Intervention to address childhood undernutrition: A systematic review

Introduction: Childhood undernutrition while being a preventable condition remains a major public health issue because it contributes to the mortality and morbidity of children globally. Intervention strategies to improve the nutritional status of children include therapeutic food, cash transfers, antibiotics and nutritional education. The objective is to review the effects of various nutritional interventions in addressing undernutrition in children. Methods: Comprehensive search of literature in electronic databases were conducted in PubMed, Science Direct, and Scopus containing the Medical Subject Headings (MeSH) and the title terms ‘Undernutrition’ OR ‘Malnutrition AND ‘Intervention’ OR ‘Management’ AND ‘Children’ OR ‘Childhood’ between January 2000 and August 2019. Of the 4358 studies that were identified, 17 studies matched the inclusion criteria and were reviewed. Results: Therapeutic food is an integral part of nutritional interventions in majority of the studies along with cash transfers and nutritional education. The most consistent outcome in most of the studies was improvement in the nutritional status which subsequently reduces the undernutrition in children. Conclusion: Therapeutic food, conditional cash transfer and nutritional education yielded the best outcome in alleviating undernutrition in developing countries

Risk factors for undernutrition in children under five years of age in Tenom, Sabah, Malaysia

ABSTRACT Undernutrition is the result of complex interplay of factors such as household food security, childcare, feeding practices, nutrition and sanitation. Therefore, this study aimed to determine the prevalence of stunting, wasting, underweight based on WHO child growth standards 2006 and undernutrition based on Composite Index Anthropometric Failure (CIAF) and its association with the biological, behavioural, socio-economic and physical environment factors among children under-5 years. This was a cross sectional study involving children aged between 6 and 59 months recruited through stratified random sampling from the Tenom district. Sociodemographic background was obtained from mothers via a questionnaire. Height and weight measurements were measured using standardised instrument. The height-for-age, weight-for-age and BMI-for-age were classified according to the WHO Child Growth Standard 2006. Bivariate analysis and multivariate logistic regression analysis were conducted. The prevalence of undernutrition based on CIAF was 42.3%, underweight 34.7%, stunting 33.3% and wasting 10.0%. After adjusting for all confounders, childhood undernutrition was significantly associated with unimproved sanitation (adjusted OR 2.98, 95% CI: 1.082 to 8.225) and frequent illness (adjusted OR 2.07, 95% CI: 1.015 to 3.274). These findings support the association of biological and physical environmental factors with the nutritional status of children under-5 years old

The association of eating behaviour on the growth of children from the interior districts of Sabah, Malaysia

Background: The double burden of malnutrition among children is an emerging public health problem, especially in developing countries. Eating behaviours have been hypothesised to contribute to both being underweight and overweight in children and adults. The objective of this study was to examine the association between the Child Eating Behaviour Questionnaire (CEBQ) subscale scores and body mass index (BMI) z-scores among Malaysian children under-5 years. Methods: This was a cross-sectional study conducted in 2020 by recruiting a sample of 500 children aged 24–59 months old from clinics located in the interior districts of Sabah, Malaysia. The CEBQ was completed by the mothers on behalf of the child to assess their eating behaviour traits. The height and weight of the child were measured using standardised instrument. The BMI-for-age percentile, z-scores for BMI-for-age, height-for-age and weight-for-age were determined and classified using World Health Organization AnthroPlus software. The relationship between the CEBQ subscale scores and BMI z-scores were evaluated using multiple linear regression models adjusting for potential confounders. Results: The prevalence of underweight, stunting and wasting were 20.2%, 29.2% and 5.6%, respectively, whereas the prevalence of overweight and obese was 5.0%. There were significant positive association between Food responsiveness, Emotional overeating, Enjoyment of food with BMI z-scores (p<0.05; unstandardised regression coefficient: 0.17 to 0.38). In contrast, there were significant negative association between Satiety responsiveness, Slowness of eating, Food fussiness with BMI z-scores (p<0.01; unstandardised regression coefficient: −0.35 to −0.36). Conclusion: These findings show that specific eating behaviours can influence the growth of children under-5 years. Therefore, policymakers should formulate a nutrition policy that incorporates behavioural assessment and behavioural intervention in the prevention and management of malnutrition among children in Malaysia

Complications of Melioidosis: A Systematic Review

Introduction: Melioidosis, also known as Whitmore disease, is caused by the gram-negative bacillus, Burkholderia pseudomallei and remains a public health concern in Southeast Asia and northern parts of Australia. This study attempts to identify all possible complications of melioidosis and its outcomes. Methods: Literature search was conducted from databases such as PubMed, Science Direct and Scopus from 1st January 2000 to 31st August 2019. Medical Subject Headings (MeSH) search strategy was used with the terms ‘Melioidosis’ or ‘Burkholderia pseudomallei’ and ‘Complications’. Results: A total of 162 titles were identified and 22 articles were included in the review. Findings showed that among the 22 articles, the ratio of male to female melioidosis incidence was 2.3 to 1, with most cases (86.4%) aged older than 14 years old and showed a mean age of 46 years old. A third (7/22) of the papers reported the involvement of the nervous system as a complication of melioidosis followed by cardiovascular complications. Among the 23 cases reported, 13 had underlying medical conditions with most of them (84.6%) having diabetes mellitus or newly diagnosed with diabetes mellitus. Overall, only one case (4.3%) had resulted in mortality, while 17.4% developed complications and 78.3% managed a full recovery after undergoing treatment for melioidosis. Conclusion: The most commonly found complication of melioidosis involved the nervous system but patient outcomes were favourable. Rare complications included mycotic aneurysm that can be fatal. Melioidosis can affect almost any organ leading to various complications

Paediatric COVID-19 mortality: a database analysis of the impact of health resource disparity

Background The impact of the COVID-19 pandemic on paediatric populations varied between high-income countries (HICs) versus low-income to middle-income countries (LMICs). We sought to investigate differences in paediatric clinical outcomes and identify factors contributing to disparity between countries.Methods The International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) COVID-19 database was queried to include children under 19 years of age admitted to hospital from January 2020 to April 2021 with suspected or confirmed COVID-19 diagnosis. Univariate and multivariable analysis of contributing factors for mortality were assessed by country group (HICs vs LMICs) as defined by the World Bank criteria.Results A total of 12 860 children (3819 from 21 HICs and 9041 from 15 LMICs) participated in this study. Of these, 8961 were laboratory-confirmed and 3899 suspected COVID-19 cases. About 52% of LMICs children were black, and more than 40% were infants and adolescent. Overall in-hospital mortality rate (95% CI) was 3.3% [=(3.0% to 3.6%), higher in LMICs than HICs (4.0% (3.6% to 4.4%) and 1.7% (1.3% to 2.1%), respectively). There were significant differences between country income groups in intervention profile, with higher use of antibiotics, antivirals, corticosteroids, prone positioning, high flow nasal cannula, non-invasive and invasive mechanical ventilation in HICs. Out of the 439 mechanically ventilated children, mortality occurred in 106 (24.1%) subjects, which was higher in LMICs than HICs (89 (43.6%) vs 17 (7.2%) respectively). Pre-existing infectious comorbidities (tuberculosis and HIV) and some complications (bacterial pneumonia, acute respiratory distress syndrome and myocarditis) were significantly higher in LMICs compared with HICs. On multivariable analysis, LMIC as country income group was associated with increased risk of mortality (adjusted HR 4.73 (3.16 to 7.10)).Conclusion Mortality and morbidities were higher in LMICs than HICs, and it may be attributable to differences in patient demographics, complications and access to supportive and treatment modalities

Association of Country Income Level With the Characteristics and Outcomes of Critically Ill Patients Hospitalized With Acute Kidney Injury and COVID-19

Introduction: Acute kidney injury (AKI) has been identified as one of the most common and significant problems in hospitalized patients with COVID-19. However, studies examining the relationship between COVID-19 and AKI in low- and low-middle income countries (LLMIC) are lacking. Given that AKI is known to carry a higher mortality rate in these countries, it is important to understand differences in this population. Methods: This prospective, observational study examines the AKI incidence and characteristics of 32,210 patients with COVID-19 from 49 countries across all income levels who were admitted to an intensive care unit during their hospital stay. Results: Among patients with COVID-19 admitted to the intensive care unit, AKI incidence was highest in patients in LLMIC, followed by patients in upper-middle income countries (UMIC) and high-income countries (HIC) (53%, 38%, and 30%, respectively), whereas dialysis rates were lowest among patients with AKI from LLMIC and highest among those from HIC (27% vs. 45%). Patients with AKI in LLMIC had the largest proportion of community-acquired AKI (CA-AKI) and highest rate of in-hospital death (79% vs. 54% in HIC and 66% in UMIC). The association between AKI, being from LLMIC and in-hospital death persisted even after adjusting for disease severity. Conclusions: AKI is a particularly devastating complication of COVID-19 among patients from poorer nations where the gaps in accessibility and quality of healthcare delivery have a major impact on patient outcomes

Liver injury in hospitalized patients with COVID-19: An International observational cohort study

Background: Using a large dataset, we evaluated prevalence and severity of alterations in liver enzymes in COVID-19 and association with patient-centred outcomes.MethodsWe included hospitalized patients with confirmed or suspected SARS-CoV-2 infection from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) database. Key exposure was baseline liver enzymes (AST, ALT, bilirubin). Patients were assigned Liver Injury Classification score based on 3 components of enzymes at admission: Normal; Stage I) Liver injury: any component between 1-3x upper limit of normal (ULN); Stage II) Severe liver injury: any component &amp; GE;3x ULN. Outcomes were hospital mortality, utilization of selected resources, complications, and durations of hospital and ICU stay. Analyses used logistic regression with associations expressed as adjusted odds ratios (OR) with 95% confidence intervals (CI).ResultsOf 17,531 included patients, 46.2% (8099) and 8.2% (1430) of patients had stage 1 and 2 liver injury respectively. Compared to normal, stages 1 and 2 were associated with higher odds of mortality (OR 1.53 [1.37-1.71]; OR 2.50 [2.10-2.96]), ICU admission (OR 1.63 [1.48-1.79]; OR 1.90 [1.62-2.23]), and invasive mechanical ventilation (OR 1.43 [1.27-1.70]; OR 1.95 (1.55-2.45). Stages 1 and 2 were also associated with higher odds of developing sepsis (OR 1.38 [1.27-1.50]; OR 1.46 [1.25-1.70]), acute kidney injury (OR 1.13 [1.00-1.27]; OR 1.59 [1.32-1.91]), and acute respiratory distress syndrome (OR 1.38 [1.22-1.55]; OR 1.80 [1.49-2.17]).ConclusionsLiver enzyme abnormalities are common among COVID-19 patients and associated with worse outcomes

Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry

Background: COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives: The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods: Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results: The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion: In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings

At-admission prediction of mortality and pulmonary embolism in an international cohort of hospitalised patients with COVID-19 using statistical and machine learning methods

By September 2022, more than 600 million cases of SARS-CoV-2 infection have been reported globally, resulting in over 6.5 million deaths. COVID-19 mortality risk estimators are often, however, developed with small unrepresentative samples and with methodological limitations. It is highly important to develop predictive tools for pulmonary embolism (PE) in COVID-19 patients as one of the most severe preventable complications of COVID-19. Early recognition can help provide life-saving targeted anti-coagulation therapy right at admission. Using a dataset of more than 800,000 COVID-19 patients from an international cohort, we propose a cost-sensitive gradient-boosted machine learning model that predicts occurrence of PE and death at admission. Logistic regression, Cox proportional hazards models, and Shapley values were used to identify key predictors for PE and death. Our prediction model had a test AUROC of 75.9% and 74.2%, and sensitivities of 67.5% and 72.7% for PE and all-cause mortality respectively on a highly diverse and held-out test set. The PE prediction model was also evaluated on patients in UK and Spain separately with test results of 74.5% AUROC, 63.5% sensitivity and 78.9% AUROC, 95.7% sensitivity. Age, sex, region of admission, comorbidities (chronic cardiac and pulmonary disease, dementia, diabetes, hypertension, cancer, obesity, smoking), and symptoms (any, confusion, chest pain, fatigue, headache, fever, muscle or joint pain, shortness of breath) were the most important clinical predictors at admission. Age, overall presence of symptoms, shortness of breath, and hypertension were found to be key predictors for PE using our extreme gradient boosted model. This analysis based on the, until now, largest global dataset for this set of problems can inform hospital prioritisation policy and guide long term clinical research and decision-making for COVID-19 patients globally. Our machine learning model developed from an international cohort can serve to better regulate hospital risk prioritisation of at-risk patients

The value of open-source clinical science in pandemic response: lessons from ISARIC

International audienc