Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations.

Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).

Association between gut MIcrobiota, GROWth and Diet in peripubertal children from the TARGet Kids! cohort (The MiGrowD) study: protocol for studying gut microbiota at a community-based primary healthcare setting.

INTRODUCTION: The gut microbiota interacts with diet to affect body health throughout the life cycle. Critical periods of growth, such as infancy and puberty, are characterised by microbiota remodelling and changes in dietary habits. While the relationship between gut microbiota and growth in early life has been studied, our understanding of this relationship during puberty remains limited. Here, we describe the MIcrobiota, GROWth and Diet in peripubertal children (The MiGrowD) study, which aims to assess the tripartite growth-gut microbiota-diet relationship at puberty. METHODS AND ANALYSIS: The MiGrowD study will be a cross-sectional, community-based study involving children 8-12 years participating in the TARGet Kids! COHORT: TARGet Kids! is a primary healthcare practice-based research network in Canada. Children will be asked to provide a stool sample, complete two non-consecutive 24-hour dietary recalls and a pubertal self-assessment based on Tanner Stages. Anthropometry will also be conducted. The primary outcome is the association between gut microbiota composition and longitudinal growth from birth until entry into the study. Anthropometrics data from birth will be from the data collected prospectively through TARGet Kids!. Body mass index z-scores will be calculated according to WHO. The secondary outcome is the association between gut microbiota, diet and pubertal stage. ETHICS AND DISSEMINATION: Ethics approval has been obtained by the Hospital for Sick Children and St. Michael's Hospital-Unity Health, and the University of Toronto. Results will be disseminated in the public and academic sector, including participants, TARGet Kids! primary healthcare physicians teams, scientists via participation in the TARGet Kids! science and physician meetings, conferences and publications in peer-reviewed journals. The MiGrowD study results will help researchers understand the relationships underlying growth, gut microbiota and pubertal maturation in children.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework.

BACKGROUND: Although guidelines long have recommended objective pulmonary function testing to diagnose asthma and COPD, many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side effects and delays actual diagnosis. RESEARCH QUESTION: What are the barriers and enablers to lung function testing for asthma, COPD, or both in primary care? STUDY DESIGN AND METHODS: We searched the literature for qualitative and quantitative studies reporting barriers, enablers, or both to in-office or out-of-office lung function testing for diagnosing asthma, COPD, or both in primary care. Two reviewers independently screened abstracts and full texts, assessed methodologic quality using the Mixed Methods Appraisal Tool, and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual. RESULTS: We identified 7,988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, three were qualitative, and three used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in-office and out-of-office settings. We identified more reported barriers (eg, lack of knowledge of the usefulness of spirometry) than enablers (eg, skills for performing reliable spirometry). Barriers mapped to nine (of a possible 14) TDF domains (for both in-office and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing. INTERPRETATION: Barriers to objective testing for airway disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behavior change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD now should be developed and tested.

Ready-to-Use Therapeutic Food (RUTF) Containing Low or No Dairy Compared to Standard RUTF for Children with Severe Acute Malnutrition: A Systematic Review and Meta-Analysis.

Ready-to-use therapeutic food (RUTF) containing less dairy may be a lower-cost treatment option for severe acute malnutrition (SAM). The objective was to understand the effectiveness of RUTF containing alternative sources of protein (nondairy), or <50% of protein from dairy products, compared with standard RUTF in children with SAM. The Cochrane Library, MEDLINE, Embase, CINAHL, and Web of Science were searched using terms relating to RUTF. Studies were eligible if they included children with SAM and evaluated RUTF with <50% of protein from dairy products compared with standard RUTF. Meta-analysis and meta-regression were completed to assess the effectiveness of intervention RUTF on a range of child outcomes. The quality of the evidence across outcomes was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A total of 5868 studies were identified, of which 8 articles of 6 studies met the inclusion criteria evaluating 7 different intervention RUTF recipes. Nondairy or lower-dairy RUTF showed less weight gain (standardized mean difference: -0.20; 95% CI: -0.26, -0.15; P < 0.001), lower recovery (relative risk ratio: 0.93; 95% CI: 0.87, 1.00; P = 0.046), and lower weight-for-age z scores (WAZ) near program discharge (mean difference: -0.10; 95% CI: -0.20, 0.0; P = 0.047). Mortality, time to recovery, default (consecutive absences from outpatient therapeutic feeding program visits), nonresponse, and other anthropometric measures did not differ between groups. The certainty of evidence was high for weight gain and ranged from very low to moderate for other outcomes. RUTF with lower protein from dairy or dairy-free RUTF may not be as effective as standard RUTF for treatment of children with SAM based on weight gain, recovery, and WAZ evaluated using meta-analysis, although further research is required to explore the potential of alternative formulations. This review was registered at https://www.crd.york.ac.uk/prospero/ as CRD42020160762.