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2.
Artigo em Inglês | MEDLINE | ID: mdl-34535798

RESUMO

BACKGROUND: Malnutrition is a leading cause of morbidity and mortality in children aged <5 y, especially in low- and middle-income countries (LMICs). Unlike severe acute malnutrition, moderate acute malnutrition (MAM) affects greater numbers globally, and guidelines lack a robust evidence base. This systematic review and meta-analysis assessed the evidence for lipid-based nutrient supplements (LNSs), fortified blended flours (FBFs) and nutrition counselling, in the treatment of MAM. METHODS: Four databases were systematically searched for studies conducted in LMICs that compared the effectiveness of food-based products with any comparator group in promoting recovery from MAM in children aged 6-59 mo. Where appropriate, pooled estimates of effect were estimated using random-effects meta-analyses. RESULTS: A total of 13 trials were identified for inclusion. All used active controls. There was evidence of increased probability of recovery (gaining normal weight-for-height and/or mid-upper arm circumference) among children treated with LNSs compared with children treated with FBFs (risk ratio 1.05, 95% CI 1.01 to 1.09, p=0·009). CONCLUSION: Based on a relatively small number of studies mainly from Africa, LNSs are superior to FBFs in improving anthropometric recovery from MAM. Current evidence for the use of food supplements in MAM treatment is based on comparisons with active controls. Future studies should assess a wider range of comparator groups, such as nutrition education/counselling alone, and outcomes, including body composition, morbidity and development.

3.
PLoS One ; 16(8): e0256188, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34407128

RESUMO

BACKGROUND: Small and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants' needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth. METHODS: We conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data. RESULTS: We included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women's empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering. CONCLUSION: Our findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.

4.
Nutrients ; 13(8)2021 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-34444646

RESUMO

A poor understanding of malnutrition burden is a common reason for not prioritizing the care of small and nutritionally at-risk infants aged under-six months (infants u6m). We aimed to estimate the anthropometric deficit prevalence in infants u6m attending health centres, using the Composite Index of Anthropometric Failure (CIAF), and to assess the overlap of different individual indicators. We undertook a two-week survey of all infants u6m visiting 18 health centres in two zones of the Oromia region, Ethiopia. We measured weight, length, and MUAC (mid-upper arm circumference) and calculated weight-for-length (WLZ), length-for-age (LAZ), and weight-for-age z-scores (WAZ). Overall, 21.7% (95% CI: 19.2; 24.3) of infants u6m presented CIAF, and of these, 10.7% (95% CI: 8.93; 12.7) had multiple anthropometric deficits. Low MUAC overlapped with 47.5% (95% CI: 38.0; 57.3), 43.8% (95% CI: 34.9; 53.1), and 42.6% (95% CI: 36.3; 49.2) of the stunted, wasted, and CIAF prevalence, respectively. Underweight overlapped with 63.4% (95% CI: 53.6; 72.2), 52.7% (95% CI: 43.4; 61.7), and 59.6% (95% CI: 53.1; 65.9) of the stunted, wasted, and CIAF prevalence, respectively. Anthropometric deficits, single and multiple, are prevalent in infants attending health centres. WAZ overlaps more with other forms of anthropometric deficits than MUAC.


Assuntos
Centros Comunitários de Saúde , Transtornos da Nutrição do Lactente/epidemiologia , Antropometria , Estatura , Estudos Transversais , Etiópia/epidemiologia , Feminino , Humanos , Lactente , Masculino , Prevalência , Magreza
5.
J Hum Lact ; : 8903344211018161, 2021 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-33993793

RESUMO

BACKGROUND: Inappropriate marketing of human milk substitutes negatively influences efforts to protect breastfeeding. Although healthcare professionals can positively influence infant feeding decisions, government regulations permit manufacturers to communicate messages to them through advertising. RESEARCH AIMS: (1) To identify the extent of human milk substitute advertising in publications aimed at United Kingdom healthcare professionals and (2) to describe compliance with the International Code of Marketing of Breast-Milk Substitutes and United Kingdom Formula and Follow-on Formula Regulations. METHODS: This was a cross-sectional observational study. We reviewed publications targeting healthcare professionals working with families in the United Kingdom (N = 19). Quantity and type of human milk substitute advertisements, as a proportion of all advertising, in each publication were recorded. All unique advertisements were double assessed for compliance. RESULTS: Human milk substitute advertising was found in nine (47%) of the 19 publications (four affiliated with professional associations), making up 10.3% (n = 196) of these publications' total advertising. Of human milk substitute advertisements found, 65.4% (n = 110) were for products used to manage cows' milk protein allergy. Of the 32 unique human milk substitute advertisements found, none complied with the International Code of Marketing of Breast Milk Substitutes or United Kingdom Formula and Follow-on Formula Regulations. CONCLUSIONS: Many healthcare professionals' publications had non-compliant human milk substitute advertisements. There is an urgent need to ensure full compliance with international and local regulation in future advertisements and to consider whether advertisements are justified at all.

6.
Nutrients ; 13(4)2021 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-33805040

RESUMO

Weight-for-age z-score (WAZ) is not currently an admission criterion to therapeutic feeding programs, and children with low WAZ at high risk of mortality may not be admitted. We conducted a secondary analysis of RCT data to assess response to treatment according to WAZ and mid-upper arm circumference (MUAC) and type of feeding protocol given: a simplified, combined protocol for severe and moderate acute malnutrition (SAM and MAM) vs. standard care that treats SAM and MAM, separately. Children with a moderately low MUAC (11.5-12.5 cm) and a severely low WAZ (<-3) respond similarly to treatment in terms of both weight and MUAC gain on either 2092 kJ (500 kcal)/day of therapeutic or supplementary food. Children with a severely low MUAC (<11.5 cm), with/without a severely low WAZ (<-3), have similar recovery with the combined protocol or standard treatment, though WAZ gain may be slower in the combined protocol. A limitation is this analysis was not powered for these sub-groups specifically. Adding WAZ < -3 as an admission criterion for therapeutic feeding programs admitting children with MUAC and/or oedema may help programs target high-risk children who can benefit from treatment. Future work should evaluate the optimal treatment protocol for children with a MUAC < 11.5 and/or WAZ < -3.0.


Assuntos
Transtornos da Nutrição Infantil/dietoterapia , Desnutrição Aguda Grave/dietoterapia , Magreza/dietoterapia , Pré-Escolar , Análise por Conglomerados , Feminino , Humanos , Lactente , Masculino , Resultado do Tratamento
7.
BMJ Glob Health ; 6(3)2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33692144

RESUMO

INTRODUCTION: Child malnutrition (undernutrition) and adult non-communicable diseases (NCDs) are major global public health problems. While convincing evidence links prenatal malnutrition with increased risk of NCDs, less is known about the long-term sequelae of malnutrition in childhood. We therefore examined evidence of associations between postnatal malnutrition, encompassing documented severe childhood malnutrition in low/middle-income countries (LMICs) or famine exposure, and later-life cardiometabolic NCDs. METHODS: Our peer-reviewed search strategy focused on 'severe childhood malnutrition', 'LMICs', 'famine', and 'cardiometabolic NCDs' to identify studies in Medline, Embase, Global Health, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. We synthesised results narratively and assessed study quality with the UK National Institute for Health and Care Excellence checklist. RESULTS: We identified 57 studies of cardiometabolic NCD outcomes in survivors of documented severe childhood malnutrition in LMICs (n=14) and historical famines (n=43). Exposure to severe malnutrition or famine in childhood was consistently associated with increased risk of cardiovascular disease (7/8 studies), hypertension (8/11), impaired glucose metabolism (15/24) and metabolic syndrome (6/6) in later life. Evidence for effects on lipid metabolism (6/11 null, 5/11 mixed findings), obesity (3/13 null, 5/13 increased risk, 5/13 decreased risk) and other outcomes was less consistent. Sex-specific differences were observed in some cohorts, with women consistently at higher risk of glucose metabolism disorders and metabolic syndrome. CONCLUSION: Severe malnutrition or famine during childhood is associated with increased risk of cardiometabolic NCDs, suggesting that developmental plasticity extends beyond prenatal life. Severe malnutrition in childhood thus has serious implications not only for acute morbidity and mortality but also for survivors' long-term health. Heterogeneity across studies, confounding by prenatal malnutrition, and age effects in famine studies preclude firm conclusions on causality. Research to improve understanding of mechanisms linking postnatal malnutrition and NCDs is needed to inform policy and programming to improve the lifelong health of severe malnutrition survivors.


Assuntos
Doenças Cardiovasculares , Desnutrição , Doenças não Transmissíveis , Adulto , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Criança , Fome Epidêmica , Feminino , Humanos , Masculino , Desnutrição/epidemiologia , Doenças não Transmissíveis/epidemiologia , Pobreza , Gravidez
8.
Nutrients ; 13(2)2021 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-33672692

RESUMO

Small and nutritionally at-risk infants under six months, defined as those with wasting, underweight, or other forms of growth failure, are at high-risk of mortality and morbidity. The World Health Organisation 2013 guidelines on severe acute malnutrition highlight the need to effectively manage this vulnerable group, but programmatic challenges are widely reported. This review aims to inform future management strategies for small and nutritionally at-risk infants under six months in low- and middle-income countries (LMICs) by synthesising evidence on existing breastfeeding support packages for all infants under six months. We searched PubMed, CINAHL, Cochrane Library, EMBASE, and Global Health databases from inception to 18 July 2018. Intervention of interest were breastfeeding support packages. Studies reporting breastfeeding practices and/or caregivers'/healthcare staffs' knowledge/skills/practices for infants under six months from LMICs were included. Study quality was assessed using NICE quality appraisal checklist for intervention studies. A narrative data synthesis using the Synthesis Without Meta-analysis (SWiM) reporting guideline was conducted and key features of successful programmes identified. Of 15,256 studies initially identified, 41 were eligible for inclusion. They were geographically diverse, representing 22 LMICs. Interventions were mainly targeted at mother-infant pairs and only 7% (n = 3) studies included at-risk infants. Studies were rated to be of good or adequate quality. Twenty studies focused on hospital-based interventions, another 20 on community-based and one study compared both. Among all interventions, breastfeeding counselling (n = 6) and education (n = 6) support packages showed the most positive effect on breastfeeding practices followed by breastfeeding training (n = 4), promotion (n = 4) and peer support (n = 3). Breastfeeding education support (n = 3) also improved caregivers' knowledge/skills/practices. Identified breastfeeding support packages can serve as "primary prevention" interventions for all infants under six months in LMICs. For at-risk infants, these packages need to be adapted and formally tested in future studies. Future work should also examine impacts of breastfeeding support on anthropometry and morbidity outcomes. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO 2018 CRD42018102795).


Assuntos
Aleitamento Materno , Aconselhamento/métodos , Transtornos da Nutrição do Lactente/prevenção & controle , Mães/educação , Cuidado Pós-Natal/métodos , Adulto , Países em Desenvolvimento , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Gravidez , Avaliação de Programas e Projetos de Saúde , Apoio Social
9.
PLoS One ; 16(2): e0245477, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33534818

RESUMO

INTRODUCTION: Severe and moderate acute malnutrition (SAM and MAM) affect more than 50 million children worldwide yet 80% of these children do not access care. The Combined Protocol for Acute Malnutrition Study (ComPAS) trial assessed the effectiveness of a simplified, combined SAM/MAM protocol for children aged 6-59 months and found non-inferior recovery compared to standard care. To further inform policy, this study assessed post-discharge outcomes of children treated with this novel protocol in Kenya. METHODS: Six 'combined' protocol clinics treated SAM and MAM children using an optimised mid-upper arm circumference (MUAC)-based dose of ready-to-use therapeutic food (RUTF). Six 'standard care' clinics treated SAM with weight-based RUTF rations; MAM with ready-to-use supplementary food (RUSF). Four months post-discharge, we assessed anthropometry, recent history of illness, and body composition by bioelectrical impedance analysis. Data was analysed using multivariable linear regression, adjusted for age, sex and allowing for clustering by clinic. RESULTS: We sampled 850 children (median age 18 months, IQR 15-23); 44% of the original trial sample in Kenya. Children treated with the combined protocol had similar anthropometry, fat-free mass, fat mass, skinfold thickness z-scores, and frequency of common illnesses 4 months post-discharge compared the standard protocol. Mean subscapular skinfold z-scores were close to the global norm (standard care: 0.24; combined 0.27). There was no significant difference in odds of relapse between protocols (SAM, 3% vs 3%, OR = 1.0 p = 0.75; MAM, 10% vs 12%, OR = 0.90 p = 0.34). CONCLUSIONS: Despite the lower dosage of RUTF for most SAM children in the combined protocol, their anthropometry and relapse rates at 4 months post-discharge were similar to standard care. MAM children treated with RUTF had similar body composition to those treated with RUSF and neither group exhibited excess adiposity. These results add further evidence that a combined protocol is as effective as standard care with no evidence of adverse effects post-discharge. A simplified, combined approach could treat more children, stretch existing resources further, and contribute to achieving Sustainable Development Goal Two.


Assuntos
Assistência ao Convalescente , Composição Corporal , Desnutrição Aguda Grave , Antropometria , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Quênia , Masculino , Recidiva , Desnutrição Aguda Grave/epidemiologia , Desnutrição Aguda Grave/terapia , Sudão , Resultado do Tratamento , Ganho de Peso
10.
Nutrients ; 13(1)2021 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-33467102

RESUMO

Since 1955, international adoption has been a way of finding homes for children who have been orphaned or abandoned. We aimed to describe the nutritional status of individuals adopted internationally and their long-term nutritional and health outcomes. We searched four databases for articles published from January 1995 to June 2020, which included information on anthropometric or micronutrient status of children adopted internationally (CAI). Mean Z-scores on arrival to adoptive country ranged from -2.04 to -0.31 for weight for age; -0.94 to 0.39 for weight for height; -0.7 to 0 for body mass index; -1.89 to -0.03 for height for age; -1.43 to 0.80 for head circumference for age. Older children, those adopted from institutionalized care or with underlying disability, were more likely to be malnourished. Though long-term data was scarce, mean Z-scores post-adoption ranged from -0.59 to 0.53 for weight for age; -0.31 to 1.04 for weight for height; 0.39 to 1.04 for body mass index; -1.09 to 0.58 for height for age; -0.06 to 1.23 for head circumference for age. We conclude that though CAI are at high risk of malnutrition at baseline, marked catch-up growth is possible, including for those older than two years of age on arrival. This has implications not only for CAI but for the wider population of malnourished children worldwide. Research on how to optimize catch-up growth is a priority.


Assuntos
Adoção , Constituição Corporal , Transtornos da Nutrição Infantil/epidemiologia , Fenômenos Fisiológicos da Nutrição Infantil , Criança Adotada , Internacionalidade , Estado Nutricional , Adolescente , Fatores Etários , Criança , Desenvolvimento Infantil , Pré-Escolar , Bases de Dados como Assunto , Feminino , Humanos , Lactente , Masculino , Fatores de Tempo
11.
BMJ Glob Health ; 5(12)2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33328202

RESUMO

BACKGROUND: Excess male morbidity and mortality is well recognised in neonatal medicine and infant health. In contrast, within global nutrition, it is commonly assumed that girls are more at risk of experiencing undernutrition. We aimed to explore evidence for any male/female differences in child undernutrition using anthropometric case definitions and the reasons for differences observed. METHODS: We searched: Medline, Embase, Global health, Popline and Cochrane databases with no time limits applied. Eligible studies focused on children aged 0-59 months affected by undernutrition where sex was reported. In the meta-analysis, undernutrition-specific estimates were examined separately for wasting, stunting and underweight using a random-effects model. RESULTS: 74 studies were identified: 44/74 studies were included in the meta-analysis. In 20 which examined wasting, boys had higher odds of being wasted than girls (pooled OR 1.26, 95% CI 1.13 to 1.40). 38 examined stunting: boys had higher odds of stunting than girls (pooled OR 1.29 95% CI 1.22 to 1.37). 23 explored underweight: boys had higher odds of being underweight than girls (pooled OR 1.14, 95% CI 1.02 to 1.26). There was some limited evidence that the female advantage, indicated by a lower risk of stunting and underweight, was weaker in South Asia than other parts of the world. 43/74 (58%) studies discussed possible reasons for boy/girl differences; 10/74 (14%) cited studies with similar findings with no further discussion; 21/74 (28%) had no sex difference discussion. 6/43 studies (14%) postulated biological causes, 21/43 (49%) social causes and 16/43 (37%) to a combination. CONCLUSION: Our review indicates that undernutrition in children under 5 is more likely to affect boys than girls, though the magnitude of these differences varies and is more pronounced in some contexts than others. Future research should further explore reasons for these differences and implications for nutrition policy and practice.


Assuntos
Transtornos da Nutrição Infantil , Desnutrição , Síndrome de Emaciação , Criança , Feminino , Transtornos do Crescimento , Humanos , Lactente , Recém-Nascido , Masculino , Desnutrição/epidemiologia , Caracteres Sexuais
12.
Nutrients ; 12(11)2020 Nov 23.
Artigo em Inglês | MEDLINE | ID: mdl-33238545

RESUMO

This study aimed to determine the associations of targeted metabolomics and hormone profiles data with lean mass index (LMI), which were estimated using bioelectrical impedance, in survivors of child severe malnutrition (SM) (n = 69) and controls (n = 77) in Malawi 7 years after being treated. Linear associations between individual metabolite or hormone and LMI were determined, including their interaction with nutrition status 7 years prior. Path analysis was performed to determine structural associations. Lastly, predictive models for LMI were developed using the metabolome and hormone profile by elastic net regularized regression (EN). Metabolites including several lipids, amino acids, and hormones were individually associated (p < 0.05 after false discovery rate correction) with LMI. However, plasma FGF21 (Control: ß = -0.02, p = 0.59; Case: ß = -0.14, p < 0.001) and tryptophan (Control: ß = 0.15, p = 0.26; Case: ß = 0.70, p < 0.001) were associated with LMI among cases but not among controls (both interaction p-values < 0.01). Moreover, path analysis revealed that tryptophan mediates the association between child SM and LMI. EN revealed that most predictors of LMI differed between groups, further indicating altered metabolic mechanisms driving lean mass accretion among SM survivors later in life.


Assuntos
Composição Corporal , Transtornos da Nutrição Infantil/epidemiologia , Hormônios/sangue , Metaboloma , Magreza/epidemiologia , Adolescente , Criança , Transtornos da Nutrição Infantil/sangue , Impedância Elétrica , Feminino , Fatores de Crescimento de Fibroblastos/sangue , Seguimentos , Humanos , Malaui/epidemiologia , Masculino , Somatomedinas/análise , Magreza/sangue
14.
BMJ Glob Health ; 5(10)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33028697

RESUMO

INTRODUCTION: Severe acute malnutrition (SAM) and disability are major global health issues. Although they can cause and influence each other, data on their co-existence are sparse. We aimed to describe the prevalence and patterns of disability among a cohort of children with SAM. METHODS: A longitudinal cohort study in Malawi followed SAM survivors up to 7 years postdischarge. Clinical and anthropometric profiles were compared with sibling and community controls. Disability at original admission was identified clinically; at 7-year follow-up a standardised screening tool called 'the Washington Group Questionnaire' was used. RESULTS: 60/938 (6.4%) of admissions to SAM treatment had clinically obvious disability at admission. Post-treatment mortality was high, with only 11/60 (18%) surviving till 7-year follow-up. SAM children with a disability at admission had 6.99 (95% CI 3.49 to 14.02; p<0.001) greater risk of dying compared with children without disability. They were also older, less likely to be HIV positive or have oedema and more severely malnourished. Long-term survivors were more stunted, had less catch-up growth, smaller head circumference, weaker hand grip strength and poorer school achievement than non-disabled survivors.The Washington Group Questionnaire confirmed disability in all who had been identified clinically, and identified many who had not been previously flagged. CONCLUSION: Disability is common among children affected by SAM. Those with disability-associated SAM have greatly increased risk of dying even if they survive the initial episode of malnutrition. Survivors have poorer growth, physical strength and school achievement. To enable all children to survive and thrive post-SAM, it is vital to focus more on those with disabilities. SAM treatment programmes should consider using not just clinical assessment but structured assessments to better identify at-risk individuals as well as understand the population of children for which they are developing services.


Assuntos
Crianças com Deficiência , Desnutrição Aguda Grave , Assistência ao Convalescente , Criança , Força da Mão , Humanos , Estudos Longitudinais , Malaui/epidemiologia , Alta do Paciente , Desnutrição Aguda Grave/epidemiologia
15.
PeerJ ; 8: e9175, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32974089

RESUMO

Background: Infants under 6 months (U6M) contribute a significant proportion of the burden and mortality of severe malnutrition globally. Evidence of underlying aetiology in this population is sparse, but it is known that the group includes ex-preterm and low birthweight (LBW) infants. They represent a unique population given their dependence on breastmilk or a safe, secure alternative. Nutrition agencies and health providers struggle to make programming decisions on which interventions should be provided to this group based upon the 2013 WHO Guidelines for the 'Management of Severe Acute Malnutrition in Infants and Young Children' since there are no published interventional trial data focussed on this population. Interim guidance for this group might be informed by evidence of safety and efficacy in adjacent population groups. Methodology: A narrative literature review was performed of systematic reviews, meta-analyses and randomised controlled trials of antimicrobial and micronutrient interventions (antibiotics, deworming, vitamin A, vitamin D, iron, zinc, folic acid and oral rehydration solution (ORS) for malnutrition) across the population groups of low birthweight/preterm infants, infants under 6 months, infants and children over 6 months with acute malnutrition or through supplementation to breastfeeding mothers. Outcomes of interest were safety and efficacy, in terms of mortality and morbidity. Results: Ninety-four articles were identified for inclusion within this review. None of these studied interventions exclusively in severely malnourished infants U6M. 64% reported on the safety of studied interventions. Significant heterogeneity was identified in definitions of study populations, interventions provided, and outcomes studied. The evidence for efficacy and safety across population groups is reviewed and presented for the interventions listed. Conclusions: The direct evidence base for medical interventions for severely malnourished infants U6M is sparse. Our review identifies a specific need for accurate micronutrient profiling and interventional studies of micronutrients and oral fluid management of diarrhoea amongst infants U6M meeting anthropometric criteria for severe malnutrition. Indirect evidence presented in this review may help shape interim policy and programming decisions as well as the future research agenda for the management of infants U6M identified as malnourished.

16.
PLoS Med ; 17(7): e1003192, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32645109

RESUMO

BACKGROUND: Malnutrition underlies 3 million child deaths worldwide. Current treatments differentiate severe acute malnutrition (SAM) from moderate acute malnutrition (MAM) with different products and programs. This differentiation is complex and costly. The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6-59 months. Eliminating the need for separate products and protocols could improve the impact of programs by treating children more easily and cost-effectively, reaching more children globally. METHODS AND FINDINGS: A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm. Standard care clinics treated SAM with weight-based RUTF rations, and MAM with ready-to-use supplementary food (RUSF). The primary outcome was nutritional recovery. Secondary outcomes included cost-effectiveness, coverage, defaulting, death, length of stay, and average daily weight and MUAC gains. Main analyses were per-protocol, with intention-to-treat analyses also conducted. The non-inferiority margin was 10%. From 8 May 2017 to 31 March 2018, 2,071 children were enrolled in 12 combined protocol clinics (mean age 17.4 months, 41% male), and 2,039 in 12 standard care clinics (mean age 16.7 months, 41% male). In total, 1,286 (62.1%) and 1,202 (59.0%), respectively, completed treatment; 981 (76.3%) on the combined protocol and 884 (73.5%) on the standard protocol recovered, yielding a risk difference of 0.03 (95% CI -0.05 to 0.10, p = 0.52; per-protocol analysis, adjusted for country, age, and sex). The amount of ready-to-use food (RUTF or RUSF) required for a child with SAM to reach full recovery was less in the combined protocol (122 versus 193 sachets), and the combined protocol cost US$123 less per child recovered (US$918 versus US$1,041). There were 23 (1.8%) deaths in the combined protocol arm and 21 (1.8%) deaths in the standard protocol arm (adjusted risk difference 95% CI -0.01 to 0.01, p = 0.87). There was no evidence of a difference between the protocols for any of the other secondary outcomes. Study limitations included contextual factors leading to defaulting, a combined multi-country power estimate, and operational constraints. CONCLUSIONS: Combined treatment for SAM and MAM is non-inferior to standard care. Further research should focus on operational implications, cost-effectiveness, and context (Asia versus Africa; emergency versus food-secure settings). This trial is complete and registered at ISRCTN (ISRCTN30393230). TRIAL REGISTRATION: The trial is registered at ISRCTN, trial number ISRCTN30393230.


Assuntos
Desnutrição/dietoterapia , Braço/anatomia & histologia , Pré-Escolar , Fast Foods , Feminino , Humanos , Lactente , Estimativa de Kaplan-Meier , Quênia , Masculino , Desnutrição/economia , Desnutrição Aguda Grave/dietoterapia , Desnutrição Aguda Grave/economia , Sudão do Sul , Resultado do Tratamento
17.
Nutrients ; 12(7)2020 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-32660020

RESUMO

(1) Introduction: Current evidence on managing infants under six months with growth failure or other nutrition-related risk is sparse and low quality. This review aims to inform research priorities to fill this evidence gap, focusing on breastfeeding practices. (2) Methods: We searched PubMed, CINAHL Plus, and Cochrane Library for studies on feeding interventions that aim to restore or improve the volume or quality of breastmilk and breastfeeding when breastfeeding practices are sub-optimal or prematurely stopped. We included studies from both low- and middle-income countries and high-income countries. (3) Results: Forty-seven studies met the inclusion criteria. Most were from high-income countries (n = 35, 74.5%) and included infants who were at risk of growth failure at birth (preterm infants/small for gestational age) and newborns with early growth faltering. Interventions included formula fortification or supplementation (n = 31, 66%), enteral feeds (n = 8, 17%), cup feeding (n = 2, 4.2%), and other (n = 6, 12.8%). Outcomes included anthropometric change (n = 40, 85.1%), reported feeding practices (n = 16, 34%), morbidity (n = 11, 23.4%), and mortality (n = 5, 10.6%). Of 31 studies that assessed formula fortification or supplementation, 30 reported anthropometric changes (n = 17 no effect, n = 9 positive, n = 4 mixed), seven morbidity (n = 3 no effect, n = 2 positive, n = 2 negative), five feeding (n = 2 positive, n = 2 no effect, n = 1 negative), and four mortality (n = 3 no effect, n = 1 negative). Of eight studies that assessed enteral feed interventions, seven reported anthropometric changes (n = 4 positive, n = 3 no effect), five feeding practices (n = 2 positive, n = 2 no effect, n = 1 negative), four morbidity (n = 4 no effect), and one reported mortality (n = 1 no effect). Overall, interventions with positive effects on feeding practices were cup feeding compared to bottle-feeding among preterm; nasogastric tube feed compared to bottle-feeding among low birth weight preterm; and early progressive feeding compared to delayed feeding among extremely low birth weight preterm. Bovine/cow milk feeding and high volume feeding interventions had an unfavourable effect, while electric breast pump and Galactagogue had a mixed effect. Regarding anthropometric outcomes, overall, macronutrient fortified formula, cream supplementation, and fortified human milk formula had a positive effect (weight gain) on preterm infants. Interventions comparing human breastmilk/donor milk with formula had mixed effects. Overall, only human milk compared to formula intervention had a positive effect on morbidity among preterm infants, while none of the interventions had any positive effect on mortality. Bovine/cow milk supplementation had unfavourable effects on both morbidity and mortality. (4) Conclusion: Future research should prioritise low- and middle-income countries, include infants presenting with growth failure in the post-neonatal period and record effects on morbidity and mortality outcomes.


Assuntos
Aleitamento Materno , Nutrição Enteral , Fórmulas Infantis , Fenômenos Fisiológicos da Nutrição do Lactente , Recém-Nascido de Baixo Peso/crescimento & desenvolvimento , Recém-Nascido Pequeno para a Idade Gestacional/crescimento & desenvolvimento , Alimentação Artificial , Insuficiência de Crescimento , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Leite Humano , Ganho de Peso
18.
PLoS One ; 15(6): e0230452, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32492023

RESUMO

BACKGROUND: Severe and moderate acute malnutrition (SAM and MAM) are currently treated with different food products in separate treatment programs. The development of a unified and simplified treatment protocol using a single food product aims to increase treatment program efficiency and effectiveness. This study, the first stage of the ComPAS trial, sought to assess rate of growth and energy requirements among children recovering from acute malnutrition in order to design a simplified, MUAC-based dosage protocol. METHODS: We obtained secondary data from patient cards of children aged 6-59 months recovering from SAM in outpatient therapeutic feeding programs (TFPs) and from MAM in supplementary feeding programs (SFPs) in five countries in Africa and Asia. We used local polynomial smoothing to assess changes in MUAC and proportional weight gain between clinic visits and assessed their normalized differences for a non-zero linear trend. We estimated energy needs to meet or exceed the growth observed in 95% of visits. RESULTS: This analysis used data from 5518 patients representing 33942 visits. Growth trends in MUAC and proportional weight gain were not significantly different, each lower at higher MUAC values: MUAC growth averaged 2mm/week at lower MUACs (100 to <110mm) and 1mm/week at higher MUACs (120mm to <125mm); and proportional weight gain declined from 3.9g/kg/day to 2.4g/kg/day across the same MUAC values. In 95% of visits by children with a MUAC 100mm to <125mm who were successfully treated, energy needs could be met or exceeded with 1,000 kilocalories a day. CONCLUSION: Two 92g sachets of Ready-to-Use Therapeutic Food (RUTF) (1,000kcal total) is proposed to meet the estimated total energy requirements of children with a MUAC 100mm to <115mm, and one 92g sachet of RUTF (500kcal) is proposed to meet half the energy requirements of children with a MUAC of 115 to <125mm. A simplified, combined protocol may enable a more holistic continuum of care, potentially contributing to increased coverage for children suffering from acute malnutrition.


Assuntos
Metabolismo Energético , Fenômenos Fisiológicos da Nutrição do Lactente , Desnutrição Aguda Grave/metabolismo , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Desnutrição Aguda Grave/patologia , Ganho de Peso
19.
PLoS One ; 15(2): e0228151, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32049994

RESUMO

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.


Assuntos
Caquexia/prevenção & controle , Saúde da Criança , Pesquisa/estatística & dados numéricos , Criança , Saúde Global , Humanos , Estado Nutricional , Inquéritos e Questionários
20.
PeerJ ; 8: e8484, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32071812

RESUMO

Background: There are an estimated 2.7 million children living within institutionalized care worldwide. This review aimed to evaluate currently available data on the nutrition status of children living within institutionalized care. Methods: We searched four databases (Pubmed/Medline, CINHAL Plus, Embase and Global Health Database) for relevant articles published from January 1990 to January 2019. Studies that included information on anthropometry or micronutrient status of children living within institutionalized care were eligible for inclusion. The review is registered on PROSPERO: CRD42019117103. Results: From 3,602 titles screened, we reviewed 98 full texts, of which 25 papers were eligible. Two (8%) studies reported data from multiple countries, nine (36%) were from Asia, four (16%) from Africa, three (12%) from Eastern Europe, four (16%) from the European Union and one (4%) from each of the remaining regions (Middle East, South America and the Caribbean). Twenty-two (88%) were cross sectional. Ten (40%) of the studies focused on children >5 years, seven (28%) on children <5 years, seven (28%) covered a wide age range and one did not include ages. Low birth weight prevalence ranged from 25-39%. Only five (20%) included information on children with disabilities and reported prevalence from 8-75%. Prevalence of undernutrition varied between ages, sites and countries: stunting ranged from 9-72%; wasting from 0-27%; underweight from 7-79%; low BMI from 5-27%. Overweight/obesity ranged from 10-32% and small head circumference from 17-41%. The prevalence of HIV was from 2-23% and anemia from 3-90%. Skin conditions or infections ranged from 10-31% and parasites from 6-76%. Half the studies with dietary information found inadequate intake or diet diversity. Younger children were typically more malnourished than older children, with a few exceptions. Children living within institutions were more malnourished than community peers, although children living in communities were also often below growth standards. High risk of bias was found. Conclusions: This study highlights the limited amount of evidence-based data available on the nutritional status of children in institutions. Of the studies reviewed, children living within institutionalized care were commonly malnourished, with undernutrition affecting young children particularly. Micronutrient deficiencies and obesity were also prevalent. Data quality was often poor: as well as suboptimal reporting of anthropometry, few looked for or described disabilities, despite disability being common in this population and having a large potential impact on nutrition status. Taken together, these findings suggest a need for greater focus on improving nutrition for younger children in institutions, especially those with disabilities. More information is needed about the nutritional status of the millions of children living within institutionalized care to fully address their right and need for healthy development.

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