Admission profile and discharge outcomes for infants aged less than 6 months admitted to inpatient therapeutic care in 10 countries. A secondary data analysis.

Evidence on the management of acute malnutrition in infants aged less than 6 months (infants <6mo) is scarce. To understand outcomes using current protocols, we analysed a sample of 24 045 children aged 0-60 months from 21 datasets of inpatient therapeutic care programmes in 10 countries. We compared the proportion of admissions, the anthropometric profile at admission and the discharge outcomes between infants <6mo and children aged 6-60 months (older children). Infants <6mo accounted for 12% of admissions. The quality of anthropometric data at admission was more problematic in infants <6mo than in older children with a greater proportion of missing data (a 6.9 percentage point difference for length values, 95% CI: 6.0; 7.9, P < 0.01), anthropometric measures that could not be converted to indices (a 15.6 percentage point difference for weight-for-length z-score values, 95% CI: 14.3; 16.9, P < 0.01) and anthropometric indices that were flagged as outliers (a 2.7 percentage point difference for any anthropometric index being flagged as an outlier, 95% CI: 1.7; 3.8, P < 0.01). A high proportion of both infants <6mo and older children were discharged as recovered. Infants <6mo showed a greater risk of death during treatment (risk ratio 1.30, 95% CI: 1.09; 1.56, P < 0.01). Infants <6mo represent an important proportion of admissions to therapeutic feeding programmes, and there are crucial challenges associated with their care. Systematic compilation and analysis of routine data for infants <6mo is necessary for monitoring programme performance and should be promoted as a tool to monitor the impact of new guidelines on care

Use of verbal autopsy for establishing causes of child mortality in camps for internally displaced people in Mogadishu, Somalia: a population-based, prospective, cohort study

BACKGROUND: People in humanitarian emergencies are likely to experience excess mortality but information on the causes of death is often unreliable or non-existent. This study aimed to provide evidence on the causes of death among children younger than 5 years in camps for internally displaced people in southern Somalia, during periods of protracted displacement and emergency influx amid the 2017 drought and health emergency. METHODS: We did a prospective, cohort study in 25 camps in the Afgooye corridor, on the outskirts of Mogadishu, Somalia. All internally displaced children aged 6-59 months were included and followed up with monthly household visits by community health workers. Nutrition, health, and vaccination status were ascertained and verbal autopsy interviews were done with the caregivers of deceased children. We calculated death rates in these children and used verbal autopsy to establish the cause-specific mortality fraction (CSMF). Bayesian InterVA software was used to assign likely causes to each death. FINDINGS: Between March, 2016, and March, 2018, 3898 children were followed up. 153 deaths were recorded during 34 746 person-months of observation. The death rate among children younger than 5 years exceeded emergency thresholds (>2 deaths per 10 000 children per day), reaching a peak of seven deaths per 10 000 children per day during the emergency influx. Verbal autopsy data were gathered for 80% of deaths, and the CSMF for the three leading causes of death were diarrhoeal diseases (25·9%), measles (17·8%), and severe malnutrition (8·8%). Coverage of measles vaccination during the first 3 months of the emergency was 42% and the CSMF for measles doubled during the influx. During protracted displacement, symptoms that could be attributable to HIV/AIDS related deaths accounted for 1·6% of the CSMF. INTERPRETATION: It is feasible to establish a health and nutrition surveillance system that ascertains causes of death, using verbal autopsy, in this humanitarian context. These data can inform policy, response planning, and priority setting. The high mortality rate from infectious diseases and malnutrition among children younger than 5 years suggests the need for strengthening a range of public health interventions, including vaccination and provision of water, sanitation, and hygiene. FUNDING: UK Department of International Development

Bioelectrical impedance vector analysis as an indicator of malnutrition in children under five years with and without pneumonia in Mchinji District, Malawi: An exploratory mixed-methods analysis [version 1; peer review: awaiting peer review]

Background: Bioelectrical impedance vector analysis (BIVA) is a non-invasive assessment of body composition and cellular health, which may improve the assessment of nutritional status in sick children. We explored the reliability, clinical utility, and acceptability of BIVA, as an indicator of nutritional status for children under five years with and without pneumonia, in Malawi. Methods: We conducted a parallel convergent mixed-methods exploratory study in Mchinji District Hospital, Malawi, in 2017. We planned to recruit a convenience sample of children aged 0-59 months with clinical pneumonia, and without an acute illness. Children had duplicate anthropometric and BIVA measurements taken. BIVA measurements of phase angle (PA) were taken of the whole body, and trunk and arm segments. Reliability was assessed by comparing the variability in the two measures, and clinical utility by estimating the association between anthropometry and PA using linear regression. Focus group discussions with healthcare workers who had not previously used BIVA instrumentation were conducted to explore acceptability. Results: A total of 52 children (24 with pneumonia and 28 healthy) were analysed. The reliability of sequential PA measurements was lower than anthropometric measurements, but trunk and arm segments performed better. The largest associations with PA were a negative relationship with weight-for-age z-score (WAZ) and PA in children with pneumonia in the trunk segment, and a positive association with WAZ in the full body measurement in healthy children. Healthcare workers in focus group discussions expressed trust in BIVA technology and that it would enable more accurate diagnosis of malnutrition; however, they raised concerns about the sustainability and necessary resources to implement BIVA. Conclusions: While healthcare workers were positive towards BIVA as a novel technology, implementation challenges should be expected. The differential direction of association between anthropometry and PA for children with pneumonia warrants further investigation

Socioeconomic determinants of growth in a longitudinal study in Nepal.

Socioeconomic status (SES) is associated with childhood anthropometry, but little is known about how it is associated with tissue growth and body composition. To investigate this, we looked at components of SES at birth with growth in early and mid-childhood, and body composition in a longitudinal study in Nepal. The exposure variables (material assets, land ownership, and maternal education) were quantified from questionnaire data before birth. Anthropometry data at birth, 2.5 and 8.5 years, were normalized using WHO reference ranges and conditional growth calculated. Associations with child growth and body composition were explored using multiple regression analysis. Complete anthropometry data were available for 793 children. There was a positive association between SES and height-for-age and weight-for-age, and a reduction in odds of stunting and underweight for each increase in rank of SES variable. Associations tended to be significant when moving from the lower to the upper asset score, from none to secondary education, and no land to >30 dhur (~500 m2 ). The strongest associations were for maternal secondary education, showing an increase of 0.6-0.7 z scores in height-for-age and weight-for-age at 2.5 and 8.5 years and 0.3 kg/m2 in fat and lean mass compared to no education. There was a positive association with conditional growth in the highest asset score group and secondary maternal education, and generally no association with land ownership. Our results show that SES at birth is important for the growth of children, with a greater association with fat mass. The greatest influence was maternal secondary education

A cash-based intervention and the risk of acute malnutrition in children aged 6-59 months living in internally displaced persons camps in Mogadishu, Somalia: A non-randomised cluster trial.

BACKGROUND: Somalia has been affected by conflict since 1991, with children aged <5 years presenting a high acute malnutrition prevalence. Cash-based interventions (CBIs) have been used in this context since 2011, despite sparse evidence of their nutritional impact. We aimed to understand whether a CBI would reduce acute malnutrition and its risk factors. METHODS AND FINDINGS: We implemented a non-randomised cluster trial in internally displaced person (IDP) camps, located in peri-urban Mogadishu, Somalia. Within 10 IDP camps (henceforth clusters) selected using a humanitarian vulnerability assessment, all households were targeted for the CBI. Ten additional clusters located adjacent to the intervention clusters were selected as controls. The CBI comprised a monthly unconditional cash transfer of US$84.00 for 5 months, a once-only distribution of a non-food-items kit, and the provision of piped water free of charge. The cash transfers started in May 2016. Cash recipients were female household representatives. In March and September 2016, from a cohort of randomly selected households in the intervention (n = 111) and control (n = 117) arms (household cohort), we collected household and individual level data from children aged 6-59 months (155 in the intervention and 177 in the control arms) and their mothers/primary carers, to measure known malnutrition risk factors. In addition, between June and November 2016, data to assess acute malnutrition incidence were collected monthly from a cohort of children aged 6-59 months, exhaustively sampled from the intervention (n = 759) and control (n = 1,379) arms (child cohort). Primary outcomes were the mean Child Dietary Diversity Score in the household cohort and the incidence of first episode of acute malnutrition in the child cohort, defined by a mid-upper arm circumference < 12.5 cm and/or oedema. Analyses were by intention-to-treat. For the household cohort we assessed differences-in-differences, for the child cohort we used Cox proportional hazards ratios. In the household cohort, the CBI appeared to increase the Child Dietary Diversity Score by 0.53 (95$29.60 (95% CI 3.51; 55.68), increase the household Food Consumption Score by 14.8 (95% CI 4.83; 24.8), and decrease the Reduced Coping Strategies Index by 11.6 (95% CI 17.5; 5.96). The study limitations were as follows: the study was not randomised, insecurity in the field limited the household cohort sample size and collection of other anthropometric measurements in the child cohort, the humanitarian vulnerability assessment data used to allocate the intervention were not available for analysis, food market data were not available to aid results interpretation, and the malnutrition incidence observed was lower than expected. CONCLUSIONS: The CBI appeared to improve beneficiaries' wealth and food security but did not appear to reduce acute malnutrition risk in IDP camp children. Further studies are needed to assess whether changing this intervention, e.g., including specific nutritious foods or social and behaviour change communication, would improve its nutritional impact. TRIAL REGISTRATION: ISRCTN Registy ISRCTN29521514

Bioelectrical impedance vector analysis as an indicator of malnutrition in children under five years with and without pneumonia in Mchinji District, Malawi: An exploratory mixed-methods analysis.

Background: Bioelectrical impedance vector analysis (BIVA) is a non-invasive assessment of body composition and cellular health, which may improve the assessment of nutritional status in sick children. We explored the reliability, clinical utility, and acceptability of BIVA, as an indicator of nutritional status for children under five years with and without pneumonia, in Malawi. Methods: We conducted a parallel convergent mixed-methods exploratory study in Mchinji District Hospital, Malawi, in 2017. We planned to recruit a convenience sample of children aged 0-59 months with clinical pneumonia, and without an acute illness. Children had duplicate anthropometric and BIVA measurements taken. BIVA measurements of phase angle (PA) were taken of the whole body, and trunk and arm segments. Reliability was assessed by comparing the variability in the two measures, and clinical utility by estimating the association between anthropometry and PA using linear regression. Focus group discussions with healthcare workers who had not previously used BIVA instrumentation were conducted to explore acceptability. Results: A total of 52 children (24 with pneumonia and 28 healthy) were analysed. The reliability of sequential PA measurements was lower than anthropometric measurements, but trunk and arm segments performed better. The largest associations with PA were a negative relationship with weight-for-age z-score (WAZ) and PA in children with pneumonia in the trunk segment, and a positive association with WAZ in the full body measurement in healthy children. Healthcare workers in focus group discussions expressed trust in BIVA technology and that it would enable more accurate diagnosis of malnutrition; however, they raised concerns about the sustainability and necessary resources to implement BIVA. Conclusions: While healthcare workers were positive towards BIVA as a novel technology, implementation challenges should be expected. The differential direction of association between anthropometry and PA for children with pneumonia warrants further investigation

Bioelectrical impedance vector analysis as an indicator of malnutrition in children under five years with and without pneumonia in Mchinji District, Malawi: An exploratory mixed-methods analysis [version 3; peer review: 1 approved, 1 approved with reservations]

Bioelectrical impedance vector analysis (BIVA) is a non-invasive approach to assessing body composition and cellular health, which may improve the assessment of nutritional status in sick children. We explored the reliability, clinical utility, and acceptability of BIVA, as an indicator of nutritional status for children under five years with and without pneumonia, in Malawi. Methods We conducted a parallel convergent mixed-methods exploratory study in Mchinji District Hospital, Malawi, in 2017. We recruited a convenience sample of children aged 0–59 months with clinical pneumonia, and without an acute illness. Children had duplicate anthropometric and BIVA measurements taken. BIVA measurements of phase angle were taken of the whole body, and trunk and arm segments. Reliability was assessed by comparing the variability in the two measures, and clinical utility by estimating the association between anthropometry and phase angle using linear regression. Focus group discussions with healthcare workers who had not previously used BIVA instrumentation were conducted to explore acceptability. Results A total of 52 children (24 with pneumonia and 28 healthy) were analysed. The reliability of sequential phase angle measurements was lower than anthropometric measurements, but trunk and arm segments performed better. The largest associations with phase angle were a negative relationship with weight-for-age z-score (WAZ) in children with pneumonia in the trunk segment, and a positive association with WAZ in the full body measurement in healthy children. Healthcare workers in focus group discussions expressed trust in BIVA technology and that it would enable more accurate diagnosis of malnutrition; however, they raised concerns about the sustainability and necessary resources to implement BIVA. Conclusions While healthcare workers were positive towards BIVA as a novel technology, implementation challenges should be expected. The differential direction of association between anthropometry and phase angle for children with pneumonia warrants further investigation

Implementing a Care Pathway for small and nutritionally at-risk infants under six months of age: A multi-country stakeholder consultation

Nutritional vulnerability under the age of 6 months is prevalent in low- and middle-income countries with 20.1% infants underweight, 21.3% wasted and 17.6% stunted in a recent review. A novel Care Pathway for improved management of small and nutritionally at-risk infants under 6 months and their mothers (MAMI) has recently been developed to provide outpatient care at large coverage. We aimed to investigate stakeholders' views on the feasibility of its implementation and to identify barriers and enablers. This was an early stage formative mixed-methods study: an online survey plus in-depth interviews with country-level stakeholders in nutrition and child health from different geographical regions and stakeholder groups. 189 stakeholders from 42 countries responded to the online survey and 14 remote interviews were conducted. Participants expressed an urgent need for improved detection and care for small and nutritionally at-risk infants under 6 months. Whilst they considered the MAMI Care Pathway feasible and relevant, they noted it was largely unknown in their country. The most mentioned implementation barriers were: community-specific needs and health care seeking barriers, health workers' lack of competence in breastfeeding counselling and the absence of a validated anthropometric screening method. Possible enablers for its implementation were: patients' preference for outpatient care, integrating the MAMI care pathway into existing maternal and child health programmes and the possibility of a local pilot project. Adaptation to the local context was considered crucial in further scale-up

Malnutrition in Infants Aged under 6 Months Attending Community Health Centres: A Cross Sectional Survey.

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