Towards identifying malnutrition among infants under 6 months: a mixed methods study of South-Sudanese refugees in Ethiopia

Objectives: To determine (i) whether distinct groups of infants under 6 months old (U6M) were identifiable as malnourished based on anthropometric measures and if so to determine the probability of admittance to GOAL Ethiopia’s Management of At Risk Mothers and Infants (MAMI) programme based on group membership; (ii) whether there were discrepancies in admission using recognised anthropometric criteria, compared with group membership and (iii) the barriers and potential solutions to identifying malnutrition within U6M. Design: Mixed-methods approaches were used, whereby data collected by GOAL Ethiopia underwent: factor mixture modelling, χ 2 analysis and logistic regression analysis. Qualitative analysis was performed through coding of key informant interviews. Setting: Data were collected in two refugee camps in Ethiopia. Key informant interviews were conducted remotely with international MAMI programmers and nutrition experts. Participants: Participants were 3444 South-Sudanese U6M and eleven key informants experienced in MAMI programming. Results: Well-nourished and malnourished groups were identified, with notable discrepancies between group membership and MAMI programme admittance. Despite weight for age z-scores (WAZ) emerging as the most discriminant measure to identify malnutrition, admittance was most strongly associated with mid-upper arm circumference (MUAC). Misconceptions surrounding malnutrition, a dearth of evidence and issues with the current identification protocol emerged as barriers to identifying malnutrition among U6M. Conclusions: Our model suggests that WAZ is the most discriminating anthropometric measure for malnutrition in this population. However, the challenges of using WAZ should be weighed up against the more scalable, but potentially overly sensitive and less accurate use of MUAC among U6M

¹H and ¹³C NMR chemical shifts (δ, ppm) of the exopolysaccharide (recorded at 338 K) and the tetrasaccharide os211 (recorded at 300 K) from <i>B</i>. <i>longum</i> 35624.

<p>¹H and ¹³C NMR chemical shifts (δ, ppm) of the exopolysaccharide (recorded at 338 K) and the tetrasaccharide os211 (recorded at 300 K) from <i>B</i>. <i>longum</i> 35624.</p

Phylogenetic tree based on the B. longum core-genome.

<p>(A) The <i>B</i>. <i>longum</i> subsp. <i>longum</i> phylogenetic group. (B) The <i>B</i>. <i>longum</i> subsp. <i>infantis</i> phylogenetic group. <i>B</i>. <i>longum</i> subsp. <i>longum</i> and <i>B</i>. <i>longum</i> subsp. <i>infantis</i> type strains are indicated in blue text. <i>Lactobacillus salivarius</i> was included as an outlier.</p

B. longum 35624 electron microscopy.

<p>(A) A layer of extracellular polysaccharide is clearly visible by electronic microscopy of the <b>35624</b> strain. (B) The isolated and purified EPS is illustrated.</p

Mild acid hydrolysis of EPS.

<p>(A) Separation of EPS fragments by PGC HPLC with MS/MS detection. The extracted ion chromatogram for mass 1008.39 Da shows four peaks. Their reducing end sugar was clearly revealed by ESI-MS/MS. Their assignment as either Gal or Glc and the interpretation in terms of fragment structures was done <i>a posteriori</i> based on MALDI-TOF data and on knowledge of the EPS structure. (B) Example of a MALDI-TOF/TOF fragment spectrum showing b-ions from the non-reducing and y- and y´ (= ^1,5x) -ions from the reducing end.</p

<i>Bifidobacterium longum</i> general genome features.

<p><i>Bifidobacterium longum</i> general genome features.</p

B. longum 35624 EPS characterization.

<p>(A) The 600 MHz ¹H NMR proton spectrum of the acid-treated <b>35624</b> EPS (D₂O, 338 K) is illustrated. A part of the high-field region is displayed in the insert. <b>(B)</b> Expansion plot of the 150 MHz 13C NMR spectrum of the acid-treated <b>35624</b> exopolysaccharide. The anomeric signals on the left confirmed the presence of a hexasaccharide repeat unit.</p