and the cut-off values for BMI and height for age of the Robert Koch Institut (RKI) were evaluated. RESULTS: In total, 329 children with CP (181 males, 148 females, Gross Motor Function Classification System levels I-V) were eligible for analysis. The mean age was 12 years 4 months (SD 2y 9mo). The BMI cut-off values showed the following sensitivities and specificities: WHO, sensitivity of 0.474 (95% confidence interval [CI] 0.244-0.711), specificity of 0.897 (95% CI: 0.857-0.928); CDC, sensitivity of 0.632 (95% CI: 0.384-0.837), specificity of 0.819 (95% CI: 0.772-0.861); RKI, sensitivity of 0.789 (95% CI: 0.544-0.939), specificity of 0.732 (95% CI: 0.679-0.781); and for height for age, sensitivity of 0.263 (95% CI: 0.091-0.512), specificity of 0.668 (95% CI: 0.612-0.720). INTERPRETATION: BMI had a high specificity but very low sensitivity in identifying undernutrition in children with CP. Z-scores for height for age had even lower specificity and sensitivity and seemed not to be appropriate for predicting undernutrition in children with CP. WHAT THIS PAPER ADDS: Body mass index (BMI) z-scores had a high specificity but very low sensitivity in identifying undernutrition in children with cerebral palsy (CP). Height z-scores were not appropriate for predicting undernutrition in children with CP. Undernutrition assessed by BMI was overestimated in children with CP versus when assessed by dual-energy X-ray absorptiometry (DXA).

MEDICIONES ANTROPOMÉTRICAS PARA IDENTIFICAR DESNUTRICIÓN EN NIÑOS CON PARÁLISIS CEREBRAL: OBJETIVO: Evaluar el rendimiento diagnóstico de los indicadores antropométricos para identificar la desnutrición en niños con parálisis cerebral (PC). MÉTODO: El presente estudio realizado en un solo centro de atención, fue un análisis retrospectivo de datos recopilados prospectivamente entre niños y adolescentes con PC que participan en un programa de rehabilitación. La desnutrición se definió como una puntuación z para la absorciometría de rayos X de energía dual (DXA), y porcentaje de grasa corporal determinado menor o igual a -2,0. Fueron evaluados los valores de corte para el índice de masa corporal (IMC) de la Organización Mundial de la Salud (OMS) y los Centros para el Control y la Prevención de Enfermedades (CDC), y los valores de corte para el IMC y la altura para la edad del Robert Koch Institut (RKI). RESULTADOS: En total, 329 niños con PC (181 varones, 148 mujeres, con niveles I - V del Sistema de clasificación de la función motora gruesa) fueron elegibles para el análisis. La edad media fue de 12 años 4 meses (DS 2a 9m). Los valores de corte del IMC mostraron las siguientes sensibilidades y especificidades: OMS, sensibilidad de 0,474 (intervalo de confianza del 95% [IC] 0,244-0,711), especificidad de 0,897 (IC del 95%: 0,857-0,928); CDC, sensibilidad de 0,632 (IC del 95%: 0,384 a 0,837), especificidad de 0,819 (IC del 95%: 0,772 a 0,861); RKI, sensibilidad de 0,789 (IC 95% 0,544-0,939), especificidad de 0,732 (IC 95% 0,679-0,781); y para la altura para la edad, la sensibilidad de 0,263 (IC del 95%: 0,091 a 0,512), la especificidad de 0,668 (IC del 95%: 0,612 a 0,720). INTERPRETACIÓN: El IMC tenía una alta especificidad, pero una sensibilidad muy baja para identificar la desnutrición en niños con PC. Las puntuaciones Z para la altura para la edad tenían una especificidad y sensibilidad aún más bajas y no parecían ser adecuadas para predecir la desnutrición en niños con PC.

MEDIDAS ANTROPOMÉTRICAS PARA IDENTIFICAR SUBNUTRIÇÃO EM CRIANÇAS COM PARALISIA CEREBRAL: OBJETIVO: Avaliar o desempenho diagnóstico de indicadores antropométricos para avaliar subnutrição em crianças com paralisia cerebral (PC). MÉTODO: O presente estudo foi uma análise monocêntrica retrospectiva de dados coletados prospectivamente entre crianças e adolescentes com PC que participavam de um programa de reabilitação. A subnutrição foi definida como um escore z para porcentagem de gordura corporal determinada por absorciometria de dupla energia de raio-X (DXA) menor ou igual a -2.0. Os valores de corte para o índice de massa corporal IMC) da Organização Mundial de Saúde (OMS) e dos Centros para Controle e Prevenção de Doenças (CCPD), e os valores de corte para IMC e altura por idade do Robert Koch Institut (RKI) foram avaliados. RESULTADOS: No total, 329 crianças com PC (181 do sexo masculino, 148 do sexo feminino, níveis do Sistema de Classificação da Função Motora Grossa I-V) foram elegíveis para análise. A média de idade foi 12 anos e 4 meses (DP 2a 9m). Os valores de corte do IMC mostraram as seguintes sensibilidades e especificidades: OMS, sensibilidade de 0,474 (intervalo de confiança [IC] a 95% 0,244-0,711), especificidade de 0,897 (IC 95% 0,857-0,928); CCPD, sensibilidade de 0,632 (IC 95% 0,384-0,837), especifididade de 0,819 (IC 95% 0,772-0,861); RKI, sensibilidade de 0,789 (IC 95% 0,544-0,939), especificidade de 0,732 (IC 95% 0,679-0,781); e de altura por idade, sensibilidade de 0,263 (IC 95% 0,091-0,512), especificidade de 0,668 (IC 95% 0,612-0,720). INTERPRETAÇÃO: O IMC teve alta especificidade mas sensibilidade muito baixa para identificar subnutrição em crianças com PC. Os escores z para altura por idade tiveram especificidade ainda menor e não pareceram apropriados para predizer subnutrição em crianças com PC.

Development and validation of a screening tool for feeding/swallowing difficulties and undernutrition in children with cerebral palsy.

AIM: To develop and validate a screening tool for feeding/swallowing difficulties and/or undernutrition in children with cerebral palsy (CP). METHOD: This cross-sectional, observational study included 89 children with CP (63 males, 26 females; median age 6y 0mo; interquartile range 4y 0mo-8y 11mo), across all Gross Motor Function Classification System levels. Children with feeding tubes were excluded. Children were classified as well-nourished or moderately to severely undernourished, using the paediatric Subjective Global Nutrition Assessment. Eating and drinking abilities were classified using the Eating and Drinking Ability Classification System (EDACS) from mealtime observation and videofluoroscopic swallow studies when indicated. Parents/caregivers answered 33 screening questions regarding their child's feeding/swallowing abilities and nutritional status. The diagnostic ability of each question for identifying children with feeding/swallowing difficulties and undernutrition was calculated and the combination of questions with the highest sensitivity and specificity identified. RESULTS: Feeding difficulties impacted on swallow safety in 26 children (29%) and 26 children (29%) were moderately or severely undernourished. The 4-item final tool had high sensitivity and specificity for identifying children with feeding/swallowing difficulties (81% and 79% respectively) and undernutrition (72% and 75% respectively). The tool successfully identified 100 per cent of children with severe undernutrition and 100 per cent of those classified as EDACS level IV or V. INTERPRETATION: Screening for feeding/swallowing difficulties and undernutrition will enable early identification, assessment, and management for those children in need. WHAT THIS PAPER ADDS: A screening tool with high sensitivities and specificities for identifying children with feeding/swallowing difficulties and undernutrition. The tool identified 100 per cent of children with severe undernutrition. The tool identified 100 per cent of children in Eating and Drinking Ability Classification System levels IV or V.

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

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

The prevalence and risk of urinary tract infection in malnourished children: a systematic review and meta-analysis.

BACKGROUND: There are vast differences in prevalence rates of urinary tract infection (UTI) reported among malnourished children globally. We conducted a systematic review and meta-analysis to provide estimates of pooled prevalence of UTI among these children and combined UTI risk in comparison with their well-nourished counterparts. METHODS: We systematically searched electronic databases (MEDLINE, EMBASE, ISI Web of Science and African Journals Online; date of the last search: 22 December 2018) for studies reporting either the prevalence of UTI in malnourished children or parallel healthy controls. Eligible primary studies were observational studies of children in English Language reporting UTI prevalence with background malnutrition or with enough data to compute these estimates, as well as studies which reported at the same time UTI prevalence in healthy controls. We synthesized published prevalence rates or associations (odds ratios [OR]) between malnutrition and UTI and their 95% confidence intervals (CI) using random effects meta-regression and explored potential heterogeneity determinants using meta-regression analysis. This review is registered with PROSPERO, number- CRD42018084765. RESULTS: We included 26 cross-sectional and 8 case-control studies reporting on UTI prevalence in malnourished children, and in malnourished children vs. healthy controls, respectively. The pooled prevalence of UTI in 3294 malnourished children was 17% (95% CI, 13, 21%). Heterogeneity was high (I2 = 87.6%; Tau2 = 0.06) as studies varied in their sample size, degree of malnutrition, and study period. Multivariate meta-regression model, including these factors, explained 34.6% of the between-study variance. Pooled OR of UTI in association with malnutrition in 2051 children (1052 malnourished children vs. 999 controls) was 2.34 (95% CI, 1.15, 3.34), with lower between-study heterogeneity (I2 = 53.6%; Tau2 = 0.47). CONCLUSIONS: UTI is more prevalent in malnourished children than in their well-nourished counterparts. Screening and treatment for UTI should be incorporated in the management protocol of malnourished children to improve disease outcomes.

Undernourished children presenting to an urban emergency department of a tertiary hospital in Tanzania: a prospective descriptive study.

BACKGROUND: Childhood undernutrition causes significant morbidity and mortality in low- and middle-income countries (LMICs). In Tanzania, the in-hospital prevalence of undernutrition in children under five years of age is approximated to be 30% with a case fatality rate of 8.8%. In Tanzania, the burden of undernourished children under five years of age presenting to emergency departments (EDs) and their outcomes are unknown. This study describes the clinical profiles and outcomes of this population presenting to the emergency department of Muhimbili National Hospital (ED-MNH), a large, urban hospital in Dar es Salaam, Tanzania. METHODS: This was a prospective descriptive study of children aged 1-59 months presenting to the ED-MNH over eight weeks in July and August 2016. Enrolment occurred through consecutive sampling. Children less than minus one standard deviation below World Health Organization mean values for Weight for Height/Length, Height for Age, or Weight for Age were recruited. Structured questionnaires were used to document primary outcomes of patient demographics and clinical presentations, and secondary outcomes of 24-h and 30-day mortality. Data was summarised using descriptive statistics and relative risks (RR). RESULTS: A total of 449 children were screened, of whom 34.1% (n = 153) met criteria for undernutrition and 95.4% (n = 146) of those children were enrolled. The majority of these children, 56.2% (n = 82), were male and the median age was 19 months (IQR 10-31 months). They presented most frequently with fever 24.7% (n = 36) and cough 24.0% (n = 35). Only 6.7% (n = 9) were diagnosed with acute undernutrition by ED-MNH physicians. Mortality at 24 h and 30 days were 2.9% (n = 4) and 12.3% (n = 18) respectively. A decreased level of consciousness with Glasgow Coma Scale below fifteen on arrival to the ED and tachycardia from initial vital signs were found to be associated with a statistically significant increased risk of death in undernourished children, with mortality rates of 16.1% (n = 23), and 24.6% (n = 35), respectively. CONCLUSIONS: In an urban ED of a tertiary referral hospital in Tanzania, undernutrition remains under-recognized and is associated with a high rate of in-hospital mortality.

Malnutrition as predictor of survival from anti-retroviral treatment among children living with HIV/AIDS in Southwest Ethiopia: survival analysis.

BACKGROUND: Approximately 70% of HIV positive people live in Africa where food insecurity and under nutrition are endemic. However the impact of malnutrition on treatment outcome is not clear. This study assessed the effect of under nutrition on Anti-Retroviral Therapy treatment outcome among pediatric age group living with HIV/AIDS in Public Hospitals, Southwest Ethiopia. METHOD: A retrospective cohort study was conducted on records of 242 pediatric children in Guraghe zone Public Hospitals. Also median, mean, standard deviation and interquartile range were calculated. Life table, hazard function and survival function were plotted. Log rank test with 95% confidence interval of mean survival time was done. The nutritional status data were managed via WHO Anthros plus and BMI for age Z score was calculated. To assess effects of nutritional status on mortality, both Bivariate and multivariate cox proportional hazard regression was conducted with crude (CHR) and adjusted hazard ratio (AHR) (95% confidence interval and p value). P value of less than 0.05 was used as cut off point to declare statistical significance. RESULTS: A total of 243 records of pediatric ART records with mean age of 11.6 (± 3.8 years) were reviewed. About 178 (73.3%) have got therapeutic feeding on the course of ART treatment. Whereas significant number of children, 163 (67.1%) reported to had eating problems. A total of 13 (5.3%) children were dead with incidence density of 11.2 deaths per 1000 person years. There is significantly higher survival time among well nourished (11.1 years with 95% CI: 10.8 to 11.4) as compared to underweight children (9.76 with 95% CI: 9.19 to 10.32 years). Underweight children had almost three fold increase incidence of death (AHR = 3.01; 95% CI: 0.80-11.4). Similarly children with anemia had higher incidence of death than children without anemia (AHR = 1.55; 95% CI: 0.49-4.84). CONCLUSIONS: Low nutritional status at the start of ART evidenced by underweight and anemia were found to be predictors of survival among HIV positive children. There should be improved, sustained and focused nutritional screening, care and treatment for children on ART follow up.

Copper deficiency-induced bicytopenia caused by poor compliance in a paediatric patient with chronic malnutrition: A case report.

A 12-year-old boy who underwent gastric wedge resection was transferred to our hospital because of vomiting, growth failure, and weight loss in January, 2016. We tried to restore his general condition by maintaining additional nutritional supply through peripheral parenteral nutrition (PN). However, continuous vomiting, weight loss, and superior mesenteric artery syndrome persisted because of low treatment compliance. The findings of hyponatraemia and bicytopenia did not improve. Bone marrow biopsy was performed, and it revealed copper deficiency. PN with additional micronutrient agents, including copper, were administered. In particular, invasive diagnosis and treatment, and adequate education improved the treatment compliance of the child. His copper deficiency and bicytopenia improved, and his weight and dietary intake also increased. We confirmed that treatment compliance is important in paediatric patients with malnutrition. In chronic malnutrition, attention should also be paid to deficiency of micronutrients such as copper, which can lead to haematologic problems.

Amoebic liver abscess: Outcomes of percutaneous needle aspiration vs drain placement in paediatric population.

OBJECTIVE: To compare the effectiveness of percutaneous catheter drain placement with percutaneous needle aspiration in terms of hospital stay, time to resolution of symptoms and cost of intervention performed. Methods: The retrospective cohort study was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients with amoebic liver abscess from, January 2006 to December 2016 which was collected using non-probability purposeful sampling. Primary outcome included length of hospital stay, time to resolution of symptoms and cost of intervention. Secondary outcomes included development of complications, need for re-intervention and abscess resolution. SPSS 22 was used for data analysis. . Results: Of the 62 patients, 36(58%) underwent percutaneous needle aspiration Group A, and 26(42%) were treated with percutaneous catheter drain placement Group B. Both groups were malnourished and anaemic at presentation. Overall, 56(90.3%) patients had single abscess and 44(71%) had it in the right lobe. Mean duration of symptoms was less in Group B compared to Group A (11.2±4.5 versus 16.4±3.2 days). Mean abscess size was 6.13cm ± 9.75cm in Group A and 7.40cm ± 8.40cm in Group B. The mean length of hospital stay Group A was shorter than in Group B (p=0.047) with earlier resolution of symptoms (p=0.027). Conclusion: Both methods were found to be effective in treating amoebic liver abscess in children, but percutaneous needle aspiration was more effective.

Malaria and Nutritional Status Among Children With Severe Acute Malnutrition in Niger: A Prospective Cohort Study.

Background: The relationship between malaria infection and nutritional status is complex. Previous studies suggest malaria may increase the incidence and severity of malnutrition, while malnutrition may increase the risk of malaria infection. Here, we report bidirectional associations between malaria and nutritional status among children with uncomplicated severe acute malnutrition (SAM). Methods: This study is a secondary analysis of a randomized, controlled trial for the treatment of uncomplicated SAM in Niger. Children aged 6-59 months were enrolled and followed for 12 weeks. Malaria infection was assessed using an histidine-rich protein 2 (HRP2) rapid diagnostic test at admission and at any follow-up visit with fever. We assessed the association of nutritional status at admission on malaria incidence using Cox proportional hazards regression and malaria infection at admission on nutritional recovery and weight and height gain using linear regression. Results: Of 2399 children included in the analysis, 1327 (55.3%) were infected with malaria at admission. Malaria incidence was 12.1 cases/100 person-months among those without malaria infection at admission. Nutritional status at admission was not associated with malaria incidence. Children with malaria infection at admission and subsequently treated with an artemisinin-based combination therapy had increased weight gain (0.38 g/kg/day; 95% confidence interval [CI], 0.07 to 0.69) and reduced height gain (-0.002 mm/day; 95% CI, -0.004 to -0.0008). Conclusions: Malaria infection was common among children treated for uncomplicated SAM. Malaria infection may impair height gain. Proper medical and nutritional management should be ensured to prevent adverse effects of malaria infection. Clinical Trials Registration: NCT01613547.