Situação da desnutrição aguda na província de Cabo Delgado / Situation of acute malnutrition in Cabo Delgado province

Quão Grave, Quantos e Quando? Nas 16 unidades de análise consideradas na Província de Cabo Delgado, ao total, estima-se que cerca de 75,000 crianças com idade entre 6-59 meses sofrem e poderão sofrer da desnutrição aguda nos próximos 12 meses e, por consequente, necessitam e necessitarão de tratamento. Em termos de gravidade da situação, no período de Outubro de 2020 a Março de 2021, correspondente a época sazonal onde o inquérito foi realizado (Fevereiro 2021), 8 distritos e 2 centros de acolhimento de IDPs foram classificados em Fase de Alerta (Fase 2 de IPC DA), 5 distritos e 1 centro de acolhimento de IDPs classificados em Fase Aceitável (Fase 1 de IPC DA). Análises de projecção da situação indicam que, para o período de Abril a Setembro de 2021, nos distritos com acesso humanitário limitado ou sem acesso, até o final do período de projecção, é provável que a situação deteriore-se até a Fase Crítica (Fase 4 de IPC DA) em 1 distrito e à Fase Grave (Fase 3 de IPC DA) em 3 distritos, Fase de Alerta em 4 distritos e, nos 4 restantes distritos e nos 3 centros de acolhimento de IDPs, apesar de provável deterioração, poderão manter-se na mesma Fase em relação ao período inicial. Para o segundo período de projecção, que vai de Outubro de 2021 a Janeiro de 2022, projecta-se uma continuidade na deterioração da situação, podendo 2 distritos com acesso humanitário limitado ou sem acesso, passar para a Fase Crítica, 1 distrito poderá permanecer na mesma Fase Crítica em relação a projecção anterior, 6 novos distritos poderão passar para a Fase Grave, 1 centro de acolhimento poderá passar para a Fase de Alerta, e as restantes unidades de análise, embora possa a situação possa deteriorar-se, são prováveis de manter-se nas mesmas Fases em relação a projecção anterior. Onde: No primeiro período de projecção, todos os distritos com acesso humanitário limitado ou sem acesso poderão ser os mais afectados. São eles: o distrito de Palma que poderá deteriorar até a Fase Crítica e os distritos de Macomia, Quissanga e Nangade que poderão passar para Fase Grave. No segundo período de projecção, Macomia e Quissanga são os distritos que poderão passar para uma Fase Crítica e Palma que poderá permanecer na Fase Crítica em relação a primeira projecção. Chiúre, Ibo, Mecúfi, Mueda, Muidumbe e Meluco, são os que poderão passar a Fase Crítica. Porquê: A maioria dos principais factores contribuintes para a desnutrição aguda são comuns nas diferentes unidades de análise. O conflicto armado como um choque não usual destaca-se nas áreas com acesso humanitário limitado que levou à destruição das infraestruturas de saúde e disfuncionamento dos sistemas de saúde, ao deslocamento massivo de pessoas como nunca observado antes, destruição dos modos de vida dos IDPs e da população ainda residente. A insegurança compromete a provisão de serviços de saúde e nutrição, quer como rotina, assim como parte assistência humanitária às populações que ainda vivem nessas áreas. Por outro lado, a insegurança alimentar aguda (situação de Crise alimentar) nos agregados familiares, qualidade e quantidade no consumo alimentar das crianças muito baixo, fraco acesso à fontes de água potável e a saneamento melhorado, principalmente nos distritos, os indicadores de saúde e nutrição mostraram-se baixos na altura em que o inquérito foi realizado: prevalências elevadas de doenças infecciosas nas crianças, muitas crianças com desnutrição aguda na comunidade não tem acesso ao tratamento, altos níveis de analfabetismo em mulheres.

Effects of probiotics and synbiotics on diarrhea in undernourished children: Systematic review with meta-analysis.

BACKGROUND: Undernutrition predisposes children to a greater incidence and duration of diarrhea. No review and meta-analysis have yet been conducted to assess effectiveness of probiotics and synbiotics in undernourished children. AIMS: To assess the effectiveness of probiotics and synbiotics on diarrhea in undernourished children. METHODS: Randomized, double-blind, placebo-controlled trials evaluating the effects of probiotics and synbiotics on diarrhea in undernourished children were searched from 1990 to May 2020. Recommendations of the Cochrane Handbook and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement were followed. RESULTS: The systematic review identified 15 trials with 6986 patients. The meta-analysis revealed that treatment with probiotic or synbiotic reduced significantly both the duration of diarrhea [Weighted mean difference (WMD) = -1.05 day, 95% CI (-1.98, -0.11)] and the hospital stay duration [Standard mean difference (SMD) = -2.87 days, 95% CI (-5.33, -0.42)], especially in specific patient subsets. In both groups, similar rates of vomiting and nutritional recovery were observed. No probiotics or synbiotics-related adverse effects were reported. Subgroup analyses showed that probiotic and synbiotic treatment were more effective in reducing risk of diarrhea in outpatients [Risk ratio (RR) = 0.86, 95%CI (0.75-0.98)]. CONCLUSION: This meta-analysis supports the potential beneficial roles of probiotics and synbiotics on diarrhea in undernourished children.

Biannual azithromycin distribution and child mortality among malnourished children: A subgroup analysis of the MORDOR cluster-randomized trial in Niger.

BACKGROUND: Biannual azithromycin distribution has been shown to reduce child mortality as well as increase antimicrobial resistance. Targeting distributions to vulnerable subgroups such as malnourished children is one approach to reaching those at the highest risk of mortality while limiting selection for resistance. The objective of this analysis was to assess whether the effect of azithromycin on mortality differs by nutritional status. METHODS AND FINDINGS: A large simple trial randomized communities in Niger to receive biannual distributions of azithromycin or placebo to children 1-59 months old over a 2-year timeframe. In exploratory subgroup analyses, the effect of azithromycin distribution on child mortality was assessed for underweight subgroups using weight-for-age Z-score (WAZ) thresholds of -2 and -3. Modification of the effect of azithromycin on mortality by underweight status was examined on the additive and multiplicative scale. Between December 2014 and August 2017, 27,222 children 1-11 months of age from 593 communities had weight measured at their first study visit. Overall, the average age among included children was 4.7 months (interquartile range [IQR] 3-6), 49.5% were female, 23% had a WAZ < -2, and 10% had a WAZ < -3. This analysis included 523 deaths in communities assigned to azithromycin and 661 deaths in communities assigned to placebo. The mortality rate was lower in communities assigned to azithromycin than placebo overall, with larger reductions among children with lower WAZ: -12.6 deaths per 1,000 person-years (95% CI -18.5 to -6.9, P < 0.001) overall, -17.0 (95% CI -28.0 to -7.0, P = 0.001) among children with WAZ < -2, and -25.6 (95% CI -42.6 to -9.6, P = 0.003) among children with WAZ < -3. No statistically significant evidence of effect modification was demonstrated by WAZ subgroup on either the additive or multiplicative scale (WAZ < -2, additive: 95% CI -6.4 to 16.8, P = 0.34; WAZ < -2, multiplicative: 95% CI 0.8 to 1.4, P = 0.50, WAZ < -3, additive: 95% CI -2.2 to 31.1, P = 0.14; WAZ < -3, multiplicative: 95% CI 0.9 to 1.7, P = 0.26). The estimated number of deaths averted with azithromycin was 388 (95% CI 214 to 574) overall, 116 (95% CI 48 to 192) among children with WAZ < -2, and 76 (95% CI 27 to 127) among children with WAZ < -3. Limitations include the availability of a single weight measurement on only the youngest children and the lack of power to detect small effect sizes with this rare outcome. Despite the trial's large size, formal tests for effect modification did not reach statistical significance at the 95% confidence level. CONCLUSIONS: Although mortality rates were higher in the underweight subgroups, this study was unable to demonstrate that nutritional status modified the effect of biannual azithromycin distribution on mortality. Even if the effect were greater among underweight children, a nontargeted intervention would result in the greatest absolute number of deaths averted. TRIAL REGISTRATION: The MORDOR trial is registered at clinicaltrials.gov NCT02047981.

Antibioticoterapia em crianças indígenas e não indígenas desnutridas / Antibiotic therapy in indigenous and non-indigenous undernourished children

INTRODUÇÃO: A prevalência da desnutrição infantil vem diminuindo em todo o mundo, mas ainda acomete milhões de crianças, especialmente indígenas. Devido ao elevado número de doenças infecciosas associadas à desnutrição, a antibioticoterapia faz parte da terapêutica recomendada. OBJETIVO: Observar os casos de desnutrição entre crianças indígenas e não indígenas hospitalizadas e a terapêutica empregada durante o tratamento. MÉTODOS: Estudo de coorte retrospectivo, farmacoepidemiológico, realizado com informações extraídas de prontuários arquivados do período de janeiro de 2012 a dezembro de 2014 de um hospital público. RESULTADOS: Participaram 166 crianças, sendo o número de crianças indígenas aproximadamente seis vezes maior do que não indígenas. Houve maior prevalência entre lactentes e crianças com idade inferior a um ano apresentaram mais chances de serem internadas por desnutrição. Os diagnósticos de desnutrição mais vistos foram os inespecíficos, com uma proporção significativa de óbitos relacionados ao diagnóstico E43. As infecções mais comuns foram do sistema digestório e respiratório. Crianças indígenas tiveram quase cinco vezes mais chances de apresentarem infecção respiratória. A maior proporção recebeu até três antibióticos, havendo crianças que receberam mais que sete antibióticos diferentes durante o período de internação. CONCLUSÃO: A população infantil deve ser acompanhada por meio de inquéritos que possam subsidiar políticas de saúde que atendam suas necessidades. É necessária a capacitação dos profissionais envolvidos no cuidado da criança desnutrida, recursos materiais e financeiros, a fim diminuir o número de diagnósticos inespecíficos e evitar o uso indiscriminado de antibióticos, sendo imprescindível uma política de controle efetiva no uso da politerapia antimicrobiana.

INTRODUCTION: The prevalence of child malnutrition is declining worldwide, but still affects millions of children, especially indigenous people. Due to the high number of infectious diseases associated with malnutrition, antibiotic therapy is part of the recommended therapy. OBJECTIVE: To observe the cases of malnutrition among hospitalized indigenous and non-indigenous children and the therapy used during treatment. METHODS: Retrospective cohort study, pharmacoepidemiological, carried out with information extracted from medical records filed from January 2012 to December 2014 of a public hospital. RESULTS: 166 children participated, with the number of indigenous children being approximately six times higher than that of nonindigenous children. There was a higher prevalence among infants and children under one year of age who were more likely to be hospitalized for malnutrition. The most frequent diagnoses of malnutrition were nonspecific, with a significant proportion of deaths related to diagnosis E43. The most common infections were of the digestive and respiratory system. Indigenous children were almost five times more likely to have respiratory infection. The highest proportion received up to three antibiotics, with children receiving more than seven different antibiotics during the hospitalization period. CONCLUSION: The child population must be accompanied by surveys that can subsidize health policies that meet their needs. It is necessary to train the professionals involved in the care of malnourished children, material and financial resources, in order to reduce the number of non-specific diagnoses and to avoid the indiscriminate use of antibiotics, a policy of effective control in the use of antimicrobial polytherapy is essential.

High-dose vitamin D3 in the treatment of severe acute malnutrition: a multicenter double-blind randomized controlled trial.

Background: Vitamin D deficiency is common in children with severe acute malnutrition, in whom it is associated with severe wasting. Ready-to-use therapeutic food (the standard treatment) contains modest amounts of vitamin D that do not reliably correct deficiency. Objective: The aim of this study was to determine whether high-dose oral vitamin D3 enhances weight gain and development in children with uncomplicated severe acute malnutrition. Design: We conducted a randomized placebo-controlled trial of high-dose vitamin D3 supplementation in children aged 6-58 mo with uncomplicated severe acute malnutrition in Pakistan. Participants were randomly assigned to receive 2 oral doses of 200,000 IU vitamin D3 or placebo at 2 and 4 wk after starting ready-to-use therapeutic food. The primary outcome was the proportion of participants gaining >15% of baseline weight at 8 wk after starting ready-to-use therapeutic food (the end of the study). Secondary outcomes were mean weight-for-height or -length z score and the proportion of participants with delayed development at the end of the study (assessed with the Denver Development Screening Tool II), adjusted for baseline values. Results: Of the 194 randomly assigned children who started the study, 185 completed the follow-up and were included in the analysis (93 assigned to intervention, 92 to control). High-dose vitamin D3 did not influence the proportion of children gaining >15% of baseline weight at the end of the study (RR: 1.04; 95% CI: 0.94,1.15, P = 0.47), but it did increase the weight-for-height or -length z score (adjusted mean difference: 1.07; 95% CI: 0.49,1.65, P < 0.001) and reduce the proportion of participants with delayed global development [adjusted RR (aRR): 0.49; 95% CI: 0.31, 0.77, P = 0.002], delayed gross motor development (aRR: 0.29; 95% CI: 0.13, 0.64, P = 0.002), delayed fine motor development (aRR: 0.59; 95% CI: 0.38, 0.91, P = 0.018), and delayed language development (aRR: 0.57; 95% CI: 0.34, 0.96, P = 0.036). Conclusions: High-dose vitamin D3 improved the mean weight-for-height or -length z score and developmental indexes in children receiving standard therapy for uncomplicated severe acute malnutrition in Pakistan. This trial was registered at clinicaltrials.gov as NCT03170479.

Cut-off Serum Zinc Concentration Affecting the Appetite, Growth, and Nutrition Status of Undernourished Children Supplemented With Zinc.

BACKGROUND: Zinc supplementation has varied effects on the linear growth of children who exhibited stunted growth. MATERIALS AND METHODS: This observational study involved 761 undernourished children, aged 2-10 years, who received a 24-week course of 10-mg elemental zinc per day. The clinical parameters for evaluation included appetite, height, weight, and body mass index (BMI). Evaluation of the effect of zinc supplementation was stratified by the initial serum zinc concentration. RESULTS: The enrolled participants comprised 390 boys and 371 girls. The mean age was 5.63 years. The height-for-age, weight-for-age, and BMI-for-age z scores increased gradually during the study period. When compared with the children with a serum zinc concentration ≥75 µg/dL, the height, weight, weight-for-age, and BMI-for-age z scores increased significantly in the patients with serum zinc concentrations of <75 µg/dL after 12- and 24-week zinc supplementation (all P < .001). BMI, height-for-age z score, and appetite also increased significantly in patients with serum zinc concentrations of <75 µg/dL after 24-week zinc supplementation (P = .003, .019, and <.001, respectively). CONCLUSION: The findings of this study indicate that undernourished children with serum zinc concentrations of <75 µg/dL experienced greater increments in appetite and growth as a result of zinc supplementation.

Myocardial and haemodynamic responses to two fluid regimens in African children with severe malnutrition and hypovolaemic shock (AFRIM study).

BACKGROUND: Fluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints. METHODS: A prospective observational study of two sequential fluid management strategies was conducted at two East African hospitals. Eligible participants were severely malnourished children, aged 6-60 months, with hypovolaemic shock secondary to gastroenteritis. Group 1 received up to two boluses of 15 ml/kg/h of Ringer's lactate (RL) prior to rehydration as per WHO guidelines. Group 2 received rehydration only (10 ml/kg/h of RL) up to a maximum of 5 h. Comprehensive clinical, haemodynamic and echocardiographic data were collected from admission to day 28. RESULTS: Twenty children were enrolled (11 in group 1 and 9 in group 2), including 15 children (75%) with kwashiorkor, 8 (40%) with elevated brain natriuretic peptide >300 pg/ml, and 9 (45%) with markedly elevated median systemic vascular resistance index (SVRI) >1600 dscm-5/m2 indicative of severe hypovolaemia. Echocardiographic evidence of fluid-responsiveness (FR) was heterogeneous in group 1, with both increased and decreased stroke volume and myocardial fractional shortening. In group 2, these variables were more homogenous and typical of FR. Median SVRI marginally decreased post fluid administration (both groups) but remained high at 24 h. Mortality at 48 h and to day 28, respectively, was 36% (4 deaths) and 81.8% (9 deaths) in group 1 and 44% (4 deaths) and 55.6% (5 deaths) in group 2. We observed no pulmonary oedema or congestive cardiac failure on or during admission; most deaths were unrelated to fluid interventions or echocardiographic findings of response to fluids. CONCLUSION: Baseline and cardiac response to fluid resuscitation do not indicate an effect of compromised cardiac function on response to fluid loading or that fluid overload is common in severely malnourished children with hypovolaemic shock. Endocrine response to shock and persistently high SVRI post fluid-therapy resuscitation may indicate a need for further research investigating enhanced fluid volumes to adequately correct volume deficit. The adverse outcomes are concerning, but appear to be unrelated to immediate fluid management.

Evaluation of pharmacokinetics of single-dose chloroquine in malnourished children with malaria- a comparative study with normally nourished children.

OBJECTIVES: Studies on antimalarial kinetics in children or adults who are undernourished or malnourished are both limited and have yielded conflicting results. The present study was carried out with the objectives of evaluating the pharmacokinetics of single dose chloroquine and its metabolite desethylchloroquine in children who were undernourished and compare them with children who were normally nourished. METHODS: Children of either gender between the ages of 5 and 12 years, smear positive for P. vivax malaria and classified either as well nourished or undernourished were included. Undernourishment was adjudged based on the Indian Academy of Pediatrics (IAP) classification of protein energy malnutrition [PEM] which in turn was based on Khadilkar's growth charts. All participants received 10 mg/kg on the first day followed by 10 mg/kg on Day 2 and 5 mg/kg on Day 3 along with supportive treatment. Blood samples for the levels of chloroquine [CQ] and desethylchloroquine [DECQ] were collected at 0, 0.5, 1, 2 4, 8, 12, 24, 48, 72 hours and 14 days after the first dose and levels assessed by High Performance Liquid Chromatography. RESULTS: A total of 12 children who were normally nourished and 13 who were undernourished were studied. Wide inter-individual variability was seen in the levels of both drug and metabolite in both groups of patients. However, the differences in Cmax, AUC 0-inf, Clearance, half life and Vd between the two groups were not significantly different. DISCUSSION: Our results indicate that dosage requirement is unlikely to be needed for chloroquine in undernourished children with uncomplicated P. vivax malaria.

Clinical significance of neuropsychological improvement after supplementation with omega-3 in 8-12 years old malnourished Mexican children: a randomized, double-blind, placebo and treatment clinical trial.

It has been shown that supplementation with omega-3 improves cognitive performance, especially in infants and toddlers, but it is unknown whether these results are effective in older malnourished children. The aims of this study, therefore, were to investigate the omega-3 supplementation effects in 8- to 12-year-old children and to know which neuropsychological functions improve after three months of intervention in a sample of Mexican children with mild to moderate malnutrition. This study was a randomized, double-blind, treatment and placebo study of 59 children aged 8-12 years who were individually allocated to 2 groups. The duration of the intervention lasted 3 months. Neuropsychological performance was measured at baseline and at 3 months. Results show that more than 50% of children in the treatment group had greater improvement in 11 of the 18 neuropsychological variables studied. Processing speed, visual-motor coordination, perceptual integration, attention and executive function showed improvement in more than 70% of the omega-3 supplemented children. This trial was registered at clinicaltrials.gov as NCT01199120.

Microbes and the malnourished child.

New research implicates a dysfunctional gut microbiome in the etiology of severe childhood malnutrition and confirms a role for antibiotics in its treatment.

Do children with uncomplicated severe acute malnutrition need antibiotics? A systematic review and meta-analysis.

BACKGROUND: Current (1999) World Health Organization guidelines recommend giving routine antibiotics (AB) for all children with severe acute malnutrition (SAM), even if they have uncomplicated disease with no clinically obvious infections. We examined the evidence behind this recommendation. METHODS AND FINDINGS: OVID-MEDLINE, EMBASE, COCHRANE, GLOBAL-HEALTH, CINAHL, POPLINE, AFRICA-WIDE-NiPAD, and LILACS were searched for AB efficacy, bacterial resistance, and infection rates in SAM. Following PRISMA guidelines, a systematic review and meta-analysis were performed. Three randomised controlled trials (RCT), five Cochrane reviews, and 37 observational studies were identified. One cohort-study showed no increase in nutritional-cure and mortality in uncomplicated SAM where no AB were used. (p>0.05). However, an unpublished RCT in this setting did show mortality benefits. Another RCT did not show superiority of ceftriaxone over amoxicilllin for these same outcomes, but adressed SAM children with and without complications (p = 0.27). Another RCT showed no difference between amoxicillin and cotrimoxazole efficacies for pneumonia in underweight, but not SAM. Our meta-analysis of 12 pooled susceptibility-studies for all types of bacterial isolates, including 2767 stricly SAM children, favoured amoxicillin over cotrimoxazole for susceptibility medians: 42% (IQR 27-55%) vs 22% (IQR 17-23%) and population-weighted-means 52.9% (range 23-57%) vs 35.4% (range 6.7-42%). Susceptibilities to second-line AB were better, above 80%. Prevalence of serious infections in SAM, pooled from 24 studies, ranged from 17% to 35.2%. No study infered any association of infection prevalence with AB regimens in SAM. CONCLUSIONS: The evidence underlying current antibiotic recommendations for uncomplicated SAM is weak. Susceptibility-studies favour amoxicillin over cotrimoxazole. However, given that these antibiotics have side-effects, costs, and risks as well as benefits, their routine use needs urgent testing. With reliable monitoring, we believe that there is sufficient equipoise for placebo controlled RCTs, the only robust way to demonstrate true efficacy.

Role of combined zinc, vitamin A, and fish oil supplementation in childhood tuberculosis.

This objective of this study was to determine benefit of one month combined supplementation (zinc, vitamin A, fish oil) along with anti-tuberculosis drugs (ATD) on increasing serum leptin levels and decreasing tumor necrosis factor-alpha (TNF-alpha) in children with tuberculosis (TB). A quasi experimental study was conducted on 22 children (aged 5-14 years) with a positive acid-fast bacilli (AFB) smear. The children were divided into 2 groups. A history, physical examination, anthropometric measurements, serum leptin levels, TNF-alpha levels, retinol and zinc levels were examined in all subjects before and after treatment. Nutritional supplementation and ATD were given to group I while ATD only were given to group II. The change in leptin, TNF-alpha, retinol and zinc levels were analyzed with the Mann-Whitney test, while a t-test was used to determine changes in body mass index (BMI). Group I had a higher significant increase in serum leptin levels than group II (p=0.034). Group I had a significantly greater decrease in TNF-a levels than group II (p=0.032). No significant differences in retinol or zinc levels were seen between the two, but both groups had an increase after treatment. Both groups had a significant increase in BMI (p=<0.001) post-treatment compared to pre-treatment. Supplementation with zinc, vitamin A and fish oil is associated with a significant increase in leptin levels and a significant decrease in TNF-alpha levels among children treated for TB. No significant benefit was seen in BMI among children receiving supplementation compared to those without it, although ATD resulted in a significant increase in BMI in both groups.

The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review.

BACKGROUND: Severe acute malnutrition (SAM) arises as a consequence of a sudden period of food shortage and is associated with loss of a person's body fat and wasting of their skeletal muscle. Many of those affected are already undernourished and are often susceptible to disease. Infants and young children are the most vulnerable as they require extra nutrition for growth and development, have comparatively limited energy reserves and depend on others. Undernutrition can have drastic and wide-ranging consequences for the child's development and survival in the short and long term. Despite efforts made to treat SAM through different interventions and programmes, it continues to cause unacceptably high levels of mortality and morbidity. Uncertainty remains as to the most effective methods to treat severe acute malnutrition in young children. OBJECTIVES: To evaluate the effectiveness of interventions to treat infants and children aged < 5 years who have SAM. DATA SOURCES: Eight databases (MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, CAB Abstracts Ovid, Bioline, Centre for Reviews and Dissemination, EconLit EBSCO and The Cochrane Library) were searched to 2010. Bibliographies of included articles and grey literature sources were also searched. The project expert advisory group was asked to identify additional published and unpublished references. REVIEW METHODS: Prior to the systematic review, a Delphi process involving international experts prioritised the research questions. Searches were conducted and two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full texts of retrieved papers by one reviewer and checked independently by a second. Included studies were mapped to the research questions. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer. Differences in opinion were resolved through discussion at each stage. Studies were synthesised through a narrative review with tabulation of the results. RESULTS: A total of 8954 records were screened, 224 full-text articles were retrieved, and 74 articles (describing 68 studies) met the inclusion criteria and were mapped. No evidence focused on treatment of children with SAM who were human immunodeficiency virus sero-positive, and no good-quality or adequately reported studies assessed treatments for SAM among infants < 6 months old. One randomised controlled trial investigated fluid resuscitation solutions for shock, with none adequately treating shock. Children with acute diarrhoea benefited from the use of hypo-osmolar oral rehydration solution (H-ORS) compared with the standard World Health Organization-oral rehydration solution (WHO-ORS). WHO-ORS was not significantly different from rehydration solution for malnutrition (ReSoMal), but the safety of ReSoMal was uncertain. A rice-based ORS was more beneficial than glucose-based ORSs, and provision of zinc plus a WHO-ORS had a favourable impact on diarrhoea and need for ORS. Comparisons of different diets in children with persistent diarrhoea produced conflicting findings. For treating infection, comparison of amoxicillin with ceftriaxone during inpatient therapy, and routine provision of antibiotics for 7 days versus no antibiotics during outpatient therapy of uncomplicated SAM, found that neither had a significant effect on recovery at the end of follow-up. No evidence mapped to the next three questions on factors that affect sustainability of programmes, long-term survival and readmission rates, the clinical effectiveness of management strategies for treating children with comorbidities such as tuberculosis and Helicobacter pylori infection and the factors that limit the full implementation of treatment programmes. Comparison of treatment for SAM in different settings showed that children receiving inpatient care appear to do as well as those in ambulatory or home settings on anthropometric measures and response time to treatment. Longer-term follow-up showed limited differences between the different settings. The majority of evidence on methods for correcting micronutrient deficiencies considered zinc supplements; however, trials were heterogeneous and a firm conclusion about zinc was not reached. There was limited evidence on either supplementary potassium or nicotinic acid (each produced some benefits), and nucleotides (not associated with benefits). Evidence was identified for four of the five remaining questions, but not assessed because of resource limitation. LIMITATIONS: The systematic review focused on key questions prioritised through a Delphi study and, as a consequence, did not encompass all elements in the management of SAM. In focusing on evidence from controlled studies with the most rigorous designs that were published in the English language, the systematic review may have excluded other forms of evidence. The systematic review identified several limitations in the evidence base for assessing the effectiveness of interventions for treating young children with severe acute malnutrition, including a lack of studies assessing the different interventions; limited details of study methods used; short follow-up post intervention or discharge; and heterogeneity in participants, interventions, settings, and outcome measures affecting generalisability. CONCLUSIONS: For many of the most highly ranked questions evidence was lacking or inconclusive. More research is needed on a range of topic areas concerning the treatment of infants and children with SAM. Further research is required on most aspects of the management of SAM in children < 5 years, including intravenous resuscitation regimens for shock, management of subgroups (e.g. infants < 6 months old, infants and children with SAM who are human immunodeficiency virus sero-positive) and on the use of antibiotics.

Exceso de peso y preguntas frecuentes sobre la alimentación del niño con cáncer / Overweight and frequently asked questions about feeding the child with cancer

Durante el tratamiento del niño con cáncer, es posible requerir el uso de corticoides, los cuales como efecto adverso tienen el aumento en el apetito, que unido al sedentarismo de estos niños, incrementan de peso y pueden concurrir en sobrepeso y obesidad, malnutrición que es tan dañina como la desnutrición. Es necesario un control y seguimiento estricto por parte del pediatra y nutricionista infantil en estos niños con malnutrición.

During the treatment of children with cancer, may require the use of corticosteroids, which have the adverse effect of increased appetite, which together with the inactivity of theses children, increased weight and may attend overweight and obesity, malnutrition that is as harmful as malnutrition. It is necessary to control and closely monitored by the pediatrician and infant nutritionist in these children with malnutrition.

Nutritional rickets and vitamin D deficiency in infants, children and adolescents.

Nutritional rickets continues to be a public health problem in many countries despite the presence of cheap and effective means of preventing the disease. Deficiency of vitamin D is associated with rickets in growing children and osteomalacia in adults. Vitamin D deficiency is attributed to a variety of causes including diet, atmospheric pollution, religious practices that restrict sunlight exposure (clothing), geographic latitude and altitude, season, and time of the day. The clinical findings of rickets can vary among stages of the disease. It is recommended that healthy infants, children and adolescents take at least 400 IU vitamin D per day to prevent rickets and vitamin D deficiency. Pediatricians and other healthcare professionals should try to ensure that children and adolescents receive daily vitamin D requirements appropriate for their risk factors, traditions, and customs. Additionally, it is important to use every opportunity to ensure that effective preventive strategies are put in practice.

Hospital management of severely malnourished children: comparison of locally adapted protocol with WHO protocol.

OBJECTIVES: To compare the effectiveness of locally adapted Institute of Child and Mother Health (ICMH) protocol with the WHO protocol for the management of severely malnourished children in Bangladesh. DESIGN: Quasi-experimental non-randomized clinical trial. SETTING: Hospital based. PARTICIPANTS: Severely malnourished children (2-59 mo) with weight for height<70% (n=60). INTERVENTION: Children treated with either WHO protocol (Group I, n=30) or ICMH protocol (Group II, n=30). OUTCOME VARIABLES: Clinical improvement, weight gain, time taken to achieve target weight gain, and mortality among the study subjects. RESULTS: Mean (SD) weight related to gain in Group I and Group II was 11.2 (4.1) and 11.1 (3.9) g/kg/day, respectively. The weight gain was not related to the age group or type of malnutrition. The time taken for edema to subside (7.3 d vs 8 d) and for improvement of appetite (6.5 d to 7.3 d vs 6.7 d to 8.4 d) was similar between the groups. The target weight gain was achieved in 28.3 (11.5) days in Group I against 27.9 (6.2) days in Group II (P=0.88). The mortality rate was 6.7% in each group. CONCLUSION: Treatment of severe malnutrition with locally adapted ICMH protocol using locally available foods is as efficacious as the WHO protocol.

Effects of deworming on malnourished preschool children in India: an open-labelled, cluster-randomized trial.

BACKGROUND: More than a third of the world's children are infected with intestinal nematodes. Current control approaches emphasise treatment of school age children, and there is a lack of information on the effects of deworming preschool children. METHODOLOGY: We studied the effects on the heights and weights of 3,935 children, initially 1 to 5 years of age, of five rounds of anthelmintic treatment (400 mg albendazole) administered every 6 months over 2 years. The children lived in 50 areas, each defined by precise government boundaries as urban slums, in Lucknow, North India. All children were offered vitamin A every 6 months, and children in 25 randomly assigned slum areas also received 6-monthly albendazole. Treatments were delivered by the State Integrated Child Development Scheme (ICDS), and height and weight were monitored at baseline and every 6 months for 24 months (trial registration number NCT00396500). p Value calculations are based only on the 50 area-specific mean values, as randomization was by area. FINDINGS: The ICDS infrastructure proved able to deliver the interventions. 95% (3,712/3,912) of those alive at the end of the study had received all five interventions and had been measured during all four follow-up surveys, and 99% (3,855/3,912) were measured at the last of these surveys. At this final follow up, the albendazole-treated arm exhibited a similar height gain but a 35 (SE 5) % greater weight gain, equivalent to an extra 1 (SE 0.15) kg over 2 years (99% CI 0.6-1.4 kg, p = 10(-11)). CONCLUSIONS: In such urban slums in the 1990s, five 6-monthly rounds of single dose anthelmintic treatment of malnourished, poor children initially aged 1-5 years results in substantial weight gain. The ICDS system could provide a sustainable, inexpensive approach to the delivery of anthelmintics or micronutrient supplements to such populations. As, however, we do not know the control parasite burden, these results are difficult to generalize. TRIAL REGISTRATION: ClinicalTrials.gov NCT00396500.

Vitamin A for preventing acute lower respiratory tract infections in children up to seven years of age.

BACKGROUND: Vitamin A supplements are effective for preventing diarrhoea. There are theoretical reasons it might also be effective for acute lower respiratory tract infections (LRTIs), also very common in children, especially in low income countries. OBJECTIVES: To assess the effectiveness and safety of vitamin A for preventing acute LRTIs in children up to seven years of age. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (1966 to July 2007); EMBASE (1974 to July 2007); and the Chinese Biomedicine Database (CBM) (1976 to July 2007). SELECTION CRITERIA: Randomised controlled trials (RCTs) that assessed the effectiveness of vitamin A in the prevention of acute LRTI in children up to seven years of age. DATA COLLECTION AND ANALYSIS: The review authors independently extracted data and assessed trial quality. Study authors were contacted for additional information. MAIN RESULTS: Most studies found no significant effect of vitamin A on the incidence of acute LRTI, or prevalence of symptoms of acute LRTI. Vitamin A caused an increased incidence of acute LRTI in one study; an increase in cough and fever; and increased symptoms of cough and rapid breathing in two others. Three reported no differences and no protective effect of vitamin A. Two studies reported that vitamin A significantly reduced the incidence of acute LRTI with children with poor nutritional status or weight, but increased it in normal children. AUTHORS' CONCLUSIONS: This unexpected result is outside our current understanding of the use of vitamin A for preventing acute LRTIs. Accordingly, vitamin A should not be given to all children to prevent acute LRTIs. There is evidence for vitamin A supplements to prevent acute LRTIs in children with low serum retinol or those with a poor nutritional status.

Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia.

OBJECTIVE: To determine whether vitamin A capsule programmes fail to reach children who are at higher risk of malnutrition and morbidity. Although it has been suggested that there are health disparities between children who are reached or not reached by these programmes, little quantitative work has been undertaken to characterize this relationship. STUDY DESIGN: As part of a national surveillance system, nutritional status and other factors were compared in 138,956 children, aged 12-59 months, who had and had not received vitamin A supplementation in urban slum areas in Indonesia. RESULTS: In total, 63.1% of children had received a vitamin A capsule within the previous 6 months. Among children who had and had not received vitamin A supplementation, respectively, the proportion with weight-for-age and height-for-age Z scores <-3 were 7.8% vs 8.6% (P<0.0001) and 9.4% vs 10.7% (P<0.0001), and with a history of diarrhoea in the previous week was 8.1% vs 10.7% (P<0.0001). In families where a child had or had not received vitamin A supplementation, the proportion with a history of infant death <12 months was 5.2% vs 7.2% (P<0.0001) and child death <5 years was 6.7% vs 9.2%, respectively (P<0.0001). Children who had not received vitamin A supplementation were also significantly more likely to be anaemic and have diarrhoea or fever on the survey day compared with children who had received supplementation. CONCLUSIONS: In the urban slums of Indonesia, children who do not receive vitamin A supplementation tend to be slightly more malnourished and ill, and are more likely to come from families with higher child mortality than children who receive vitamin A. Higher rates of child mortality in non-participating households suggest that reaching preschoolers could yield a disproportionate survival benefit. Importantly, children who are not reached by the vitamin A programme are also unlikely to be reached by vaccination and other services, emphasizing the need to identify and extend efforts to reach non-participants.

Zinc supplementation in the management of shigellosis in malnourished children in Bangladesh.

OBJECTIVE: To assess the impact of zinc supplementation on clinical recovery, weight gain and subsequent growth and morbidity in moderately malnourished children with shigellosis. DESIGN: A randomized, double-blind, controlled trial. SETTING: Dhaka hospital of ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh. SUBJECTS: Fifty-six moderately malnourished children, aged 12-59 months with culture-proven shigellosis. METHODS: Subjects were randomly allocated to receive zinc (20 mg/day elemental) in multivitamin syrup (intervention) or multivitamin syrup without zinc (control) in two equally divided doses daily for 2 weeks. All children received pivmecillinam in a dose of 15 mg/kg every 6 h for 5 days. After supplementation, children were followed in their respective homes every 2 weeks for 6 months. RESULTS: Children receiving zinc recovered from acute illness significantly faster than the control children (P<0.05). The medians time (days) to recovery and disappearances of blood and mucous were significantly 50% shorter in the zinc-supplemented group compared to the control group. The mean body weight of zinc supplemented children increased significantly from 8.8 kg on admission to 9.2 kg (P<0.01) at recovery, which was not observed in the control children (from 9.3 to 9.6 kg; P=0.12). During the 6-month follow-up period, zinc-supplemented children had significantly fewer mean episodes of diarrhoea compared to the control children (2.2 vs 3.3; P=0.03). CONCLUSION: Zinc supplementation significantly shortens the duration of acute shigellosis, promotes better weight gain during recovery and reduces diarrhoeal morbidity during the subsequent 6 months.