Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Utilising emerging perspectives at the global and regional level to frame multisectoral nutrition governance landscape in Kenya

Abstract Objective: Multisectoral nutrition governance (MNG) is a vital enabling determinant of improved nutrition outcomes. Despite this, it remains to be a complex phenomenon that lacks adequate understanding, especially in developing countries like Kenya. This narrative review aims to discuss the evolution of MNG, the current state of MNG, barriers and challenges, and based on these identify entry points for improvement within the complex governance structure in Kenya. Design: The Peer Review of Electronic Search Strategies (PRESS) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to ensure rigorous and transparent identification of literature and interpretation. Setting: Kenya and developing countries with similar contexts. Participants: The review included forty-five documents (peer-reviewed articles and grey literature) that reported on MNG in developing countries. Results: We acknowledge that MNG is a complex and evolving determinant of better nutrition outcomes. The paper highlights challenges Kenya and other developing countries face such as inadequate leadership, inadequate coordination, insufficient capacity, inadequate monitoring and evaluation systems, and limited financial resources, among others. For Kenya in particular, there is inadequate understanding of what MNG is and how it can be effectively operationalised and tracked. Conclusions: To enhance understanding of MNG in Kenya, a country-specific assessment of MNG processes and impact outcomes using standard tools and defined metrics is vital. Such assessment will generate evidence of progress, successes, and challenges that will compel the government and stakeholders to invest more in multisectoral nutrition approaches to achieve its nutrition goals

Addressing the risk of inadequate and excessive micronutrient intakes: traditional versus new approaches to setting adequate and safe micronutrient levels in foods

Fortification of foods consumed by the general population or specific food products or supplements designed to be consumed by vulnerable target groups is amongst the strategies in developing countries to address micronutrient deficiencies. Any strategy aimed at dietary change needs careful consideration, ensuring the needs of at-risk subgroups are met whilst ensuring safety within the general population. This paper reviews the key principles of two main assessment approaches that may assist developing countries in deciding on effective and safe micronutrient levels in foods or special products designed to address micronutrient deficiencies, that is, the cut-point method and the stepwise approach to risk–benefit assessment. In the first approach, the goal is to shift population intake distributions such that intake prevalences below the Estimated Average Requirement (EAR) and above the Tolerable Upper Intake Level (UL) are both minimized. However, for some micronutrients like vitamin A and zinc, a narrow margin between the EAR and UL exists. Increasing their intakes through mass fortification may pose a dilemma; not permitting the UL to be exceeded provides assurance about the safety within the population but can potentially leave a proportion of the target population with unmet needs, or vice versa. Risk–benefit approaches assist in decision making at different micronutrient intake scenarios by balancing the magnitude of potential health benefits of reducing inadequate intakes against health risks of excessive intakes. Risk–benefit approaches consider different aspects of health risk including severity and number of people affected. This approach reduces the uncertainty for policy makers as compared to classic cut-point methods