Children with disabilities lack access to nutrition, health and WASH services: A secondary data analysis.

Malnutrition and disability are major global public health problems. Poor diets, inadequate access to nutrition/health services (NaHS), and poor water, sanitation and hygiene (WASH) all increase the risk of malnutrition and infection. This leads to poor health outcomes, including disability. To better understand the relationship between these factors, we explored access to NaHS and household WASH and dietary adequacy among households with and without children with disabilities in Uganda. We used cross-sectional secondary data from 2021. Adjusted logistic regression was used to explore associations between disabilities, access to NaHS, WASH and dietary adequacy. Of the 6924 households, 4019 (57.9%) reported having access to necessary NaHS, with deworming and vaccination reported as both the most important and most difficult to access services. Access to services was lower for households with children with disabilities compared to those without, after adjusting for likely confounding factors (Odds ratio = 0.70; 95% CI 0.55-0.89, p = 0.003). There is evidence of an interaction between disability and WASH adequacy, with improved WASH adequacy associated with improved access to services, including for children with disabilities (interaction odds ratio = 1.12, 95% CI: 1.02-1.22, p = 0.012). The proportion of malnourished children was higher among households with children with disabilities than households without it (6.3% vs. 2.4% p < 0.001). There are concerning gaps in access to NaHS services in Uganda, with households with children with disabilities reporting worse access, particularly for those with low WASH adequacy. Improved and inclusive access to NaHS and WASH needs to be urgently prioritized, especially for children with disabilities.

The double burden of malnutrition in individuals: Identifying key challenges and re-thinking research focus.

The 'double burden of malnutrition' is a global health challenge that increasingly affects populations in both low- and middle-income countries (LMICs). This phenomenon refers to the coexistence of undernutrition and overweight or obesity, as well as other diet-related non-communicable diseases, in the same population, household or even individual. While noteworthy progress has been made in reducing undernutrition in some parts of the world, in many of these areas, the prevalence of overweight and obesity is increasing, particularly in urban areas, resulting in greater numbers of people who were undernourished in childhood and have overweight or obesity in adulthood. This creates a complex and challenging situation for research experts and policymakers who must simultaneously address the public health burdens of undernutrition and overweight/obesity. This review identifies key challenges and limitations in the current research on the double burden of malnutrition in individuals, including the need for a more comprehensive and nuanced understanding of the drivers of malnutrition, the importance of context-specific interventions and the need for greater attention to the food environment and food systems. We advocate for the re-evaluation of research strategies and focus, with a greater emphasis on multidisciplinary and systems approaches and greater attention to the synergistic relationship between the biological, environmental, commercial and socio-economic determinants of malnutrition. Addressing these key challenges can enable us to better comprehend and tackle the multifaceted and dynamic issues of the double burden of malnutrition, particularly in individuals and work towards more effective and sustainable solutions.

Mortality risk in infants receiving therapeutic care for malnutrition: A secondary analysis.

Small and nutritionally at-risk infants aged under 6 months (<6 months) are at high risk of death, but important evidence gaps exist on how to best identify them. We aimed to determine associations between anthropometric deficits and mortality among infants <6 months admitted to inpatient therapeutic care. A secondary analysis of 2002-2008 data included 5034 infants aged <6 months from 12 countries. We estimated the prevalence, concurrence, and severity of wasted, stunted, and underweight, as stand-alone indicators, and using the Composite Index of Anthropometric Failure (CIAF), which combines these indicators into six subgroups of single and multiple anthropometric deficits and into one combined indicator called CIAF. We used logistic regression to examine the association of different anthropometric deficits with in-programme mortality. Among 3692 infants aged <6 months with complete data, 3539 (95.8%) were underweight, 3058 (82.8%) were wasted, 2875 (77.8%) were stunted and 3575 (96.8%) had CIAF. Infants with multiple anthropometric deficits were presented with significantly lower anthropometric indices, that is, they were more severely wasted, stunted and underweight. A total of 141 infants died during inpatient therapeutic care. Among these, severely wasted (116) and severely underweight (138) infants had higher odds of mortality than normal infants (odds ratio [OR] = 2.1, 95% confidence interval [CI]: 1.2-2.7, p = 0.009, and OR = 3.3, 95% CI: 0.8-13.6, p = 0.09, respectively). Boys had higher odds of inpatient mortality than girls (OR = 1.40, 95% CI: 1.02-1.92, p = 0.03). Mortality was only observed in infants <6 months presenting multiple anthropometric deficits, although their odds of mortality were not significant, for example, OR = 2.4, 95% CI: 0.5-10.0, p = 0.21 for stunted, wasted and underweight infants <6 months. In conclusion, multiple anthropometric deficits (CIAF) is common among infants <6 months and may be reported in nutrition care programmes and surveys. Both weight-for-length/height z-score and weight-for-age z-score were found to be useful indicators for programme admission and in-programme prognosis. Future work needs to explore which better accounts for admission bias. Boys appear to be most at-risk of dying while receiving malnutrition therapeutic care. Programmes should ensure that all infants receive timely, evidence-based, effective care.

Effectiveness of Postnatal Maternal or Caregiver Interventions on Outcomes among Infants under Six Months with Growth Faltering: A Systematic Review.

The care of infants at risk of poor growth and development is a global priority. To inform new WHO guidelines update on prevention and management of growth faltering among infants under six months, we examined the effectiveness of postnatal maternal or caregiver interventions on outcomes among infants between 0 and 6 months. We searched nine electronic databases from January 2000 to August 2021, included interventional studies, evaluated the quality of evidence for seven outcome domains (anthropometric recovery, child development, anthropometric outcomes, mortality, readmission, relapse, and non-response) and followed the GRADE approach for certainty of evidence. We identified thirteen studies with preterm and/or low birth weight infants assessing effects of breastfeeding counselling or education (n = 8), maternal nutrition supplementation (n = 2), mental health (n = 1), relaxation therapy (n = 1), and cash transfer (n = 1) interventions. The evidence from these studies had serious indirectness and high risk of bias. Evidence suggests breastfeeding counselling or education compared to standard care may increase infant weight at one month, weight at two months and length at one month; however, the evidence is very uncertain (very low quality). Maternal nutrition supplementation compared to standard care may not increase infant weight at 36 weeks postmenstrual age and may not reduce infant mortality by 36 weeks post-menstrual age (low quality). Evidence on the effectiveness of postnatal maternal or caregiver interventions on outcomes among infants under six months with growth faltering is limited and of 'low' to 'very low' quality. This emphasizes the urgent need for future research. The protocol was registered with PROSPERO (CRD42022309001).

Acceptability and Feasibility of Maternal Mental Health Assessment When Managing Small, Nutritionally At-Risk Infants Aged < 6 Months: A Key Informant Interview Study.

Maternal mental health (MMH) conditions and infant malnutrition are both major global public health concerns. Despite a well-established link between the two, many nutrition programmes do not routinely consider MMH. New World Health Organization (WHO) malnutrition guidelines do, however, emphasise MMH. To inform guideline rollout, we aimed to assess the feasibility and acceptability of MMH assessments in nutrition programmes in low-resource settings. Ten semi-structured interviews were conducted with international key informants who work on nutrition programmes or MMH research. Interview transcripts were coded using subthemes derived from the key points discussed. The benefits and risks were highlighted. These included ethical dilemmas of asking about MMH if local treatment services are suboptimal. Commonly reported challenges included governance, staff training and finance. Community and programme staff perceptions of MMH were primarily negative across the different settings. Many points were raised for improvements and innovations in practice, but fundamental developments were related to governance, care pathways, advocacy, training, funding and using existing community networks. Future implementation research is needed to understand whether assessment is safe/beneficial (as it is in other settings) to promote MMH screening. Current service providers in low-resource settings can undertake several steps, as recommended in this paper, to improve the care offered to mothers and infants.

Long-term outcomes after severe childhood malnutrition in adolescents in Malawi (LOSCM): a prospective observational cohort study.

BACKGROUND: Research on long-term outcomes of severe childhood malnutrition is scarce. Existing evidence suggests potential associations with cardiometabolic disease and impaired cognition. We aimed to assess outcomes in adolescents who were exposed to severe childhood malnutrition compared with peers not exposed to severe childhood malnutrition. METHODS: In Long-term Outcomes after Severe Childhood Malnutrition (LOCSM), we followed up adolescents who had 15 years earlier received treatment for severe childhood malnutrition at Queen Elizabeth Central Hospital in Blantyre, Malawi. Adolescents with previous severe childhood malnutrition included in LOCSM had participated in an earlier follow-up study (ChroSAM) at 7 years after treatment for severe childhood malnutrition, where they were compared to siblings and age-matched children in the community without previous severe childhood malnutrition. We measured anthropometry, body composition, strength, glucose tolerance, cognition, behaviour, and mental health during follow-up visits between Sept 9, 2021, and July 22, 2022, comparing outcomes in adolescents exposed to previous severe childhood malnutrition with unexposed siblings and adolescents from the community assessed previously (for ChroSAM) and newly recruited during current follow-up. We used a linear regression model to adjust for age, sex, disability, HIV, and socioeconomic status. This study is registered with the International Standard Randomised Controlled Trial Number Registry (ISRCTN17238083). FINDINGS: We followed up 168 previously malnourished adolescents (median age 17·1 years [IQR 16·5 to 18·0]), alongside 123 siblings (18·2 years [15·0 to 20·5]), and 89 community adolescents (17·1 years [16·3 to 18·1]). Since last measured 8 years previously, mean height-for-age Z (HAZ) scores had improved in previously malnourished adolescents (difference 0·33 [95% CI 0·20 to 0·46]) and siblings (0·32 [0·09 to 0·55]), but not in community adolescents (difference -0·01 [-0·24 to 0·23]). Previously malnourished adolescents had sustained lower HAZ scores compared with siblings (adjusted difference -0·32 [-0·58 to -0·05]) and community adolescents (-0·21 [-0·52 to 0·10]). The adjusted difference in hand-grip strength between previously malnourished adolescents and community adolescents was -2·0 kg (-4·2 to 0·3). For child behaviour checklist internalising symptom scores, the adjusted difference for previously malnourished adolescents was 2·8 (0·0 to 5·5) compared with siblings and 2·1 (-0·1 to 4·3) compared with community adolescents. No evidence of differences between previously malnourished adolescents and unexposed groups were found in any of the other variables measured. INTERPRETATION: Catch-up growth into adolescence was modest compared with the rapid improvement seen in childhood, but provides optimism for ongoing recovery of height deficits. We found little evidence of heightened non-communicable disease risk in adolescents exposed to severe childhood malnutrition, although long-term health implications need to be monitored. Further investigation of associated home and environmental factors influencing long-term outcomes is needed to tailor preventive and treatment interventions. FUNDING: The Wellcome Trust.

Weight gain during nutritional rehabilitation post-childhood malnutrition may influence the associations between adulthood desaturases activity and anthro-cardiometabolic risk factors.

BACKGROUNDS & AIMS: Childhood malnutrition is a major global health problem with long-term sequelae, including non-communicable diseases (NCDs). Mechanisms are unknown but may involve metabolic programming, resulting from "short-term" solutions to optimise survival by compromising non-priority organs. As key players in lipid metabolism, desaturases have been shown to be predictive of NCDs. We hypothesised that the association between specific desaturase activities and NCD risk determinants (including body composition, serum glucose, insulin levels, and blood pressure) are influenced by childhood post-malnutrition weight gain. METHODS: 278 Afro-Caribbean adults with well-documented clinical history of severe malnutrition in childhood were studied. Extensive metabolic analyses including body composition (DXA), fasting serum glucose and lipidomics (n = 101), and fasting serum insulin (n = 83) were performed in malnutrition survivors and matched community controls (n = 90). Established lipid ratios were used as proxies of desaturase activities: CE 16:1/CE 16:0 for stearoyl-CoA desaturase (SCD1), LysoPC 20:4/20:3 for fatty acid desaturase 1 (FADS1), and LysoPC 20:3/18:2 for FADS2. RESULTS: Compared to community controls, adult malnutrition survivors (mean ± SD) age 28.3 ± 7.8 and BMI 23.6 ± 5.2 had higher SCD1 and FADS1 activity, (B ± SE) 0.07 ± 0.02 and 0.7 ± 0.08, respectively, but lower FADS2 activities (B ± SE) -0.05 ± 0.01, adjusted for sex and age (p < 0.0005). SCD1 was positively associated with adult BMI and body fat percentage, and negatively associated with lean mass and height. Stratification based on weight gain during nutritional rehabilitation among malnutrition survivors might signal the potential associations between weight gain during that critical period, desaturase activities, and some of adult metabolic parameters, with the lowest tertiles (slowest catch-up weight gain) performing more similarly to controls. CONCLUSIONS: In adult survivors of early-life severe acute malnutrition, desaturase activity is associated with markers of NCD risk, especially adiposity. These associations seem to be strengthened by faster weight gain during nutritional rehabilitation.

Adolescent pregnancy is associated with child undernutrition: Systematic review and meta-analysis.

Adolescent pregnancy is associated with poor fetal growth and development which, in turn, increases the risk of childhood wasting and underweight. However, evidence on how young maternal age affects childhood anthropometry beyond the neonatal period is limited. This systematic review and meta-analysis examined associations between adolescent pregnancy and child wasting and underweight and explored potential underlying social and biological factors. Peer-reviewed literature published in English since 1990 was systematically searched. Eligible studies presented data on wasting and/or underweight in children (≤59 months) born to adolescent mothers (10-19, or ≤24 years where applicable) from low- and middle-income countries. Data extraction used a predefined extraction sheet. Both meta-analysis and qualitative synthesis were performed. Of 92 identified studies, 57 were included in the meta-analysis. The meta-analysis showed that children born to adolescent versus adult mothers were at a higher risk of moderate (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.00-1.26 p = 0.04) and severe underweight (OR: 1.21, 95% CI: 1.08-1.35 p < 0.01). Associated risk of wasting was not statistically significant: (OR: 1.05, 95% CI: 0.98-1.12 p = 0.17); severe wasting (OR: 1.16, 95% CI: 0.68-1.96 p = 0.59). These findings were supported by the qualitative synthesis. Evidence on the potential role of biological/social factors was limited, but suggested an intermediary role of maternal nutritional status which warrants further exploration. Particularly in contexts where adolescent pregnancy remains common, interventions to both delay adolescent pregnancy and improve adolescent nutritional status could help reduce the risk of undernutrition in children and contribute to breaking the intergenerational cycle of malnutrition.

How age and sex affect treatment outcomes for children with severe malnutrition: A multi-country secondary data analysis.

Age and sex influence the risk of childhood wasting. We aimed to determine if wasting treatment outcomes differ by age and sex in children under 5 years, enroled in therapeutic and supplementary feeding programmes. Utilising data from stage 1 of the ComPAS trial, we used logistic regression to assess the association between age, sex and wasting treatment outcomes (recovery, death, default, non-response, and transfer), modelling the likelihood of recovery versus all other outcomes. We used linear regression to calculate differences in mean length of stay (LOS) and mean daily weight gain by age and sex. Data from 6929 children from Kenya, Chad, Yemen and South Sudan was analysed. Girls in therapeutic feeding programmes were less likely to recover than boys (pooled odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.72-0.97, p = 0.018). This association was statistically significant in Chad (OR: 0.61, 95% CI: 0.39-0.95, p = 0.030) and Yemen (OR: 0.47, 95% CI: 0.27-0.81, p = 0.006), but not in Kenya and South Sudan. Multinomial analysis, however, showed no difference in recovery between sexes. There was no difference between sexes for LOS, but older children (24-59 months) had a shorter mean LOS than younger children (6-23 months). Mean daily weight gain was consistently lower in boys compared with girls. We found few differences in wasting treatment outcomes by sex and age. The results do not indicate a need to change current programme inclusion requirements or treatment protocols on the basis of sex or age, but future research in other settings should continue to investigate the aetiology of differences in recovery and implications for treatment protocols.

Faster rehabilitation weight gain during childhood is associated with risk of non-communicable disease in adult survivors of severe acute malnutrition.

Nutritional rehabilitation during severe acute malnutrition (SAM) aims to quickly restore body size and minimize poor short-term outcomes. We hypothesized that faster weight gain during treatment is associated with greater cardiometabolic risk in adult life. Anthropometry, body composition (DEXA), blood pressure, blood glucose, insulin and lipids were measured in a cohort of adults who were hospitalized as children for SAM between 1963 and 1993. Weight and height measured during hospitalization and at one year post-recovery were abstracted from hospital records. Childhood weight gain during nutritional rehabilitation and weight and height gain one year post-recovery were analysed as continuous variables, quintiles and latent classes in age, sex and minimum weight-for-age z-scores-adjusted regression models against adult measurements. Data for 278 adult SAM survivors who had childhood admission records were analysed. Of these adults, 85 also had data collected 1 year post-hospitalisation. Sixty percent of participants were male, mean (SD) age was 28.2 (7.7) years, mean (SD) BMI was 23.6 (5.2) kg/m2. Mean admission age for SAM was 10.9 months (range 0.3-36.3 months), 77% were wasted (weight-for-height z-scores<-2). Mean rehabilitation weight gain (SD) was 10.1 (3.8) g/kg/day and 61.6 (25.3) g/day. Rehabilitation weight gain > 12.9 g/kg/day was associated with higher adult BMI (difference = 0.5 kg/m2, 95% CI: 0.1-0.9, p = 0.02), waist circumference (difference = 1.4 cm, 95% CI: 0.4-2.4, p = 0.005), fat mass (difference = 1.1 kg, 95% CI: 0.2-2, p = 0.02), fat mass index (difference = 0.32kg/m2, 95% CI: -0.0001-0.6, p = 0.05), and android fat mass (difference = 0.09 kg, 95% CI: 0.01-0.2, p = 0.03). Post-recovery weight gain (g/kg/month) was associated with lean mass (difference = 1.3 kg, 95% CI: 0.3-2.4, p = 0.015) and inversely associated with android-gynoid fat ratio (difference = -0.03, 95% CI: -0.07to-0.001 p = 0.045). Rehabilitation weight gain exceeding 13g/kg/day was associated with adult adiposity in young, normal-weight adult SAM survivors. This challenges existing guidelines for treating malnutrition and warrants further studies aiming at optimising these targets.

Mapping the range of policies relevant to care of small and nutritionally at-risk infants under 6 months and their mothers in Ethiopia: a scoping review protocol.

INTRODUCTION: Evidence gaps limit management of small and/or nutritionally at-risk infants under 6 months and their mothers, who are at higher risk of death, illness, malnutrition and poor growth and development. These infants may be low birth weight, wasted, stunted and/or underweight. An integrated care model to guide their management (MAMI Care Pathway) is being tested in a randomised controlled trial in Ethiopia. Evaluating the extent to which an innovation is consistent with national policies and priorities will aid evidence uptake and plan for scale. METHODS AND ANALYSIS: This review will evaluate the extent to which the MAMI Care Pathway is consistent with national policies that relate to the care of at-risk infants under 6 months and their mothers in Ethiopia. The objectives are to describe the range and characteristics, concepts, strategic interventions, coherence and alignment of existing policies and identify opportunities and gaps. It will be conducted in accordance with the JBI methodology for scoping reviews (PRISMA-ScR). Eligible documents include infant and maternal health, nutrition, child development, food and social welfare-related policies publicly available in English and Amharic. The protocol was registered on the Open Science Framework Registry on 20 June 2022 (https://osf.io/m4jt6).Grey literature will be identified through government and agency websites, national and subnational contacts and Google Scholar, and published policies through electronic database searches (MEDLINE, EMBASE and Global and Health Information). The searches will take place between October 2023 and March 2024. A standardised data extraction tool will be used. Descriptive analysis of data will be undertaken. Data will be mapped visually and tabulated. Results will be described in narrative form. National stakeholder discussions will inform conclusions and recommendations. ETHICS AND DISSEMINATION: Ethical approval is not required as data consist solely of publicly available material. Findings will be used to evidence national and international policy and practice.

Training Packages and Patient Management Tools for Healthcare Staff Working with Small, Nutritionally At-Risk Infants Aged under 6 Months: A Mixed-Methods Study.

Skilled staff are essential for successfully managing child malnutrition, especially when dealing with small, nutritionally at-risk infants aged under 6 months. Training and patient management tools provide healthcare workers with core knowledge, skills, and support. To inform more effective future approaches and support the rollout of new WHO wasting prevention/treatment guidelines, we aimed to map and understand globally available training and patient management tools. In a mixed-methods study, we searched the literature to identify different training packages and management tools and conducted semi-structured key informant interviews with staff working in a variety of internationally organizations and settings. Data were analyzed using a phenomenological approach. We found 14 different training packages targeting different settings, including inpatient, outpatient, and humanitarian contexts. Curricula varied, especially around breastfeeding and maternal assessment, mental health, and nutritional status. Key informants (n = 9) reported gaps regarding counseling skills, time for practice, and how to effectively provide mental health counseling. Training delivery was highly dependent on resources and setting. In conclusion, future training should consider setting-specific needs, opportunities, and limitations. Emphasis on breastfeeding-support skills, mental health support, and counseling skills is needed. Enhanced practical sessions, refresher trainings, and ongoing monitoring and support are vital to ensure sustained high-quality services.

Identifying underweight in infants and children using growth charts, lookup tables and a novel "MAMI" slide chart: A cross-over diagnostic and acceptability study.

Malnutrition is a leading cause of preventable deaths in infants and children. To benefit from treatment and prevention programmes, malnourished children must first be identified. Low weight-for-age is an anthropometric indicator of malnutrition which is gaining much recent attention because it is particularly effective at identifying children at highest risk of death. However, assessing weight-for-age can be challenging. We aimed to evaluate a novel, low-cost weight-for-age slide chart and compare its performance against two traditional methods. We conducted a cross-over diagnostic study comparing a new "MAMI" slide-chart against traditional growth charts and look-up tables. Participants were health and public health professionals working or studying in the UK. Each acted as their own control, using all three methods but in random order. Under timed conditions, they evaluated hypothetical scenarios, arranged in a random sequence. Each tool's diagnostic accuracy and response rate were compared. User preferences were also recorded. Sixty-two participants took part. Diagnostic accuracy was highest for the MAMI chart: 79%(351/445) correct assessments. Accuracy using look-up tables was 70%(308/438). Growth charts performed worst: 61%(217/353) correct (p-value<0.01). The mean number of scenarios (±SD) correctly identified by each participant in 4-minutes was 3.5(±2.19) using growth charts; 4.97(±2.50) using look-up tables; 5.66(±2.69) using MAMI charts (ANOVA, p-value<0.01). This translates to approximately 53, 75 and 85 correct assessments per participant in an hour for the respective tools. No statistically significant differences were found with participants' years of experience or profession type. Most participants, 43/62(69%), preferred the MAMI chart and reported it to be easier and faster to use than traditional tools. We conclude that weight-for-age assessment is quicker and more accurate using the newly-developed MAMI slide chart as opposed to traditional methods. It should be further field tested in other settings since the potential to improve the efficiency and effectiveness of treatment programmes is great.

Exposure to the 1959-1961 Chinese famine and risk of non-communicable diseases in later life: A life course perspective.

Child undernutrition and later-life non-communicable diseases (NCDs) are major global health issues. Literature suggests that undernutrition/famine exposure in childhood has immediate and long-term adverse health consequences. However, many studies have theoretical and methodological limitations. To add to the literature and overcome some of these limitations, we adopted a life course perspective and used more robust methods. We investigated the association between exposure to the 1959-1961 Chinese famine and later-life NCDs and if this association depends on: life stage at exposure, famine severity, and sex. We conducted a secondary data analysis of a large-scale, nationally representative, longitudinal study-the China Health and Retirement Longitudinal Study (2011-2018, 11,094 participants). We measured famine exposure/severity using self-reported experience, life stage using age at exposure, and health using the number of NCDs. We performed Poisson growth curve models. We obtained three findings. First, compared with unexposed participants, those exposed before age 18 had a higher risk of later-life NCDs, particularly if exposed in-utero (IRR = 1.90, 95% CI [1.70, 2.12], p < .001) and in the "first 1,000 days" of life (IRR = 1.86, 95% CI [1.73, 2.00], p < .001; for 0-6 months group, IRR = 1.95, 95% CI [1.67, 2.29], p < .001). Second, the famine effects among participants moderately and severely exposed were similar (IRR = 1.18, 95% CI [1.09, 1.28], p < .001 and IRR = 1.24, 95% CI [1.17, 1.32], p < .001). Third, the famine effects did not differ between females and males (IRR = 0.98, 95% CI [0.90, 1.07], p = .703). In an individual's life course, in-utero and the "first 1,000 days" are a particularly sensitive time period with marked long-term implications for NCDs if undernutrition/famine is experienced in this period. However, this window remains open until young adulthood. This highlights the need to invest more in preventing and treating child/adolescent undernutrition to tackle later-life NCDs.

Tools for assessing child and adolescent stunting: Lookup tables, growth charts and a novel appropriate-technology "MEIRU" wallchart - a diagnostic accuracy study.

Stunting affects 149 million children worldwide and is a form of chronic malnutrition defined by low height-for-age. Surveys and intervention programmes depend on effective assessment and identification of affected individuals. Gold standard assessment is based on height-for-age Z-score (HAZ): HAZ <-2 defines stunting; HAZ <-3 defines severe stunting. However, a major problem for field-based programmes is that Z-scores can be time-intensive and challenging to calculate. We thus developed a novel wallchart that we have coined 'MEIRU wallchart' to easily and accurately identify stunted children and adolescents. Our study aim was to evaluate its performance and acceptability against other methods used in current clinical/field practice. We undertook a non-interventional diagnostic accuracy study in Malawi. We recruited 244 participants aged 8-19 years and determined each individual's stunting status using, in varying order: the MEIRU wallchart, traditional lookup tables, and traditional growth charts. All were compared against 'gold standard' HAZ, calculated using AnthroPlus WHO software. Local community healthcare workers performed all the assessments. The wallchart method was strongly preferred by both participants and staff. It had an overall accuracy of 95.5%(kappa = 0.91) and was faster than lookup tables by an average of 62.5%(41.4sec; p<0.001) per measurement. Lookup tables and growth charts had overall agreements of 59.4%(kappa = 0.36) and 61.9%(kappa = 0.31) respectively. At the HAZ-2 cut-off, the wallchart had a sensitivity of 97.6%(95%CI: 91.5-99.7) and specificity of 96.3%(95%CI: 92.1-98.6). We conclude that the MEIRU wallchart performs well and is acceptable for screening and identification of stunted children/adolescents by community-level health workers. It fulfils key criteria that justify a role in future screening programmes: easy to perform and interpret; acceptable; accurate; sensitive and specific. Potential future uses include: conducting rapid stunting prevalence surveys; identifying affected individuals for interventions. Current field methods, lookup tables and growth charts performed poorly and should be used with caution.

Mid-upper arm circumference (MUAC) measurement usage among children with disabilities: A systematic review.

Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used for monitoring and evaluating children's nutritional status. Evidence is limited on optimal nutritional assessment for children with disabilities, who are at high risk for malnutrition. Aim: This study describes MUAC use among children with disabilities. Methods: Four databases (Embase, Global Health, Medline, and CINHAL) were searched from January 1990 through September 2021 using a predefined search strategy. Of the 305 publications screened, 32 papers were included. Data included children 6 months to 18 years old with disabilities. Data including general study characteristics, methods for MUAC measurement, terminology, and measurement references were extracted into Excel. Due to heterogeneity of the data, a narrative synthesis was used. Results: Studies from 24 countries indicate that MUAC is being used as part of nutritional assessment, but MUAC measurement methods, references, and cutoffs were inconsistent. Sixteen (50%) reported MUAC as a mean ± standard deviation (SD), 11 (34%) reported ranges or percentiles, 6 (19%) reported z-scores, and 4 (13%) used other methods. Fourteen (45%) studies included both MUAC and weight-for-height but nonstandard reporting limited comparability of the indicators for identifying those at risk of malnutrition. Conclusion: Although its speed, simplicity, and ease of use afford MUAC great potential for assessing children with disabilities, more research is needed to understand its appropriateness, and how it performs at identifying nutritionally high-risk children in comparison to other measures. Without validated inclusive measures to identify malnutrition and monitor growth and health, millions of children could have severe consequences for their development.

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi 'ChroSAM' cohort.

OBJECTIVE: To explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition and describe associations with survival and non-communicable disease (NCD) risk 7 years post-treatment. DESIGN: Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score and height-for-age z-score (HAZ). Three categorisation methods included no categorisation, quintiles and latent class analysis (LCA). Associations with mortality risk and seven NCD indicators were analysed. SETTING: Secondary data from Blantyre, Malawi between 2006 and 2014. PARTICIPANTS: A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score < 70 % median and/or MUAC (mid-upper arm circumference) < 110 mm and/or bilateral oedema) at ages 5-168 months. RESULTS: Faster weight gain during treatment (g/d) and after treatment (g/kg/day) was associated with lower risk of death (adjusted OR 0·99, 95 % CI 0·99, 1·00; and adjusted OR 0·91, 95 % CI 0·87, 0·94, respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0·02, 95 % CI 0·00, 0·03) and larger HAZ (6·62, 95 % CI 1·31, 11·9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0·02, 95 % CI 0·01, 0·03), an indicator of later-life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/d during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder. CONCLUSIONS: A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.

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.