Response to the letter by Gedela

The letter to the editor submitted by Gedela (2013) in response to Parker et al. 2013 allows us to revisit the issue of infant formula distribution to human immunodeficiency virus (HIV)-exposed infants and children in resource-poor settings. The letter’s author advocates for the distribution of donated, almost-expired, ready-made, fortified formula to infants of HIV-infected mothers as a malnutrition prevention strategy following weaning and as a nutritional milk supplement or as a malnutrition treatment strategy for children older than 2 years of age.While we agree that creative solutions to the challenge of safely feeding HIV-exposed infants are urgently needed, the use of formula for these purposes is contrary to World Health Organization (WHO) guidelines on HIV and infant feeding (WHO 2010), which many African countries have taken measures to implement. Furthermore, evidence suggests that targeted distribution of formula is impractical, contributes to unsafe feeding practices, and subsequently increases child morbidity and mortality (WHO Collaborative Study Team 2000; Linkages 2004; Coovadia et al. 2007; WHO 2010; Doherty et al. 2011)

“Health regains but livelihoods lag”: findings from a study with people on ART in Zambia and Kenya

International audienceAlthough ART is increasingly accessible and eases some stresses, it creates other challenges including the importance of food security to enhance ART-effectiveness. This paper explores the role livelihood strategies play in achieving food security and maintaining nutritional status among ART patients in Kenya and Zambia. Ongoing quantitative studies exploring adherence to ART in Mombasa, Kenya (n=118) and in Lusaka, Zambia (n= 375) were used to identify the relationship between BMI and adherence; an additional set of in-depth interviews with people on ART (n=32) and members of their livelihood networks (n=64) were undertaken. Existing frameworks and scales for measuring food security and a positive deviance approach was used to analyse data. Findings show the majority of people on ART in Zambia are food insecure; similarly most respondents in both countries report missing meals. Snacking is important for dietary intake, especially in Kenya. Most food is purchased in both countries. Having assets is key for achieving livelihood security in both Kenya and Zambia. Food supplementation is critical to survival and for developing social capital since most is shared amongst family members and others. Whilst family and friends are key to an individual's livelihood network, often more significant for daily survival is proximity to people and the ability to act immediately, characteristics most often found amongst neighbours and tenants. In both countries findings show that with ART health has rebounded but livelihoods lag. Similarly, in both countries respondents with high adherence and high BMI are more self-reliant, have multiple income sources and assets; those with low adherence and low BMI have more tenuous livelihoods and were less likely to have farms/gardens. Food supplementation is, therefore, not a long-term solution. Building on existing livelihood strategies represents an alternative for programme managers and policy makers as do other strategies including supporting skills and asset accumulation

Mapping child growth failure across low- and middle-income countries

Childhood malnutrition is associated with high morbidity and mortality globally1. Undernourished children are more likely to experience cognitive, physical, and metabolic developmental impairments that can lead to later cardiovascular disease, reduced intellectual ability and school attainment, and reduced economic productivity in adulthood2. Child growth failure (CGF), expressed as stunting, wasting, and underweight in children under five years of age (0�59 months), is a specific subset of undernutrition characterized by insufficient height or weight against age-specific growth reference standards3�5. The prevalence of stunting, wasting, or underweight in children under five is the proportion of children with a height-for-age, weight-for-height, or weight-for-age z-score, respectively, that is more than two standard deviations below the World Health Organization�s median growth reference standards for a healthy population6. Subnational estimates of CGF report substantial heterogeneity within countries, but are available primarily at the first administrative level (for example, states or provinces)7; the uneven geographical distribution of CGF has motivated further calls for assessments that can match the local scale of many public health programmes8. Building from our previous work mapping CGF in Africa9, here we provide the first, to our knowledge, mapped high-spatial-resolution estimates of CGF indicators from 2000 to 2017 across 105 low- and middle-income countries (LMICs), where 99 of affected children live1, aggregated to policy-relevant first and second (for example, districts or counties) administrative-level units and national levels. Despite remarkable declines over the study period, many LMICs remain far from the ambitious World Health Organization Global Nutrition Targets to reduce stunting by 40 and wasting to less than 5 by 2025. Large disparities in prevalence and progress exist across and within countries; our maps identify high-prevalence areas even within nations otherwise succeeding in reducing overall CGF prevalence. By highlighting where the highest-need populations reside, these geospatial estimates can support policy-makers in planning interventions that are adapted locally and in efficiently directing resources towards reducing CGF and its health implications. © 2020, The Author(s)

L'alimentation de complément du jeune enfant

Un programme visant à améliorer l'alimentation de complément durant la période de sevrage doit avoir pour objectif d'encourager non seulement la modification des comportements alimentaires actuels du nourrisson, mais aussi la confection de recettes au niveau des ménages. Il doit aussi avoir pour objectif de développer et de promouvoir de nouveaux ingrédients et de nouveaux produits alimentaires fabriqués aussi bien au niveau communautaire que par un distributeur ou un fournisseur central. Pour cela, on ne perdra pas de vue le principe fondamental du "marketing social" : face à un choix de produits (ou de comportements), les gens choisiront le produit (ou adopteront le comportement) qui leur paraît le plus attirant. Pour déterminer l'approche à utiliser dans un programme d'amélioration des pratiques de sevrage, il faut au préalable : faire le bilan des informations existantes ; réunir les informations supplémentaires nécessaires sur le contexte culturel ; formuler des combinaisons d'aliments adéquates du point de vue nutritionnel ; faire participer les mères à la mise au point de nouvelles recettes et pratiques de sevrage ; mener des essais à domicile. Ce n'est qu'alors qu'on élaborera les messages et on choisira les média pour les véhiculer. (Résumé d'auteur

The Acceptance and Feasibility of Replacement Feeding at 6 Months as an HIV Prevention Method in Lilongwe, Malawi: Results From the BAN Study

International guidelines recommend exclusive breastfeeding to 6 months among HIV-infected mothers choosing to breastfeed and cessation thereafter if replacement feeding is acceptable, feasible, affordable, sustainable and safe. When mothers wean they are challenged to provide an adequate replacement diet. This study investigates the use and acceptability of a lipid-based nutrient supplement (LNS) as a breastmilk substitute when provided to infants (6-12mo) of HIV-positive mothers, as part of the Breastfeeding, Antiretroviral, and Nutrition (BAN) Study. A sub-sample of mothers (n=45) participated in interviews that explored exclusive breastfeeding, weaning, and strategies to feed LNS. Mothers reported several weaning strategies, including gradual reduction of breastfeeding, expressing breastmilk into a cup, and separation of mother and child. LNS, a peanut-based micronutrient fortified paste, was highly accepted and incorporated into the traditional diet. Weaning is a feasible HIV prevention method among this population in Malawi when supported by the provision of LNS as a breastmilk substitute