Management of Acute Malnutrition in Infants under 6 Months of Age

Both acute malnutrition and nutrition (breastfeeding) in infants under 6 months of age (infants <6 months) are important global health issues and have received much international attention over the years. However, it is only recently that the two in combination— the management of acute malnutrition in infants <6 months (MAMI)—have been examined. This chapter outlines the background epidemiology, why acute malnutrition in this age group matters, key challenges around infant <6 months malnutrition, current assessment and treatment strategies, and, finally, directions for the future. Readers should look to other chapters of this book for added detail, as MAMI has numerous links and synergies with other areas of malnutrition, with many opportunities to benefit both short- and long-term health

Volume marker inaccuracies: a cross-sectional survey of infant feeding bottles.

A cross-sectional examination of the accuracy of volume markers on infant feeding bottles available for sale in Australia between December 2013 and February 2014 was carried out. Ninety-one bottles representing 28 different brands were examined. Eighty-eight bottles were hard sided. Volumes in these bottles were marked in a combination of milliliters and ounces. Thirty-six (41%) bottles claimed compliance with the European standard EN14350, five (6%) with non-existent Australian standards, and forty-seven (54%) bottles had no standard claim. Nineteen bottles (22%) had at least one measured marking outside the tolerance of EN14350. Bottles claiming compliance with EN14350 were not less likely to have inaccurate markings than those that made no claim. More expensive bottles did not have fewer inaccurate markings. Three bottles were disposable liner systems and had particularly large volume inaccuracies (up to 43% outside the marked volume). Inaccurate volume markers on infant feeding bottles are a previously neglected but potentially important source of error in the reconstitution of infant formula. Over-concentrated and under-concentrated infant formula can cause serious illness or malnutrition. Over-concentrated infant formula may contribute to obesity. Bottles with inaccurate volume markers are unfit for purpose; disposable liner bottles are particularly poor in this regard and should be prohibited from having volume markers on the bottle casing. To avoid individual or public harms, well-enforced standards are needed. Guidance for parents, carers, and health professionals is needed to ensure that infant formula is accurately reconstituted

Improving the treatment of severe acute malnutrition in childhood: a randomized controlled trial of synbiotic-enhanced therapeutic food with long term follow-up of post-treatment mortality and morbidity

BACKGROUND: Tackling severe acute malnutrition (SAM) is a global public health priority. This thesis explores two major influences on treatment outcomes: -Treatment efficacy -Patient-related risk factors OBJECTIVES: 1. To explore whether a pre/probiotic mixture (Synbiotic2000 Forte™) improves treatment outcomes (nutritional and clinical) in children affected by SAM. 2. To describe long term outcomes from SAM and identify key mortality risk factors. METHODS: All 1024 malnourished children admitted to a therapeutic feeding centre in Malawi from July 2006 to March 2007 were eligible for: The PRONUT study (Pre and PRObiotics in the treatment of severe acute malNUTrition): 795 were recruited into a randomised, double-blind, placebo-controlled trial. They received Readyto- Use Therapeutic Food either with or without Synbiotic2000 Forte™. Primary outcome was nutritional cure (weight-for-height >80% of NCHS median). The FUSAM study (Long term Follow-Up after Severe Acute Malnutrition): all children known to be still alive were followed up ≥1 year post discharge. RESULTS: In PRONUT, nutritional cure was similar in both groups: 54%(215/399) for Synbiotic-enhanced RUTF and 51%(203/396) for controls (p=0.40). Main secondary outcomes were also similar (p>0.05). Overall mortality from SAM was 41%(427/1024). Mortality was highest during initial inpatient treatment: 23%(238/1024). In FUSAM, 8%(84/1024) more died within 90 days of admission and 10%(105/1024) during long term follow-up. Cox regression identified HIV, low weight-forheight, low mid-upper arm circumference and low weight-for-age as major risk factors for death (p<0.001). CONCLUSIONS: In this high-mortality setting, Synbiotic2000 ForteTM, did not improve clinical or nutritional outcomes from SAM. A more promising strategy to improve outcomes might be to tackle the major risk factors for SAM mortality: HIV and severity of malnutrition disease. It is likely that earlier treatment would be beneficial. This is a focus of current strategies for both HIV and malnutrition. Rollout of such programmes should be supported and their impact on SAM evaluated

Interpretation of World Health Organization growth charts for assessing infant malnutrition: A randomised controlled trial

Aims The study aims to assess the effects of switching from National Center for Health Statistics (NCHS) growth references to World Health Organization (WHO) growth standards on health-care workers' decisions about malnutrition in infants aged <6 months. Methods We conducted a single blind randomised crossover trial involving 78 health-care workers (doctors, clinical officers, health service assistants) in Southern Malawi. Participants were offered hypothetical clinical scenarios with the same infant plotted on NCHS-based weight-for-age charts and again on WHO-based charts. Additional scenarios compared growth charts with a single final weight against charts with the same final weight plus a preceding growth trend. Reported (i) level of concern, (ii) referral suggestions and (iii) feeding advice were elicited with a questionnaire. Results Even after adjusting for health-care worker type and experience, using WHO rather than NCHS charts increased: (i) concern: aOR 4.4 (95% CI 2.4-8.1); (ii) odds of referral: aOR 5.1 (95% CI 2.4-10.8); and (iii) odds of feeding advice which would interrupt exclusive breastfeeding (aOR 2.4, 95% CI 1.2-4.9). A preceding steady growth trend line did not affect concern, referral or feeding advice. Conclusions Health-care workers take insufficient account of linear growth trend, clinical and feeding status when interpreting a low weight-for-age plot. Because more infants <6 months fall below low centile lines on WHO growth charts, their use may increase inappropriate referrals and risks undermining already low rates of exclusive breastfeeding. To avoid their being misinterpreted in this way, WHO charts need accompanying guidelines and training materials that recognise and address this possible adverse effect. © 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

Preventing Acute Malnutrition in Young Children: Improving the Evidence for Current and Future Practice

Marko Kerac and Andrew Seal comment on the study by Langendorf and colleagues about the effectiveness of different strategies to prevent malnutrition in young children and discuss the implications of this study for food programs worldwide

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 points 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 points 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 points 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

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 &lt;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 &lt;6mo and children aged 6-60 months (older children). Infants &lt;6mo accounted for 12% of admissions. The quality of anthropometric data at admission was more problematic in infants &lt;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 &lt; 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 &lt; 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 &lt; 0.01). A high proportion of both infants &lt;6mo and older children were discharged as recovered. Infants &lt;6mo showed a greater risk of death during treatment (risk ratio 1.30, 95% CI: 1.09; 1.56, P &lt; 0.01). Infants &lt;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 &lt;6mo is necessary for monitoring programme performance and should be promoted as a tool to monitor the impact of new guidelines on care

[Accepted Manuscript] Monitoring and discharging children being treated for severe acute malnutrition using mid-upper arm circumference: secondary data analysis from rural Gambia.

Severe acute malnutrition (SAM) is a major public health problem. Mid-upper arm circumference (MUAC) is widely used to admit children to treatment programmes. However, insufficient data supporting MUAC discharge criterion limits its use as a stand-alone tool. Our aim was to evaluate MUAC for monitoring nutritional recovery and discharge. This was a secondary analysis of clinical data from children 6-59 months-old treated for SAM from January 2003 to December 2013 at the Nutritional Rehabilitation Unit in rural Gambia. Weight, weight-for-height z-score (WHZ) and MUAC response to treatment were assessed. Treatment indicators and regression models controlled for admission measurement and age were compared by discharge MUAC and WHZ. Four hundred and sixty-three children with marasmus were included. MUAC, WHZ and weight showed parallel responses to treatment. MUAC≥125 mm as a discharge criterion performed well, showing good prediction of default and referral to hospital, acceptable duration of stay, and a higher absolute MUAC measure compared to WHZ≥-2.00, closely related to lower risk of mortality. MUAC can be used as a standalone tool for monitoring nutritional recovery. MUAC≥125 mm performs well as a discharge criterion; however, follow-up data is needed to assess its safety. Further research is needed on children meeting MUAC discharge criterion but with WHZ≤2.0

Long-term sustainability of bio-components production

Biofuels play an increasingly important role in motor fuel market. The list of biofuels (bio-components) in accordance with EU legislations contains a number of substances not widely used in the market. Traditionally these include: fatty acid methyl esters (FAME, in the Czech Republic methyl ether of rape seed oil) and bioethanol (also ethyl terc. buthyl ether ETBE, based on bioethanol). The availability and possible utilizations of bio-component fuels in Czech Republic and Serbia are discussed. Additional attention is paid on the identification of the possibilities to improve effectiveness of rape seeds cultivation and utilization of by-products from FAME production (utilization of sew, rape-meal and glycerol) which will allow fulfilment of the sustainability criteria for the first generation biofuels. The new approaches on renewable co-processing are commented. The concept of 3E (emissions, energy demand, and economics) is introduced specifying three main attributes for effective production of FAME production in accordance with legal compliances. Bio-components price change is analyzed in comparison to the price of motor fuels, identifying possible (speculative) crude price break-even point at the level of 149-176 USD/bbl at which point bio-fuels would become economically cost effective for the use by refiners