A sustainable food support for non-breastfed infants: implementation and acceptability within a WHO mother-to-child HIV transmission prevention trial in Burkina Faso.

OBJECTIVE: To provide HIV-positive mothers who opted for exclusive breastfeeding or formula feeding from birth to 6 months postpartum as a means of prevention of mother-to-child transmission (PMTCT) of HIV with a sustainable infant food support programme (FSP) from 6 to 12 months postpartum. We describe the implementation and assessment of this pilot initiative. DESIGN: The FSP included a 6-month provision of locally produced infant fortified mix (IFM; 418 kJ/100 g of gruel) for non-breastfed infants coupled with infant-feeding and psychosocial counselling and support. Acceptability and feasibility were assessed in a subsample of sixty-eight mother-infant pairs. SETTING: The FSP was developed in collaboration with local partners to support participants in a PMTCT prevention study. Formula was provided for free from 0 to 6 months postpartum. Cessation by 6 months was recommended for breastfeeding mothers. RESULTS: The FSP was positively received and greatly encouraged breastfeeding mothers to cease by 6 months. As recommended, most infants were given milk as an additional replacement food, mainly formula subsidised by safety networks. Among daily IFM consumers, feeding practices were satisfactory overall; however, the IFM was shared within the family by more than one-third of the mothers. Cessation of IFM consumption was observed among twenty-two infants, seventeen of whom were fed milk and five neither of these. CONCLUSIONS: Without any food support most mothers would have been unable to provide appropriate replacement feeding. The food security of non-breastfed infants urgently needs to be addressed in HIV PMTCT programmes. Our findings on a simple cost-effective pioneer intervention provide an important foundation for this process.

Impact of intermittent preventive anti-malarial treatment on the growth and nutritional status of preschool children in rural Senegal (west Africa).

Negative consequences of malaria might account for seasonality in nutritional status in children in the Sahel. We report the impact of a randomized, double-blind, placebo-controlled trial of seasonal intermittent preventive anti-malarial treatment on growth and nutritional status in 1,063 Senegalese preschool children. A combination of artesunate and sulfadoxine-pyrimethamine was given monthly from September to November. In the intervention arm, mean weight gain was significantly greater (122.9 +/- 340 versus 42.9 +/- 344 [SD] g/mo, P < 0.0001) and losses in triceps and subscapular skinfold measurements were less (-0.39 +/- 1.01 versus -0.66 +/- 1.01 mm/mo, and -0.15 +/- 0.64 versus -0.36 +/- 0.62 mm/mo, respectively, P < 0.0001 for both). There was no difference in height increments. The prevalence of wasting increased significantly in the control arm (4.6% before versus 9.5% after, P < 0.0001), but remained constant in intervention children: 5.6% versus 7.0% (P = 0.62). The prevention of malaria would improve child nutritional status in areas with seasonal transmission.

Constraints on the delivery of animal-source foods to infants and young children: case studies from five countries.

UNLABELLED: BACKGROUND. Optimal feeding of infants and young children in developing countries includes daily feeding of animal-source foods. OBJECTIVE. To evaluate constraints on the availability of animal-source foods at the community level, access to animal-source foods at the household level, and intake of animal-source foods at the individual level among children under 3 years of age in case studies in five developing countries: Mexico, Peru, Haiti, Senegal, and Ethiopia. METHODS: Data were obtained from published and unpublished research and from program experiences of health and agriculture specialists. RESULTS: In Ethiopia, 27% to 51% of case-study children had consumed an animal-source food on the previous day; from 56% to 87% of children in the other case-study sites had consumed an animal-source food on the previous day. Data on intake of animal-source foods in grams were only available for the Latin American case-study sites, where daily milk intake was high in Mexico and Peru (195 and 180 g/day, respectively) and the intakes of meat, fish, and poultry (MFP) (29.0 and 13.6 g/day) and of egg (18.4 and 4.9 g/day) were low. The conceptual model guiding this work identified more constraining factors at the community and household levels than at the individual level. The most common constraints on feeding animal-source foods to young children were poverty, animal health, and land degradation at the community level; cost of animal-source foods and limited livestock holdings at the household level; and caregivers' perceptions of giving animal-source foods to children at the individual level. CONCLUSIONS: For program planning, it is useful to simultaneously consider factors that affect community availability of household access to, and children's intake of animal-source foods. Efforts to overcome individual-level constraints on intake of animal-source foods should be coupled with activities to address community and household constraints.

[Assessment of 24 years of infant growth monitoring in a rural area of Senegal (1969-1992)]. / Bilan de 24 années de suivi pondéral de nourrissons d'une zone rurale au Sénégal (1969-1992).

UNLABELLED: Undernutrition in young children in developing countries is associated with an increased risk of death. But in several studies, a decrease in mortality was not associated with any decrease in the prevalence of undernutrition. STUDY AREA: A rural population of Casamance (Senegal) has been under yearly demographic surveillance by The French National Institute of Demographic Studies (INED) since 1985. Between 1960-1964 and 1990-1994, under-5 and child (1-4 years) mortality rates dropped from 312 to 127 and from 201 to 68 per 1,000, respectively. Since 1961, French Catholic nuns who are also professional nurses have been in charge of a private village dispensary located in a rural area of Casamance. This dispensary delivers permanent, high quality service and is widely attended. GROWTH MONITORING PROGRAMME: A growth-monitoring programme, supported by Cathwell, was initiated in 1969 for 0-5-year-old children (0-3 from 1985). Children were weighed wearing light clothes to the nearest 10g. Weights were recorded in a register that also contained information concerning identity (name, sex, date of birth) and address. All weights were plotted on growth charts kept by the mothers. During the sessions, the nurses provided nutrition education messages (i.e., preparation of high-energy and nutrient-dense infant gruels using local foods), advice on illness management (oral rehydration during diarrhoea) and hygiene (well and water-jar disinfection, construction of pit-latrines), importance of vaccination. From 1975, they also distributed free chloroquine during the malaria transmission season (May-November) for prevention and early presumptive treatment. Most likely thanks to this programme, infant and child mortality reached a low level at the end of the 1980s. In 1990, plasmodium resistance to chloroquine appeared, increasing malaria mortality. METHODS: All weight measurements taken in 1969-1994 were entered into a database. This paper presents an analysis of weight measurements taken at 3-23 months of age from 1969-1992. A total of 4,636 infants were weighed at least once, but only 3,912 infants (1,983 boys and 1,929 girls) were available for the analysis, 724 being excluded due to missing data. RESULTS: The average coverage of the programme during the month of February was 88% for infants aged 3-23 months. Mean weight was examined at three target ages: 5, 11 and 15 months. Not only did the nutritional status not improve between 1969 and 1989, it even deteriorated in some years for all three age-cohorts. The nutritional status of infants in this community did not differ significantly from that of 12-23 month-old Senegalese children in the 1992-1993 Demographic and Health Survey (DHS). Seasonal differences in mean weight and the prevalence of underweight became significant in the rainy season since 1975. Underweight for the 15-month-old children increased over time during the rainy season. These findings were unexpected, since malaria morbidity is thought to be at least partially responsible for seasonal variations in the nutritional status of young children, and despite the fact that the nurses began a malaria control programme in 1975. CONCLUSION: The rapid transition towards lower childhood mortality observed in this rural area of Casamance (Senegal), was not concomitant with any improvement in infants' nutritional status from 1969 through 1992. Focused public health interventions such as vaccinations and malaria prevention probably did not improve the nutritional status. Paradoxically, growth monitoring may have been more helpful in improving health than growth. Targeted specific nutritional interventions are needed to significantly improve growth of children in this community.

Lactational amenorrhea is associated with child age at the time of introduction of complementary food: a prospective cohort study in rural Senegal, West Africa.

BACKGROUND: In Africa, lactational amenorrhea is the major reason for birth spacing. OBJECTIVE: We studied whether the early introduction of complementary food to infants is associated with an increased risk of menstruation resumption in rural African women. DESIGN: Senegalese women (n = 855) were included at 2-3 mo postpartum and followed up at 4-5 and 6-7 mo in dispensaries. A subsample of 502 women were followed up at 9-10 mo and twice yearly at home thereafter. Risk factors for menstruation resumption were assessed with logistic regression, with control for maternal parity, occupation, education, postpartum body mass index, child sex and weight-for-age, and season. RESULTS: The risk of menstruation resumption was 4.2% (95% CI: 2.8%, 5.6%) at 6-7 mo and 6.5% (4.0%, 8.9%) at 9-10 mo. Compared with the introduction of complementary food after 6-7 mo, introduction at 2-3, 4-5, or 6-7 mo was associated with a greater odds of menstruation resumption at 6-7 mo [odds ratios (ORs): 5.08 (1.01, 25.5), 6.00 (1.29, 27.4), and 4.45 (0.96, 20.6; NS), respectively]. Introduction of food at 4-5 or 6-7 mo compared with that after 6-7 mo was associated with significantly greater odds of menstruation resumption at 6-7 mo (5.13; 1.16, 22.6) but not at 9-10 mo (3.07; 0.65, 14.4; NS) or year 2. CONCLUSION: Child age at introduction of complementary food was significantly associated with the odds of menstruation resumption at 6-7 mo postpartum.

Season of birth is not associated with risk of early adult death in rural Senegal.

BACKGROUND: In a rural area of the Gambia, West Africa, young adults born in the 'hungry' season had a high excess of deaths (mortality ratios (MR): 3.7 from 14.5 years and 10.3 from 25 years, P < 0.0001). Among several potential causal factors, fetal undernutrition was considered the most plausible. This study is a similar analysis of children and young adults living in rural Senegal, close to the Gambia. METHODS: A cohort of 9192 subjects born 1962-2001 with prospectively collected dates of birth and death was analysed. MR by season of birth (July-December/January-June) was estimated using Cox's proportional hazards analysis. The nutritional status of non-pregnant women was analysed at monthly intervals 1990-1996. RESULTS: MR by season of birth was slightly greater than 1 during infancy, and close to 1 from 1-5 years and from 5-14.5 years. From 14.5 years old the MR was 0.77 (95% CI: 0.47, 1.25, P = 0.29), compared with 0.53 (95% CI: 0.28, 1.02, P = 0.056) from 20 years and 0.33 (95% CI: 0.09, 1.25, P = 0.10) from 25 years. The weight of women varied strongly by season: means were 3.0-3.9 kg lower at the end of the rainy season (September-November) than during the dry season (February-May, P < 0.001 for each year). CONCLUSIONS: This study found no increased risk of death among young adults born during the hungry season in a rural West African area despite large seasonal variations in women's nutritional status. The strongly increased risk in adult Gambians is probably not explained by fetal undernutrition.

No improvement in weight-for-age of young children in southern Senegal, 1969-1992, despite a drastic reduction in mortality. Evidence from a growth monitoring programme.

BACKGROUND: Undernutrition is associated with an increased risk of death among young children in developing countries. Infant and child nutritional status and mortality were monitored in a rural area of Casamance, Senegal. METHODS: Analysis of weight measurements taken at 3-24 months of age during routine growth monitoring in the community's private dispensary 1969-1992 (3912 children, 4642 child-years) and of mortality rates of children estimated from maternal recall for 1960-1985 and yearly census 1985-1995. RESULTS: Between 1960-1964 and 1990-1994, under-5 and child (1-4 years) mortality rates decreased from 312 to 127 and from 201 to 68 per 1000, respectively. About 90% of resident children attended growth monitoring in 1985-1992. Mean weight-for-age was at a minimum at 15 months of age (-1.60 z-scores [SD: 0.95]); the prevalence of underweight was 33.2% (95% CI: 31.5, 34.9). The latter increased significantly over time, both when comparing all years of follow-up (P for trend <0.01) and over three pre-defined time periods (28.6, 34.6, and 35.0% in 1969-1974, 1975-1984, and 1985-1992, respectively, P for trend <0.05). Mean weight-for-age decreased over time in infancy and in the second year of life. CONCLUSION: No improvement in nutritional status was found among young children 1969-1992 despite a drastic decrease in mortality. Focused public health interventions such as vaccinations and malaria prevention probably did not enhance weight-for-age. Paradoxically, growth monitoring may have been more helpful in improving health than growth.

Comparative study of five growth models applied to weight data from congolese infants between birth and 13 months of age.

Five growth models are compared using weight data from 95 rural Congolese infants between birth and 13 months of age. The objective is to find the best model in terms of goodness of fit and distribution of parameter estimates. The Infancy component of the Karlberg model, the Count model, and the Kouchi model, which are all three-parameter models, are tested together with the four- and five-parameter versions of the Reed model. The closest fits are obtained using the Reed models, followed by the Karlberg model, while the Count and Kouchi models provide poor fits. The five-parameter Reed model is not superior to the four-parameter version. Examination of mean residuals by age shows a systematic bias in neonatal weight estimation with the three-parameter models. Mean within- and between-individual correlations are especially high for the Kouchi and Reed models. Extreme skewness is observed for some parameters of the Kouchi model and of the five-parameter Reed model. Despite its high degree of collinearity, the four-parameter linear Reed model should be preferred on weight data between birth and 1 year. The I-component of the Karlberg model could be used between ages 2 and 12 months. © 1992 Wiley-Liss, Inc.

Influence of wasting and stunting at the onset of the rainy season on subsequent malaria morbidity among rural preschool children in Senegal.

In sub-Saharan Africa, malaria and malnutrition are major causes of morbidity and mortality in children less than five years of age. To explore the impact of malnutrition on subsequent susceptibility to malaria, a cohort of 874 rural preschool children in Senegal was followed-up during one malaria transmission season from July through December. Data on nutritional status and Plasmodium falciparum parasitemia were collected at baseline. Malaria morbidity was monitored through weekly home visits. Wasted children (weight-for-height z-score < -2) were at lower risk of having at least one subsequent clinical malaria attack (odds ratio = 0.33; 95% confidence interval = 0.13-0.81, P = 0.02), whereas stunting (height-for-age z-score < -2) or being underweight (weight-for-age z-score < -2) was not associated with clinical malaria. Although non-biological explanations such as overprotection of wasted children by their mothers should be considered, immunomodulation according to nutritional status could explain the lower risk of malaria attack among wasted children.

Early breastfeeding cessation in rural Senegal: causes, modes, and consequences.

OBJECTIVES: We studied reasons for cessation of breastfeeding before the age of 15 months, replacement feeding modes, and child mortality in West Africa. METHODS: Data were gathered for 12208 children born between 1987 and 1997 in a rural area of Senegal. Interviews were conducted with caregivers of early-weaned children, and child mortality risks were assessed. RESULTS: Fewer than 1% of children had been weaned early. The main reasons for early weaning were maternal death and new pregnancy (in 41% and 27% of cases, respectively). Twenty percent of children had been relactated by a wet nurse, and 16% had received formula. Many early-weaned children died before the age of 2 years (26%), particularly those weaned early as a result of the mother's death (hazard ratio = 5.1; 95% confidence interval [CI] = 1.74, 15.0). Girls had a lower hazard ratio than boys (0.16; 95% CI=0.05, 0.41). CONCLUSIONS: Our results showed that early cessation of breastfeeding was rare but that associated mortality was high, especially when the mother had died.

The relationship between iron status and thyroid hormone concentration in iron-deficient adolescent Iranian girls.

Extensive data from animal and human studies indicate that iron deficiency impairs thyroid metabolism. The aim of this study was to determine thyroid hormone status in iron-deficient adolescent girls. By stepwise random sampling from among all public high schools for girls in Lar and its vicinity in southern Iran, 103 out of 431 iron deficient subjects were selected. Urine and serum samples were collected and assayed for urinary iodine and serum ferritin, iron, total iron binding capacity (TIBC), thyroid stimulating hormone (TSH), thyroxine (T4), triiodothyronine (T3), free thyroid hormones (fT4 and fT3), triiodothyronine resin uptake (T3RU), reverse triiodothyronine (rT3), selenium and albumin concentrations. Hematological indices for iron status confirmed that all subjects were iron-deficient. There was a significant correlation between T4 and ferritin (r = 0.52, P < 0.001) and between TSH and ferritin (r = -0.3, P < 0.05). Subjects with low serum ferritin had a higher ratio of T3/T4 (r = -0.42, P < 0.01). Using stepwise regression analysis, only ferritin contributed significantly to the rT3 concentration (r = -0.35, P < 0.01). The results indicate that the degree of iron deficiency may affect thyroid hormone status in iron-deficient adolescent girls.

Preschool stunting, adolescent migration, catch-up growth, and adult height in young senegalese men and women of rural origin.

Available data on the long-term consequences of preschool stunting are scarce and conflicting. The objective of this study was to assess the amount of catch-up growth from preschool stunting and the effect of migration (change in environment) during adolescence. A cohort study from preschool age (1-5 y) to adulthood (18-23 y) was conducted among 2874 subjects born in a rural area of Senegal. The subjects were divided into 3 groups of preschool stunting: none, mild, and marked, with height-for-age Z-scores of >-1, -2 to -1, and <-2, respectively. At follow-up, the history of migration was recalled. Mean height was 161.3 cm for girls and 174.0 cm for boys (>/=20 y). Stunted subjects remained smaller than the others: the age-adjusted height deficit between the 2 extreme categories was 6.6 and 9.0 cm in girls and boys, respectively. However, their height increment from early childhood to adulthood differed (69.3, 70.5, and 72.0 cm, P = 0.0001, and 78.9, 80.0, and 80.3 cm, P < 0.01, for nonstunted, mildly stunted, and markedly stunted girls and boys, respectively). The duration of labor migration to the city was associated with height increment in girls only in a nonlinear relation (adjusted means: 67.2, 69.3, 67.4, and 67.7 cm for 4 groups of increasing duration, P < 0.01). In conclusion, Senegalese children caught up in height prior to adulthood, with the adult means approximately 2 cm below the WHO/NCHS reference. However, this global catch up did not reduce height differences between formerly stunted and nonstunted children to any greater extent and it was not enhanced by labor migration.

Longitudinal estimates of puberty timing in Senegalese adolescent girls.

This study aimed to assess the timing of sexual maturation (breast development and menarche occurrence) among sub-Saharan African adolescent girls from rural areas. In the framework of a longitudinal study of growth at puberty, the stages of pubertal development (Tanner classification) and menarche occurrence were recorded at intervals between 1995 and 2000 in a sample of 406 Senegalese adolescent girls from a rural area. Nutritional status was estimated during infancy, childhood, and adolescence within this sample, and body composition was estimated only during adolescence. At the beginning of the study (1995), the adolescent girls were 11.4 years old (SD = 0.6). At the end of the study, they were 16.5 years old (SD = 0.6). Median and quartile ages at entry into each maturity stage and its confidence limits were estimated by a lognormal parametric survival model. These adolescent girls were shorter and thinner than girls of the same age from developed countries. Median age at the onset of breast development was 12.6 years (95% CI = 12.5-12.8). Median age at the end of sexual maturation and median age at menarche were estimated respectively at 15.8 years (95% CI = 15.7-15.9) and 15.9 years (95% CI = 15.7-15.9). These adolescent girls were less mature than other adolescent girls of the same age from other developing countries. Their puberty was extremely delayed compared to that of adolescent girls of the same age from industrialized countries. Puberty in these Senegalese adolescent girls is delayed by about 3 years. This may be due to malnutrition, significant energy expenditure, and poor diet and living conditions, and possibly to genetic control.

Non-specific effects of vaccination on child survival? A prospective study in Senegal.

OBJECTIVES: Several studies have shown an association between vaccination and child mortality in developing countries. The present paper examines this issue using data from a Senegalese rural area which has been monitored from 1983 to the present. METHODS: We analysed two birth cohorts, comprising 7796 and 3573 persons who had received either BCG and DTP (diphtheria-tetanus-pertussis) simultaneously or neither of these vaccines, and who had been followed from birth to 2 years of age. The association between vaccinations and mortality was assessed by Cox proportional hazards model. RESULTS: Mortality ratios for recipients of the BCG/DTP combination were 0.59 (95% CI: 0.46-0.74) for the first cohort and 0.70 (0.50-0.97) for the second cohort. Mortality ratios for measles vaccine recipients were 0.98 (0.75-1.27) for the first cohort and 0.87 (0.57-1.30) for the second cohort. CONCLUSIONS: The BCG/DTP combination was associated with a reduction in mortality whereas measles vaccination was not associated with mortality.

A young child feeding index is not associated with either height-for-age or height velocity in rural Senegalese children.

Ruel and Menon recently published a young child feeding index based on characteristics taken from 24-h and 7-d recalls. A strong positive association was found in 7 Latin American Demographic and Health Surveys for 12- to 36-mo-old children (1). The aim of this study was to test for associations of this index with height-for-age and linear growth in African children. Children (n = 500), aged 12-42 mo, living in a rural area of Senegal were visited in their homes in April-May, and 24-h and 7-d food recalls were conducted with their mothers. Height was measured, and measurements taken 7 mo earlier were used to compute linear growth rates. General linear models were used to adjust for potential confounders (child age and sex, maternal height, BMI, and socioeconomic status). The feeding index was not associated with either height-for-age (adjusted means: -1.01, -1.06, and -1.20 Z-scores for the 1st, 2nd, and 3rd tercile, respectively) or with linear growth (6.2, 6.0, and 6.3 cm/7 mo for the 3 terciles, respectively). Continuing breast-feeding was negatively associated with height-for-age (P < 0.05) and positively associated with linear growth (P < 0.01). Frequent consumption of fruit was positively associated with both (P = 0.059 and P = 0.027, respectively, in adjusted models), whereas food consumption from an animal source was not. In conclusion, the composite feeding index was independent of height and linear growth in these rural African children, due in part to reverse causality between breast-feeding duration and stunting.

Impact of the health and living conditions of migrant and non-migrant Senegalese adolescent girls on their nutritional status and growth.

OBJECTIVE: To describe the living conditions of Senegalese adolescent girls according to their migration status, and to define the main socio-economic and biological determinants of their nutritional and growth status. DESIGN: Health and living conditions, sexual maturation, and nutritional and growth status of adolescent girls were determined within the framework of a longitudinal study on growth. SETTINGS: The capital city of Senegal (Dakar) and a rural community (Niakhar), 120 km south-east of Dakar. SUBJECTS: Three hundred and thirty-one girls, 14.5-16.6 years of age, were recruited from the same villages. Thirty-six per cent of the sample remained in the villages to attend school and/or to help with household subsistence tasks (non-migrants). The remaining (64%) migrated to cities to work as maids (migrants) and lived in two different socio-economic environments: at the home of a guardian during the night and in the house of the employer during the daytime. RESULTS: Family rural environment and guardian and employer urban environments were socio-economically different (P < 0.001). Living conditions in urban areas were better than in rural areas and the employer's environment was socio-economically more favourable. Migrants had more advanced sexual maturation and higher body mass index (BMI), fat mass index (FMI) and mid-upper arm circumference than non-migrants. However, migrants were smaller than non-migrants. BMI, FMI and weight-for-age were related to socio-economic levels and duration of migration. Schooling was positively related to height and negatively related to BMI. CONCLUSIONS: Migrants enjoyed better living conditions than non-migrants. This could be partly due to the better socio-economic environment of the employer. It was associated with earlier puberty and better nutritional status, but not with a better growth.