Chlorhexidine cord care after a national scale-up as a newborn survival strategy: A survey in four regions of Ethiopia.

INTRODUCTION: Chlorhexidine cord care is an effective intervention to reduce neonatal infection and death in resource constrained settings. The Federal Ministry of Health of Ethiopia adopted chlorhexidine cord care in 2015, with national scale-up in 2017. However, there is lack of evidence on the provision of this important intervention in Ethiopia. In this paper, we report on the coverage and determinants of chlorhexidine cord care for newborns in Ethiopia. METHODS: A standardized Nutrition International Monitoring System (NIMS) survey was conducted from January 01 to Feb 13, 2020 in four regions of Ethiopia (Tigray, Amhara, Oromia, and Southern Nations, Nationalities and Peoples Region [SNNPR]) on sample of 1020 women 0-11 months postpartum selected through a multistage cluster sampling approach. Data were collected using interviewer-administered questionnaires in the local languages through home-to-home visit. Accounting for the sampling design of the study, we analyzed the data using complex data analysis approach. Complex sample multivariable logistic regression was used to identify the determinants of chlorhexidine cord care practice. RESULTS: Overall, chlorhexidine was reportedly applied to the umbilical cord at some point postpartum among 46.1% (95% confidence interval [CI]: 41.1%- 51.2%) of all newborns. Chlorhexidine cord care started within 24 hours after birth for 34.4% (95% CI: 29.5%- 39.6%) of newborns, though this varied widely across regions: from Oromia (24.4%) to Tigray (60.0%). Among the newborns who received chlorhexidine cord care, 48.3% received it for the recommended seven days or more. Further, neonates whose birth was assisted by skilled birth attendants had more than ten times higher odds of receiving chlorhexidine cord care, relative to those born without a skilled attendant (adjusted odds ratio [AOR]: 10.36, 95% CI: 3.73-28.75). Besides, neonates born to mothers with knowledge of the benefit of chlorhexidine cord care had significantly higher odds of receiving chlorhexidine cord care relative to newborns born to mothers who did not have knowledge of the benefit of chlorhexidine cord care (AOR: 39.03, 95% CI: 21.45-71.04). CONCLUSION: A low proportion of newborns receive chlorhexidine cord care in Ethiopia. The practice of chlorhexidine cord care varies widely across regions and is limited mostly to births attended by skilled birth attendants. Efforts must continue to ensure women can reach skilled care at delivery, and to ensure adequate care for newborns who do not yet access skilled delivery.

Gender differences in nutritional status and determinants among infants (6-11 m): a cross-sectional study in two regions in Ethiopia.

BACKGROUND: A limited number of studies suggest that boys may have a higher risk of stunting than girls in low-income countries. Little is known about the causes of these gender differences. The objective of the study was to assess gender differences in nutritional status and its determinants among infants in Ethiopia. METHODS: We analyzed data for 2036 children (6-11 months old) collected as the baseline for a multiple micronutrient powders effectiveness study in two regions of Ethiopia in March-April 2015. Child, mother, and household characteristics were investigated as determinants of stunting and wasting. Multiple logistic regression models were used separately for boys and girls to check for gender differences while adjusting for confounders. The study is registered at http://www.clinicaltrials.gov/ with the clinical trials identifier of NCT02479815. RESULTS: Stunting and wasting prevalence is significantly higher among boys compared to girls, 18.7 vs 10.7% and 7.9 vs 5.4%, respectively. Untimely initiation of breastfeeding, not-exclusive breastfeeding at the age of 6 months, region of residence, and low maternal education are significant predictors of stunting in boys. Untimely introduction to complementary food and low consumption of legumes/nuts are significant predictors of stunting in both boys and girls, and low egg consumption only in girls. Region of residence and age of the mother are significant determinants of wasting in both sexes. Analysis of interaction terms for stunting, however, shows no differences in predictors between boys and girls; only for untimely initiation of breastfeeding do the results for boys (OR 1.46; 95%CI 1.02,2.08) and girls (OR 0.88; 95%CI 0.55,1.41) tend to be different (p = 0.12). CONCLUSION: In Ethiopia, boys are more malnourished than girls. Exclusive breastfeeding and adequate dietary diversity of complementary feeding are important determinants of stunting in boys and girls. There are no clear gender interactions for the main determinants of stunting and wasting. These findings suggest that appropriate gender-sensitive guidance on optimum infant and young child feeding practices is needed.

Identifying Dietary Strategies to Improve Nutrient Adequacy among Ethiopian Infants and Young Children Using Linear Modelling.

Nutrient adequacy of young children's diet and best possible strategies to improve nutrient adequacy were assessed. Data from the Ethiopian National Food Consumption Survey were analysed using Optifood (software for linear programming) to identify nutrient gaps in diets for children (6-8, 9-11 and 12-23 months), and to formulate feasible Food-Based Dietary Recommendations (FBDRs) in four regions which differ in culture and food practices. Alternative interventions including a local complementary food, micronutrient powders (MNPs), Small quantity Lipid-based Nutrient Supplement (Sq-LNS) and combinations of these were modelled in combination with the formulated FBDRs to compare their relative contributions. Risk of inadequate and excess nutrient intakes was simulated using the Estimated Average Requirement cut-point method and the full probability approach. Optimized local diets did not provide adequate zinc in all regions and age groups, iron for infants <12 months of age in all regions, and calcium, niacin, thiamine, folate, vitamin B12 and B6 in some regions and age-groups. The set of regional FBDRs, considerably different for four regions, increased nutrient adequacy but some nutrients remained sub-optimal. Combination of regional FBDRs with daily MNP supplementation for 6-12 months of age and every other day for 12-23 months of age, closed the identified nutrient gaps without leading to a substantial increase in the risk of excess intakes.

Effectiveness of a Program Intervention with Reduced-Iron Multiple Micronutrient Powders on Iron Status, Morbidity and Growth in Young Children in Ethiopia.

Despite the potential for improving iron status and child growth in low- and middle-income settings, concerns on the safety of high iron dosages of Micronutrient Powders (MNP currently limit their applicability in programs. We examined the effectiveness and risks of an integrated complementary feeding program with low iron dose (6 mg/serving) MNP among 6⁻23-month-old Ethiopian children using a quasi-experimental study design comparing children from five intervention districts (n = 1172) to those from four matched non-intervention districts (n = 1137). Haemoglobin concentrations increased in intervention and decreased in non-intervention children (group-difference +3.17 g/L), but without improvement in iron stores. Intervention children were 2.31 times more likely to have diarrhoea and 2.08 times more likely to have common cold and flu, but these differences decreased towards the end of the intervention. At end line, intervention children had higher mean Height-for-Age Zscore (HAZ) and a 51% reduced odds of being stunted compared to non-intervention children. MNP with low iron dose, when provided combined with other Infant and Young Child Feeding (IYCF) interventions, marginally improved haemoglobin status and resulted in a remarkable improvement in linear growth in 6⁻23-month-old children. These benefits likely outweigh the relatively small increase in the risk of diarrhoea.

Total aflatoxins in complementary foods produced at community levels using locally available ingredients in Ethiopia.

This study was conducted to determine the occurrence and levels of total aflatoxins in complementary foods (CFs) and their ingredients. A total of 126 samples collected from 20 Districts from Amhara, Tigray, Oromia, and Southern Nations Nationalities and Peoples (SNNP) regions were analysed for levels of total aflatoxins using enzyme linked immunosorbent assay (ELISA). Aflatoxins were detected in 62 out of 66 pre-milling samples with mean range of 0.3-9.9 µg/kg. Aflatoxins were also detected in 19 out of 20 post-production CFs and in all of the one-month stored CFs at households and grain banks, with a mean range of 0.5-8.0, 3.6-11.3, and 0.2-12.4 µg/kg, respectively. Overall, 3 out of 126 samples exceeded the maximum limit (10 µg/kg). Although most aflatoxin levels were below the maximum limit and thus considered to be safe for consumption, more effort should be implemented to reduce contamination, as these CFs are intended for consumption by young children.

Assessment of aflatoxin exposure among young children in Ethiopia using urinary biomarkers.

The direct measurement of biomarkers of exposure in biological fluids such as urine has become important for assessing aflatoxin exposure in humans as it is the only tool that integrates exposures from various routes. For this reason, a study was conducted to assess aflatoxin exposure among young children in Ethiopia using urinary biomarkers. A cross-sectional study was conducted in ten Woredas (Districts) from Amhara and Tigray regional states of Ethiopia including 200 children (aged 1-4 years). A total of 200 urine samples were collected from 200 children and assessed for the levels of aflatoxin B1 (AFB1), aflatoxin B2 (AFB2), aflatoxin G1 (AFG1), aflatoxin G2 (AFG2) and aflatoxin M1 (AFM1) using a validated LC-MS/MS method. Aflatoxins were detected in 34/200 (17%) of the urine samples whereby four out of five analysed aflatoxins were detected. AFM1 was detected in 14/200 (7%) of the urine samples in a range of 0.06-0.07 ng/mL. AFB2, AFG2 and AFG1 were detected in respectively 9/200 (4.5%), 6/200 (3%) and 5/200 (2.5%) of the urine samples whereas AFB1 was not detected in any of the samples. In this study, there was no association between the different malnutrition categories (stunted, wasting and underweight) and aflatoxin exposure. However, the biomarker analysis showed a clear exposure of young children to aflatoxins. Therefore, awareness to the public is important to prevent potential health consequences of aflatoxins.

Effect of popping and fermentation on proximate composition, minerals and absorption inhibitors, and mineral bioavailability of Amaranthus caudatus grain cultivated in Ethiopia.

This study evaluated the effect of popping and fermentation on the chemical composition of three types of Amaranthus caudatus grains cultivated in Ethiopia. Proximate composition, minerals and mineral absorption inhibitors were analyzed. Popping caused a decrease in protein content by 4 % and an increase in fat, ash, acid detergent fiber (ADF) and neutral detergent fiber (NDF) contents by 12, 10, 15 and 67 %, respectively. While fermentation increased protein, fat and ash content by 3, 22 and 14 %, respectively but did not significantly change ADF and NDF content. Fe, Ca and phytic acid (IP6) decreased during popping but Mg, Zn, galloyl and catechol did not change significantly. On the other hand, fermentation increased Fe and Mg content but decreased IP6, galloyl and catechol content. The decrease in mineral absorption inhibitors especially IP6 during popping and fermentation could contribute to enhance mineral bioavailability. However, due to the presence of high phytate content in raw amaranth, all IP6-to-mineral molar ratios were above the recommended values.

Assessment of Caregiver's Knowledge, Complementary Feeding Practices, and Adequacy of Nutrient Intake from Homemade Foods for Children of 6-23 Months in Food Insecure Woredas of Wolayita Zone, Ethiopia.

Complementary feeding should fill the gap in energy and nutrients between estimated daily needs and amount obtained from breastfeeding from 6-month onward. However, homemade complementary foods are often reported for inadequacy in key nutrients despite reports of adequacy for energy and proteins. The aim of this study was to assess caregiver's complementary feeding knowledge, feeding practices, and to evaluate adequacy daily intakes from homemade complementary foods for children of 6-23 months in food insecure woredas of Wolayita zone, Ethiopia. A cross-sectional study assessing mothers/caregiver's knowledge and complementary feeding practice, adequacy of daily energy, and selected micronutrient intakes using weighed food record method. Multi-stage cluster sampling method was also used to select 68 households. Caregivers had good complementary feeding knowledge. Sixty (88.2%) children started complementary feeding at 6 months and 48 (70.6%) were fed three or more times per day. Daily energy intake, however, was significantly lower (p < 0.05) than estimated daily needs, with only 151.25, 253.77, and 364.76 (kcal/day) for 6-8, 9-11, and 12-23 months, respectively. Similarly, Ca and Zn intakes (milligrams per day) were below the daily requirements (p = 0.000), with value of 37.76, 0.96; 18.83, 1.21; 30.13, 1.96; for the 6-8, 9-11, and 12-23 months, respectively. Significant shortfall in daily intake of Fe (p = 0.000) was observed among the 6-8 and 9-11 months (3.25 and 4.17 mg/day, respectively), even accounting for high bioavailability. The complementary foods were energy dense. Daily energy, Ca, Zn, and Fe (except 12-23 months) intake, however, was lower than estimated daily requirements.

The effectiveness bundling of zinc with Oral Rehydration Salts (ORS) for improving adherence to acute watery diarrhea treatment in Ethiopia: cluster randomised controlled trial.

BACKGROUND: Presumably bundling/co-packaging of zinc with ORS encourages the combined use of the products for diarrhea treatment; however, empirical evidences are scarce. The purpose of this work is to evaluate whether co-packing using a plastic pouch can enhance the joint adherence to the treatment or not. The study also compares the cost effectiveness (CE) of two co-packaging options: 'central' and 'health center (HC)' level bundling. METHODS: This cluster-randomised controlled trial was conducted in 2015 in eight districts of Ethiopia. Thirty two HCs were randomly assigned to one of the following four intervention arms: (i) 'Central bundling' (zinc and ORS bundled using a pouch that had instructional message, distributed to HCs); (ii) 'HC level bundling' (zinc, ORS and a similar pouch distributed to the HCs and bundled by health workers); (iii) 'Bundling without message' (zinc, ORS and plain pouch distributed and bundled by the health workers); and, (iv) 'Status quo' (zinc and ORS co-administered without bundling). In each of the four arms, 176 children 6-59 months of age, presented with acute diarrhea were enrolled. Twelve days after enrollment, level of adherence was assessed. A composite scale of adherence was developed and modeled using mixed effects linear regression analysis. The unit costs associated with the arms were estimated using secondary data sources. Incremental CE analysis was made by taking the cost and level of adherence in fourth arm as a base value. RESULTS: The follow-up rate was 95.6 %. As compared with the 'status quo' arm, the joint adherences in the 'central' and 'HC level' bundling arms raised substantially by 14.8 and 15.7 percentage points (PP), respectively (P < 0.05). No significant difference was observed between 'bundling without message' and the 'status quo' arms. The unit cost incurred by the 'central bundling' is relatively higher (USD 0.658/episode) as compared with the 'HC level bundling' approach (USD 0.608/episode). The incremental CE ratio in the 'central bundling' modality was two times higher than in the 'HC based bundling' approach. CONCLUSION: Bundling zinc with ORS using a pouch with instructional messages increases adherence to the treatment. 'HC level bundling' is more CE than the 'central bundling' approach.

Stunting, selenium deficiency and anemia are associated with poor cognitive performance in preschool children from rural Ethiopia.

BACKGROUND: Anthropometric characteristics and iron status affect cognitive performance in children. In addition, selenium can influence cognitive outcomes; protection of the brain from oxidative stress and its role in thyroid hormone metabolism are putative mechanisms. METHODS: To investigate their association with cognitive performance, anthropometric indicators, iron biomarkers, and serum selenium of children (n = 541) of 54-60mo of age from rural Ethiopia were assessed. Cognitive assessment was conducted with the administration of two reasoning subtests of the Wechsler Preschool and Primary Scale of Intelligence and the school readiness test. RESULTS: Stunting was found in 41.4 % of children, 28.7 % were underweight, and 6.3 % were wasted. The mean score of stunted children was lower than that of non-stunted children on non-verbal reasoning (7.0 ± 3.2vs7.9 ± 3.1; p = 0.01) and the school readiness tests (4.3 ± 2.2 vs 3.3 ± 2.1; p < 0.001). Compared to non-anemic children, anemic children had lower score for the verbal reasoning test (9.5 ± 1.7 vs 8.9 ± 2.2; p = 0.02). However, except for hemoglobin, none of the iron biomarkers had significant associations with the cognitive score of the study children (p > 0.05). Selenium deficient children had lower scores on all cognitive tests than normal children (p < 0.05). CONCLUSION: The present study finding linking chronic undernutrition and micronutrient deficiency to cognitive deficits suggests the need for designing effective intervention programmes to control for protein energy malnutrition and micronutrient deficiency and address cognitive development in children.

Ethiopian pre-school children consuming a predominantly unrefined plant-based diet have low prevalence of iron-deficiency anaemia.

OBJECTIVE: Children from low-income countries consuming predominantly plant-based diets but little animal products are considered to be at risk of Fe deficiency. The present study determined the Fe status of children from resource-limited rural households. DESIGN: A cross-sectional study. SETTING: Twenty six kebeles (the smallest administrative unit) from six zones of the Amhara region, Ethiopia. SUBJECTS: Children aged 54-60 months (n 628). RESULTS: Grain, roots or tubers were the main dietary components consumed by 100 % of the study participants, followed by pulses, legumes or nuts (66·6 %). Consumption of fruit and vegetables (19·3 %) and meat, poultry and fish (2·2 %) was low. Children had a mean dietary diversity score of 2·1 (sd 0·8). Most children (74·8 %, n 470) were in the lowest dietary diversity group (1-2 food groups). Rate of any morbidity in the preceding 14 d was 22·9 % (n 114). Infection or inflammation (α1-acid glycoprotein >1·2 g/l) was present in 30·2 % (n 184) of children. Children had a high rate of stunting (43·2 %). Of the total sample, 13·6 % (n 82) of children were anaemic, 9·1 % (n 57) were Fe deficient and 5·3 % (n 32) had Fe-deficiency anaemia. Fe-deficiency erythropoiesis was present in 14·2 % (n 60) of children. CONCLUSIONS: Despite consuming a predominantly plant-based diet and little animal-source foods, there was a low prevalence of Fe-deficiency anaemia. This illustrates that dietary patterns can be inharmonious with Fe biochemical status; thus, Fe-related interventions require biochemical screening.

Iron, folate and vitamin B12 status of Ethiopian professional runners.

BACKGROUND: Better macro and micro nutrient status and their adequate intake by the athletes have great role in balancing losses associated with strenuous exercise, then for better performance. The objective of this study was to determine iron, folate and vitamin B12 status of Ethiopian professional athletes. METHODS: A cross sectional study was conducted using a point time convenient sample of 101 male and female Ethiopian professional athletes of different distance categories in the period of February to April 2014. Biochemical samples, detail health and exercise related interview, performance data, 24 h dietary diversity and weekly food frequency were collected. RESULTS: The low, medium and high dietary diversity terciles were 36.1, 60.9 and 3.3 % respectively. The mean ± Sd of dietary diversity was 5.44 ± 1.8. Prevalence of iron overload (Serum ferritin >200 µg/L) was 11 %, whereas that of anemia (Hb < 12 g/dL), iron deficiency (ferritin < 12 µg/L) and moderate folate deficiency (<5.9 ng/mL) was 3, 2 and 20.8 % respectively. There was no iron deficiency anemia case in the study. In this study, the mean serum vitamin B12 concentration was 561 ± 231 pg/ml with a minimum and maximum value of 210 and 1736 pg/ml respectively, and there was no deficiency for this nutrient (>210 pg/ml). The iron status of male athletes was significantly different by running-distance categories. In contrast, such difference was absent for female athletes. Performance of the athletes was associated with their red blood cell count (RBC) at p = 0.03. The high performer athletes exhibited high mean value of micronutrient status and hematological variables than their counter parts. However, the RBC of the athletes was the only parameter whose association was statistically significant. CONCLUSIONS: The observed gender difference in the association of running-distance category with iron and folate in this study needs further investigation. Given the 11 % iron overload in the present study; there is a need of awarance creation activities and diet intervention in the athletics federation, the athletes and the coaches in order not aggravate the present overload. Prescription of supplements such as iron-folate, multivitamins and minerals should not be based on broad spectrum rather it should be based on recent history of confirmed deficiency, clinical signs and/or laboratory testing to prevent trace element toxicity.