Specialized nutritious foods and behavior change communication interventions during the first 1,000 days of life to prevent stunting: A quasi-experimental study in Afghanistan.

BACKGROUND: Considerable evidence supports the effectiveness of nutritional supplementation with or without nutrition education in preventing stunting in developing countries, but evidence from Afghanistan is scarce. OBJECTIVE: This project aimed to assess the effectiveness of specialized nutritious food (SNF), social and behavior change communication (SBCC) intervention to prevent stunting among children under 2 years during the first 1,000 days of life in Badakhshan, Afghanistan. METHODS: We used a community-based quasi-experimental pre-post study design with a control group. Pregnant and lactating women received a monthly ration of 7.5 kg of Super Cereal (250g/day) during pregnancy and the first 6 months of breastfeeding. Children aged 6-23 months received 30 sachets of medium-quantity lipid-based nutrient supplement (50g/sachet/day) monthly. We compared pre- and post-intervention assessments of the intervention and control groups to isolate the effect of the intervention on key study outcomes at the endline by difference-in-differences (DID) estimates. RESULTS: A total of 2,928 and 3,205 households were surveyed at baseline and endline. DID estimates adjusted for child, maternal, and household characteristics indicated a significant reduction in stunting (DID: -5% (95% CI: -9.9, -0.2) and underweight (DID: -4.6% (95% CI: -8.6, -0.5) among children <2 years of age. However, DID estimates for wasting among children in the intervention and control groups were not significantly different (DID: -1.7 (95% CI: -5.1,1.6). Furthermore, exposure to the SBCC messages was associated with improvements in the early initiation of breastfeeding (DID: 19.6% (95% CI: 15.6,23.6), exclusive breastfeeding under 6-months (DID: 11.0% (95% CI: 2.3,19.7), minimum meal frequency (MMF) (DID: 23% (95% CI: 17.7,28.2), minimum acceptable diet (MAD) (DID: 13% (95% CI: 9.8,16.3). CONCLUSIONS: The provision of SNF in combination with SBCC during the first 1,000 days of life was associated with reduction in stunting and underweight and improvements in IYCF practices among children under 2 years of age. CLINICAL TRIAL REGISTRY NUMBER: Clinicaltrials.gov, NCT04581993.

Do we need to reconsider the CMAM admission and discharge criteria?; an analysis of CMAM data in South Sudan.

BACKGROUND: Weight-for-height Z-score (WHZ) and Mid Upper Arm Circumference (MUAC) are both commonly used as acute malnutrition screening criteria. However, there exists disparity between the groups identified as malnourished by them. Thus, here we aim to investigate the clinical features and linkage with chronicity of the acute malnutrition cases identified by either WHZ or MUAC. Besides, there exists evidence indicating that fat restoration is disproportionately rapid compared to that of muscle gain in hospitalized malnourished children but related research at community level is lacking. In this study we suggest proxy measure to inspect body composition restoration responding to malnutrition management among the malnourished children. METHODS: The data of this study is from World Vision South Sudan's emergency nutrition program from 2006 to 2012 (4443 children) and the nutrition survey conducted in 2014 (3367 children). The study investigated clinical presentations of each type of severe acute malnutrition (SAM) by WHZ (SAM-WHZ) or MUAC (SAM-MUAC), and analysed correlation between each malnutrition and chronic malnutrition. Furthermore, we explored the pattern of body composition restoration during the recovery phase by comparing the relative velocity of MUAC3 with that of weight gain. RESULTS: As acutely malnourished children identified by MUAC more often share clinical features related to chronic malnutrition and minimal overlapping with malnourished children by WHZ, Therefore, MUAC only screening in the nutrition program would result in delayed identification of the malnourished children. CONCLUSIONS: The relative velocity of MUAC3 gain was suggested as a proxy measure for volume increase, and it was more prominent than that of weight gain among the children with SAM by WHZ and MUAC over all the restoring period. Based on this we made a conjecture about dominant fat mass gain over the period of CMAM program. Also, considering initial weight gain could be ascribed to fat mass increase, the current discharge criteria would leave the malnourished children at risk of mortality even after treatment due to limited restoration of muscle mass. Given this, further research should be followed including assessment of body composition for evidence to recapitulate and reconsider the current admission and discharge criteria for CMAM program.

Community management of acute malnutrition in the developing world.

Globally, acute malnutrition triggers more than 50% of childhood mortality in children under 5 years old, which implies that about 3.5 million children die of malnutrition each year. Prior to the advent of ready-to-use therapeutic food (RUTF), the management of acute malnutrition was limited to hospitals, resulting in low coverage rates with high mortality, as malnourished cases were indentified at later stages often plagued with complications. However, current availability of RUTF has enabled malnourished children to be treated at communities. Further, because RUTF is dehydrated and sealed, it has the added advantage of a lower risk of bacterial contamination, thereby prolonging its storage life at room temperature. Recent data indicate that Community Management of Acute Malnutrition (CMAM) is as cost effective as other high-impact public health measures such as oral rehydration therapy for acute diarrheal diseases, vitamin A supplementation, and antibiotic treatment for acute respiratory infections. Despite the high efficacy of CMAM programs, CMAM still draws insufficient attention for global implementation, suggesting that CMAM programs should be integrated into local or regional routine health systems. Knowledge gaps requiring further research include: the definition of practical screening criteria for malnourished children at communities, the need for systematic antibiotic therapy during malnutrition treatment, and the dietary management of severe malnutrition in children below 6 months of age.