Tackling the triple threats of childhood malnutrition.

The term 'double burden of malnutrition' is usually interpreted in terms of the physical status of children: stunted and wasted children on the one hand and overweight/obese children on the other. There is a third category of malnutrition that can occur at either end of the anthropometric spectrum or, indeed, in children whose physical size may be close to ideal. This third type is most commonly articulated with the phrase 'hidden hunger' and is often illustrated by micronutrient deficiencies; thus, we refer to it here as 'undernutrition'. As understanding of such issues advances, we realise that there is a myriad of factors that may be influencing a child's road to nutritional health. In this BMC Medicine article collection we consider these influences and the impact they have, such as: the state of the child's environment; the effect this has on their risk of, and responses to, infection and on their gut; the consequences of poor nutrition on cognition and brain development; the key drivers of the obesity epidemic across the globe; and how undernourishment can affect a child's body composition. This collection showcases recent advances in the field, but likewise highlights ongoing challenges in the battle to achieve adequate nutrition for children across the globe

Maternal perception of malnutrition among infants using verbal and pictorial methods in Kenya.

OBJECTIVE: To compare mothers' perceptions of their own infants' nutritional status with anthropometric indicators of undernutrition. DESIGN: A qualitative study and cross-sectional quantitative survey. The qualitative study involved developing tools to assess mother's perception. Two methods of verbal description and a pictorial scale were developed. The quantitative survey involved measuring maternal perception and comparing it with the anthropometric measures of weight-for-age Z-score (WAZ) and mid-upper arm circumference-for-age Z-score (MUACZ). SETTING: A rural community setting in Kenya. SUBJECTS: Seventy-four infants aged between 4 and 6 months, and their mothers, living in rural Kenya were enrolled. RESULTS: Using verbal description, the positive and negative likelihood ratios were 3.57 (95 % CI 1.44, 9.98) and 0.69 (95 % CI 0.50, 0.96) respectively for MUACZ<-2; and 4.60 (95 % CI 1.60, 13.3) and 0.67 (95 % CI 0.49, 0.92) respectively for WAZ<-2. Using the pictorial scale, the positive and negative likelihood ratios were 8.30 (95 % CI 1.91, 36.3) and 0.69 (95 % CI 0.52, 0.93) respectively for MUACZ<-2; and 4.31 (95 % CI 1.22, 15.0) and 0.78 (95 % CI 0.61, 1.00) respectively for WAZ<-2. CONCLUSIONS: In a rural community, mothers better identify undernutrition in their infants using a pictorial scale than verbal description. However, neither can replace formal anthropometric assessment. Objective anthropometric tools should be validated for identification of severe acute malnutrition among infants aged less than 6 months

A growth reference for mid upper arm circumference for age among school age children and adolescents, and validation for mortality: growth curve construction and longitudinal cohort study

Objectives Worldwide, school age children and adolescents are vulnerable to conflict and food insecurity and HIV-infected children are increasingly surviving into adolescence. WHO recommends assessing acute malnutrition in this age group using body mass index-for-age Z scores (BMIz). For under-fives, mid upper arm circumference (MUAC) is the mainstay of community diagnosis of acute malnutrition, is simple to perform and predicts survival better than weight-for-height Z scores. MUAC is little-used in older children and adolescents because there is no accepted international reference. This study aimed to construct growth curves for MUAC-for-age Z score (MUACz) for 5-19 year olds that accord with WHO Growth Standards, and evaluate their discriminatory performance for subsequent mortality. Design The HES/NHANES US population datasets (age 5-25 years), which were used to construct the 2007 WHO Growth Reference for BMI in this age group, were merged with an imputed dataset matching the distribution of the WHO 2006 Growth Standards age 2-6 years. To construct standardised growth curves, we used Generalized Additive Models for Location, Scale and Shape with Box-Cox Cole Green transformation and penalized B-spline smoothing. Validation for subsequent mortality in two cohorts was done using Cox proportional hazards models for pre-defined MUACz and BMIz thresholds, with age, gender and HIV status as covariates; and estimation of the area under receiver-operating characteristic curves (AUC). Participants Validation data were from 685 HIV-infected children age 5¬–17 years participating in the ARROW trial in Uganda and Zimbabwe; and 1,741 children age 5–13 years discharged from a rural Kenyan hospital (3.8% HIV-infected). Both cohorts were followed up for survival during one year. Main outcome measures Concordance with WHO 2006 Growth Standards at age 60 months and survival during one year according to MUACz and BMIz. Results The new growth curves transitioned smoothly with WHO Growth Standards at age 5 years. MUACz of -2 to -3 and <-3, compared with ≥-2, was associated with hazard ratios for death within one year of 3.63 (95%CI 0.90 to 14.7; P=0.07) and 11.1 (95%CI 3.40 to 36.0; P<0.0001) respectively among ARROW trial participants; and 2.22 (95%CI 1.01 to 4.9; P=0.04) and 5.15 (95%CI 2.49 to 10.7; P<0.0001) respectively among Kenyan children after discharge from hospital. The AUCs for MUACz and BMIz for discriminating subsequent mortality were 0.81 (95%CI 0.70 to 0.92) and 0.75 (95%CI 0.63 to 0.86) in the ARROW trial (absolute difference 0.06 (95% CI -0.032 to 0.16; P=0.2); and 0.73 (95%CI 0.65 to 0.80) and 0.58 (95% CI 0.49 to 0.67) respectively in Kenya (absolute difference in AUC 0.15 (95% CI 0.07 to 0.23; P=0.0002). Conclusions MUACz is at least as effective as BMIz for assessing mortality risks associated with undernutrition among African school-aged children and adolescents. MUAC can provide simplified screening and diagnosis within nutrition and HIV programmes, and in research

A Growth Reference for Mid Upper Arm Circumference for Age among School Age Children and Adolescents, with Validation for Mortality in Two Cohorts

OBJECTIVES: To construct growth curves for mid-upper-arm circumference (MUAC)-for-age z score for 5-19 year olds that accord with the World Health Organization growth standards, and to evaluate their discriminatory performance for subsequent mortality. DESIGN: Growth curve construction and longitudinal cohort study. SETTING: United States and international growth data, and cohorts in Kenya, Uganda, and Zimbabwe. PARTICIPANTS The Health Examination Survey (HES)/National Health and Nutrition Examination Survey (NHANES) US population datasets (age 5-25 years), which were used to construct the 2007 WHO growth reference for body mass index in this age group, were merged with an imputed dataset matching the distribution of the WHO 2006 growth standards age 2-6 years. Validation data were from 685 HIV infected children aged 5-17 years participating in the Antiretroviral Research for Watoto (ARROW) trial in Uganda and Zimbabwe; and 1741 children aged 5-13 years discharged from a rural Kenyan hospital (3.8% HIV infected). Both cohorts were followed-up for survival during one year. MAIN OUTCOME MEASURES: Concordance with WHO 2006 growth standards at age 60 months and survival during one year according to MUAC-for-age and body mass index-for-age z scores. RESULTS: The new growth curves transitioned smoothly with WHO growth standards at age 5 years. MUAC-for-age z scores of −2 to −3 and less than−3, compared with −2 or more, was associated with hazard ratios for death within one year of 3.63 (95% confidence interval 0.90 to 14.7; P=0.07) and 11.1 (3.40 to 36.0; P<0.001), respectively, among ARROW trial participants; and 2.22 (1.01 to 4.9; P=0.04) and 5.15 (2.49 to 10.7; P<0.001), respectively, among Kenyan children after discharge from hospital. The AUCs for MUAC-for-age and body mass index-for-age z scores for discriminating subsequent mortality were 0.81 (95% confidence interval 0.70 to 0.92) and 0.75 (0.63 to 0.86) in the ARROW trial (absolute difference 0.06, 95% confidence interval −0.032 to 0.16; P=0.2) and 0.73 (0.65 to 0.80) and 0.58 (0.49 to 0.67), respectively, in Kenya (absolute difference in AUC 0.15, 0.07 to 0.23; P=0.0002). CONCLUSIONS: The MUAC-for-age z score is at least as effective as the body mass index-for-age z score for assessing mortality risks associated with undernutrition among African school aged children and adolescents. MUAC can provide simplified screening and diagnosis within nutrition and HIV programmes, and in research

Phenotype is sustained during hospital readmissions following treatment for complicated severe malnutrition among Kenyan children : a retrospective cohort study

Hospital readmission is common among children with complicated severe acute malnutrition (cSAM) but not well-characterised. Two distinct cSAM phenotypes, marasmus and kwashiorkor, exist, but their pathophysiology and whether the same phenotype persists at relapse are unclear. We aimed to test the association between cSAM phenotype at index admission and readmission following recovery. We performed secondary data analysis from a multicentre randomised trial in Kenya with 1-year active follow-up. The main outcome was cSAM phenotype upon hospital readmission. Among 1,704 HIV-negative children with cSAM discharged in the trial, 177 children contributed a total of 246 readmissions with cSAM. cSAM readmission was associated with age<12 months (p = .005), but not site, sex, season, nor cSAM phenotype. Of these, 42 children contributed 44 readmissions with cSAM that occurred after a monthly visit when SAM was confirmed absent (cSAM relapse). cSAM phenotype was sustained during cSAM relapse. The adjusted odds ratio for presenting with kwashiorkor during readmission after kwashiorkor at index admission was 39.3 [95% confidence interval (95% CI) [2.69, 1,326]; p = .01); and for presenting with marasmus during readmission after kwashiorkor at index admission was 0.02 (95% CI [0.001, 0.037]; p = .01). To validate this finding, we examined readmissions to Kilifi County Hospital, Kenya occurring at least 2 months after an admission with cSAM. Among 2,412 children with cSAM discharged alive, there were 206 readmissions with cSAM. Their phenotype at readmission was significantly influenced by their phenotype at index admission (p < .001). This is the first report describing the phenotype and rate of cSAM recurrence

Mid-Upper Arm Circumference based Nutrition Programming: evidence for a new approach in regions with high burden of Acute Malnutrition

In therapeutic feeding programs (TFP), mid-upper arm circumference (MUAC) shows advantages over weight-for-height Z score (WHZ) and is recommended by the World Health Organization (WHO) as an independent criterion for screening children 6-59 months old. Here we report outcomes and treatment response from a TFP using MUAC ≤118 mm or oedema as sole admission criteria for severe acute malnutrition (SAM)

The influence of maternal psychosocial circumstances and physical environment on the risk of severe wasting in rural Gambian infants: a mixed methods approach.

BACKGROUND: Severe wasting affects 16 million under 5's and carries an immediate risk of death. Prevalence remains unacceptably high in sub-Saharan Africa and early infancy is a high-risk period. We aimed to explore risk factors for severe wasting in rural Gambian infants. METHODS: We undertook a case-control study from November 2014 to June 2015, in rural Gambia. Cases had WHO standard weight-for-length z-scores (WLZ)  -3 in the same interval, matched on age, gender, village size and distance from the clinic were selected. Standard questionnaires were used to assess maternal socioeconomic status, water sanitation and hygiene and maternal mental health. Conditional logistic regression using a multivariable model was used to determine the risk factors for severe wasting. Qualitative in depth interviews were conducted with mothers and fathers who were purposively sampled. A thematic framework was used to analyse the in-depth interviews. RESULTS: Two hundred and eighty (77 cases and 203 controls) children were recruited. In-depth interviews were conducted with 16 mothers, 3 fathers and 4 research staff members. The mean age of introduction of complementary feeds was similar between cases and controls (5.2 [SD 1.2] vs 5.1 [SD 1.3] months). Increased odds of severe wasting were associated with increased frequency of complementary feeds (range 1-8) [adjusted OR 2.06 (95%: 1.17-3.62), p = 0.01]. Maternal adherence to the recommended infant care practices was influenced by her social support networks, most importantly her husband, by infant feeding difficulties and maternal psychosocial stressors that include death of a child or spouse, recurrent ill health of child and lack of autonomy in child spacing. CONCLUSION: In rural Gambia, inappropriate infant feeding practices were associated with severe wasting in infants. Additionally, adverse psychosocial circumstances and infant feeding difficulties constrain mothers from practising the recommended child care practices. Interventions that promote maternal resilience through gender empowerment, prioritising maternal psychosocial support and encouraging the involvement of fathers in infant and child care promotion strategies, would help prevent severe wasting in these infants

The relationship between wasting and stunting: a retrospective cohort analysis of longitudinal data in Gambian children from 1976 to 2016

Background: The etiologic relationship between wasting and stunting is poorly understood, largely because of a lack of high-quality longitudinal data from children at risk of undernutrition. Objectives: The aim of this study was to describe the interrelationships between wasting and stunting in children aged <2 y. Methods: This study involved a retrospective cohort analysis, based on growth-monitoring records spanning 4 decades from clinics in rural Gambia. Anthropometric data collected at scheduled infant welfare clinics were converted to z scores, comprising 64,342 observations on 5160 subjects (median: 12 observations per individual). Children were defined as "wasted" if they had a weight-for-length z score <-2 against the WHO reference and "stunted" if they had a length-for-age z score <-2. Results: Levels of wasting and stunting were high in this population, peaking at approximately (girls-boys) 12-18% at 10-12 months (wasted) and 37-39% at 24 mo of age (stunted). Infants born at the start of the annual wet season (July-October) showed early growth faltering in weight-for-length z score, putting them at increased risk of subsequent stunting. Using time-lagged observations, being wasted was predictive of stunting (OR: 3.2; 95% CI: 2.7, 3.9), even after accounting for current stunting. Boys were more likely to be wasted, stunted, and concurrently wasted and stunted than girls, as well as being more susceptible to seasonally driven growth deficits. Conclusions: We provide evidence that stunting is in part a biological response to previous episodes of being wasted. This finding suggests that stunting may represent a deleterious form of adaptation to more overt undernutrition (wasting). This is important from a policy perspective as it suggests we are failing to recognize the importance of wasting simply because it tends to be more acute and treatable. These data suggest that stunted children are not just short children but are children who earlier were more seriously malnourished and who are survivors of a composite process