Nutrition, hygiene, and stimulation education to improve growth, cognitive, language, and motor development among infants in Uganda: A cluster-randomized trial.

Stunting is associated with impaired cognitive and motor function. The effect of an education intervention including nutrition, stimulation, sanitation, and hygiene on child growth and cognitive/language/motor development, delivered to impoverished mothers in Uganda, was assessed. In a community-based, open cluster-randomized trial, 511 mother/children dyads aged 6-8 months were enrolled to an intervention (n = 263) or control (n = 248) group. The primary outcome was change in length-for-age z-score at age 20-24 months. Secondary outcomes included anthropometry and scores on the 2 developmental scales: Bayley Scales of Infant and Toddler Development-III and the Ages and Stages Questionnaire. There was no evidence of a difference in mean length-for-age z-score at 20-24 months between the 2 study groups: 0.10, 95% CI [-0.17, 0.36], p = .49. The intervention group had higher mean composite development scores than the controls on Bayley Scales of Infant and Toddler Development-III, the mean difference being 15.6, 95% CI [10.9, 20.2], p = .0001; 9.9, 95% CI [6.4, 13.2], p = .0001; and 14.6, 95% CI [10.9, 18.2], p = .0001, for cognitive, language, and motor composite scores, respectively. The mean difference in scores from the Ages and Stages Questionnaire were 7.0, 95% CI [2.9, 11.3], p = .001; 5.9, 95% CI [1.2, 10.3], p = .01; 4.2, 95% CI [1.7, 6.7], p = .001; 8.9, 95% CI [5.3, 12.3], p = .0001; and 4.4, 95% CI [0.0, 8.8], p = .05, for communication, gross motor, fine motor, problem solving, and personal-social development, respectively. The intervention education delivered to mothers promoted early development domains in cognitive, language, and motor development but not linear growth of small children in impoverished rural communities in Uganda. Our study showed that child development may be improved with a relatively low cost intervention strategy. This trial was registered at ClinicalTrials.gov as NCT02098031.

The principles and practices of nutrition advocacy: evidence, experience and the way forward for stunting reduction.

Advocacy represents an intervention into complex, dynamic and highly contextual socio-political systems, in which strategies and tactics must be adjusted on a continual basis in light of rapidly changing conditions, reactions from actors and feedback. For this reason, the practice of advocacy is often considered more art than science. However, capacities and practices for advocacy can be strengthened by sharing and analysing experiences in varying contexts, deriving general principles and learning to adapt these principles to new contexts. Nutrition is a particular context for advocacy, but to date, there has been little systematic analysis of experiences. The purpose of this paper is to illustrate and draw lessons from the practice of nutrition advocacy, especially in relation to stunting and complementary feeding, and suggest ways to strengthen capacities and practices in the future. The strategies and tactics, achievements and lessons learnt are described for three case studies: Uganda, Vietnam and Bangladesh. These cases, and experience from elsewhere, demonstrate that concerted, well-planned and well-implemented advocacy can bring significant achievements, even in short period of time. In light of the global and national attention being given to stunting reduction through the SUN (Scaling Up Nutrition) movement and other initiatives, there is now a need for much stronger investments in strategic and operational capacities for advocacy, including the human, organisational and financial resources for the advocacy and strategic communication themselves, as well as for monitoring and evaluation, supportive research and institutional capacity-building.

Multi-sectoral interventions for healthy growth.

The risk of stunted growth and development is affected by the context in which a child is born and grows. This includes such interdependent influences as the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. Here, we briefly review how factors linked with the key sectors can contribute to healthy growth and reduced childhood stunting. Emphasis is placed on the role of agriculture/food security, especially family farming; education, particularly of girls and women; water, sanitation, and hygiene and their integration in stunting reduction strategies; social protection including cash transfers, bearing in mind that success in this regard is linked to reducing the gap between rich and poor; economic investment in stunting reduction including the work with the for-profit commercial sector balancing risks linked to marketing foods that can displace affordable and more sustainable alternatives; health with emphasis on implementing comprehensive and effective health care interventions and building the capacity of health care providers. We complete the review with examples of national and subnational multi-sectoral interventions that illustrate how critical it is for sectors to work together to reduce stunting.

Risk factors in hospital deaths in severely malnourished children in Kampala, Uganda.

BACKGROUND: Although the risk factors for increased fatality among severely malnourished children have been reported, recent information from Africa, during a period of HIV pandemic and constrained health services, remains sketchy. The aim of this study has been to establish the risk factors for excess deaths among hospitalized severely malnourished children of below five years of age. METHOD: In 2003, two hundred and twenty consecutively admitted, severely malnourished children were followed in the paediatric wards of Mulago, Uganda's national referral and teaching hospital. The children's baseline health conditions were established by physical examination, along with haematological, biochemical, microbiological and immunological indices. RESULTS: Of the 220 children, 52 (24%) died, with over 70% of the deaths occurring in the first week of admission. There was no significant difference by sex or age group. The presence of oedema increased the adjusted odds-ratio, but did not reach significance (OR = 2.0; 95% CI = 0.8 - 4.7), similarly for a positive HIV status (OR = 2.6, 95% CI = 0.8 - 8.6). Twenty four out of 52 children who received blood transfusion died (OR = 5.0, 95% CI = 2 - 12); while, 26 out of 62 children who received intravenous infusion died (OR = 4.8, 95% CI = 2 - 12). The outcome of children who received blood or intravenous fluids was less favourable than of children who did not receive them. Adjustment for severity of disease did not change this. CONCLUSION: The main risk factors for excess hospital deaths among severely malnourished children in Mulago hospital include blood transfusion and intravenous infusion. An intervention to reduce deaths needs to focus on guideline compliance with respect to blood transfusions/infusions.

Nutritional and developmental status among 6- to 8-month-old children in southwestern Uganda: a cross-sectional study.

BACKGROUND: Undernutrition continues to pose challenges to Uganda's children, but there is limited knowledge on its association with physical and intellectual development. OBJECTIVE: In this cross-sectional study, we assessed the nutritional status and milestone development of 6- to 8-month-old children and associated factors in two districts of southwestern Uganda. DESIGN: Five hundred and twelve households with mother-infant (6-8 months) pairs were randomly sampled. Data about background variables (e.g. household characteristics, poverty likelihood, and child dietary diversity scores (CDDS)) were collected using questionnaires. Bayley Scales of Infant and Toddler Development (BSID III) and Ages and Stages questionnaires (ASQ) were used to collect data on child development. Anthropometric measures were used to determine z-scores for weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ), head circumference (HCZ), and mid-upper arm circumference. Chi-square tests, correlation coefficients, and linear regression analyses were used to relate background variables, nutritional status indicators, and infant development. RESULTS: The prevalence of underweight, stunting, and wasting was 12.1, 24.6, and 4.7%, respectively. Household head education, gender, sanitation, household size, maternal age and education, birth order, poverty likelihood, and CDDS were associated (p<0.05) with WAZ, LAZ, and WLZ. Regression analysis showed that gender, sanitation, CDDS, and likelihood to be below the poverty line were predictors (p<0.05) of undernutrition. BSID III indicated development delay of 1.3% in cognitive and language, and 1.6% in motor development. The ASQ indicated delayed development of 24, 9.1, 25.2, 12.2, and 15.1% in communication, fine motor, gross motor, problem solving, and personal social ability, respectively. All nutritional status indicators except HCZ were positively and significantly associated with development domains. WAZ was the main predictor for all development domains. CONCLUSION: Undernutrition among infants living in impoverished rural Uganda was associated with household sanitation, poverty, and low dietary diversity. Development domains were positively and significantly associated with nutritional status. Nutritional interventions might add value to improvement of child growth and development.

Do street food vendors sell a sufficient variety of foods for a healthful diet? The case of Nairobi.

This study examined whether street food vendors sell a sufficient variety of foods for a healthful diet. It was hypothesized that vendors sold only low-cost food groups to enable the buyer to afford the food while the vendor also made a profit. A structured questionnaire was administered to 580 vendors in three selected locations. Data included product names, ingredients, methods of preparation, and the sex of the vendor. A little more than half of the vendors (53%) sold food of only one group; 44% sold cereals. Overall, 36% of vendors, mostly men, sold only carbohydrate products. The percentage of vendors selling foods of more than one group was higher in the working area (53%) than in the slum area (43%, p < .05), and it was higher in both of these areas taken together than in the lower-middle income area (21%, p < .001). Micronutrient and mixed-nutrient products were associated with female vendors. Although a slight majority of all street vendors sell foods of only one group, women vendors are capable of supplying a sufficient variety of food groups that consumers can afford. It appears that consumer purchasing power dictates the food groups provided by vendors, especially cereal-based-foods. A policy on micronutrient fortification of cereal flours and fats used in popular street food preparation needs to be considered. This could be coupled with consumer and vendor education programs focusing on the importance of healthful diets.

Reduction of unnecessary transfusion and intravenous fluids in severely malnourished children is not enough to reduce mortality.

AIM: To test whether standardising the use of blood transfusions and intravenous (IV) infusions could reduce fatality in severely malnourished children admitted to Mulago Hospital, Kampala. METHODS: Improved adherence to the WHO protocol for blood transfusion and IV fluids was effected in patients with severe malnutrition by continuous medical education. A 'before and after' design was used to study 450 severely malnourished children (weight-for-height < -3 Z-score or presence of oedema) under 60 months of age. A total of 220 pre- and 230 post-'improved practice' patients were enrolled consecutively during the periods September to November 2003 and September to December 2004, respectively. Patients were followed up until discharge or death. The Kaplan-Meier survival curve and the Cox regression hazard model were used for univariate and multivariate analyses, respectively. RESULTS: Overall case fatality was 23.6% (52/220) in the pre-period and 24.8% (57/230) in the post-period (p=0.78). Most of the deaths occurred in the 1st week of admission (73%, 38/52 in the pre-period and 61%, 35/57 in the post-period) and were of children who had received blood transfusion or IV infusion or both in the pre-period. Mortality in children transfused and/or infused was significantly reduced in the post-period (82%, 31/38 in the pre-period vs 23%, 8/35 in the post-period, p=0.008). In the post-period, there was a significant reduction in the number of inappropriate blood transfusions (18%, 34/194 vs 3.5%, 8/230, p=0.01) and IV fluid infusions (27%, 52/194 vs 9%, 20/230, p<0.001). Survival improved in children who received blood transfusions in the post-period [hazards ratio (HR) 0.22, 95% CI 0.30-1.67 vs HR 4.80, 95% CI 1.71-13.51], as did that of children who received IV infusions (HR 2.10, 95% CI 0.84-5.23 vs HR 3.91, 95% CI 1.10-14.04). CONCLUSION: Management according to the WHO protocol for severe malnutrition can reduce the need for blood and IV infusions. However, further studies are required to verify whether full implementation of the WHO protocol reduces the high case fatality in sub-Saharan hospitals.