Detection and management of milk allergy: Delphi consensus study.

BACKGROUND: There is significant overdiagnosis of milk allergy in young children in some countries, leading to unnecessary use of specialized formula. This guidance, developed by experts without commercial ties to the formula industry, aims to reduce milk allergy overdiagnosis and support carers of children with suspected milk allergy. METHODS: Delphi study involving two rounds of anonymous consensus building and an open meeting between January and July 2021. Seventeen experts in general practice, nutrition, midwifery, health visiting, lactation support and relevant areas of paediatrics participated, located in Europe, North America, Middle East, Africa, Australia and Asia. Five authors of previous milk allergy guidelines and seven parents provided feedback. FINDINGS: Participants agreed on 38 essential recommendations through consensus. Recommendations highlighted the importance of reproducibility and specificity for diagnosing milk allergy in children with acute or delayed symptoms temporally related to milk protein ingestion; and distinguished between children directly consuming milk protein and exclusively breastfed infants. Consensus was reached that maternal dietary restriction is not usually necessary to manage milk allergy, and that for exclusively breastfed infants with chronic symptoms, milk allergy diagnosis should only be considered in specific, rare circumstances. Consensus was reached that milk allergy diagnosis does not need to be considered for stool changes, aversive feeding or occasional spots of blood in stool, if there is no temporal relationship with milk protein ingestion. When compared with previous guidelines, these consensus recommendations resulted in more restrictive criteria for detecting milk allergy and a more limited role for maternal dietary exclusions and specialized formula. INTERPRETATION: These new milk allergy recommendations from non-conflicted, multidisciplinary experts advise narrower criteria, more prominent support for breastfeeding and less use of specialized formula, compared with current guidelines.

Findings from a cluster randomised trial of unconditional cash transfers in Niger.

Unconditional cash transfers (UCTs) are used as a humanitarian intervention to prevent acute malnutrition, despite a lack of evidence about their effectiveness. In Niger, UCT and supplementary feeding are given during the June-September "lean season," although admissions of malnourished children to feeding programmes may rise from March/April. We hypothesised that earlier initiation of the UCT would reduce the prevalence of global acute malnutrition (GAM) in children 6-59 months old in beneficiary households and at population level. We conducted a 2-armed cluster-randomised controlled trial in which the poorest households received either the standard UCT (4 transfers between June and September) or a modified UCT (6 transfers from April); both providing 130,000 FCFA/£144 in total. Eligible individuals (pregnant and lactating women and children 6-<24 months old) in beneficiary households in both arms also received supplementary food between June and September. We collected data in March/April and October/November 2015. The modified UCT plus 4 months supplementary feeding did not reduce the prevalence of GAM compared with the standard UCT plus 4 months supplementary feeding (adjusted odds ratios 1.09 (95% CI [0.77, 1.55], p = 0.630) and 0.93 (95% CI [0.58, 1.49], p = 0.759) among beneficiaries and the population, respectively). More beneficiaries receiving the modified UCT plus supplementary feeding reported adequate food access in April and May (p < 0.001) but there was no difference in endline food security between arms. In both arms and samples, the baseline prevalence of GAM remained elevated at endline (p > 0.05), despite improved food security (p < 0.05), possibly driven by increased fever/malaria in children (p < 0.001). Nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs plus supplementary feeding to prevent malnutrition in this context. Caution is required in applying the findings of this study to periods of severe food insecurity.

Factors Associated With the Risk of Acute Malnutrition Among Children Aged 6 to 36 Months in Households Targeted by an Emergency Cash Transfer Program.

BACKGROUND: Assessing whether and how the expenditure of emergency cash transfer programs (CTPs) relates to child nutritional status is a necessary step for informed program design and targeting. OBJECTIVE: We hypothesized that greater child food expenditures would have a protective effect against the risk of acute malnutrition in the context of a food crisis in Niger. METHODS: We investigated the relationship between food and medical expenditures and acute malnutrition in children aged 6 to 36 months through an observational cohort study of 420 households enrolled in an emergency CTP in Niger. A Cox proportional hazards model was used to estimate the risk of acute malnutrition while adjusting for relevant child and household characteristics. RESULTS: Seventy-four (18% of the cohort) children developed acute malnutrition. The risk was 1.79 times higher among ill children than healthy children (hazard ratio [HR]: 1.79; 95% confidence interval [CI]: 1.10-2.92; P < .05), nearly 3 times higher among children in the poorest households than those in wealthier households (HR: 2.98; 95% CI: 1.86-4.78; P < .001), and 2.85 times lower with each unit increase in baseline weight-for-height Z score (HR: 0.35; 95% CI: 0.23-0.53; P < .001). Food expenditures were not associated with risk (HR: 0.97; 95% CI: 0.87-1.07; P > .05). CONCLUSION: Our findings highlight the importance of the health-related determinants of child undernutrition and suggest that a potential role of emergency CTPs may be to enable and promote health service access where services exist. They also indicate a need for more sustained poverty reduction and undernutrition prevention activities in concert with well-timed and strategic use of emergency interventions.

The REFANI-N study protocol: a cluster-randomised controlled trial of the effectiveness and cost-effectiveness of early initiation and longer duration of emergency/seasonal unconditional cash transfers for the prevention of acute malnutrition among children, 6-59 months, in Tahoua, Niger.

BACKGROUND: The global burden of acute malnutrition among children remains high, and prevalence rates are highest in humanitarian contexts such as Niger. Unconditional cash transfers are increasingly used to prevent acute malnutrition in emergencies but lack a strong evidence base. In Niger, non-governmental organisations give unconditional cash transfers to the poorest households from June to September; the 'hunger gap'. However, rising admissions to feeding programmes from March/April suggest the intervention may be late. METHODS/DESIGN: This cluster-randomised controlled trial will compare two types of unconditional cash transfer for 'very poor' households in 'vulnerable' villages defined and identified by the implementing organisation. 3,500 children (6-59 months) and 2,500 women (15-49 years) will be recruited exhaustively from households targeted for cash and from a random sample of non-recipient households in 40 villages in Tahoua district. Clusters of villages with a common cash distribution point will be assigned to either a control group which will receive the standard intervention (n = 10), or a modified intervention group (n = 10). The standard intervention is 32,500 FCFA/month for 4 months, June to September, given cash-in-hand to female representatives of 'very poor' households. The modified intervention is 21,500 FCFA/month for 5 months, April, May, July, August, September, and 22,500 FCFA in June, providing the same total amount. In both arms the recipient women attend an education session, women and children are screened and referred for acute malnutrition treatment, and the households receive nutrition supplements for children 6-23 months and pregnant and lactating women. The trial will evaluate whether the modified unconditional cash transfer leads to a reduction in acute malnutrition among children 6-59 months old compared to the standard intervention. The sample size provides power to detect a 5 percentage point difference in prevalence of acute malnutrition between trial arms. Quantitative and qualitative process evaluation data will be prospectively collected and programme costs will be collected and cost-effectiveness ratios calculated. DISCUSSION: This randomised study design with a concurrent process evaluation will provide evidence on the effectiveness and cost-effectiveness of earlier initiation of seasonal unconditional cash transfer for the prevention of acute malnutrition, which will be generalisable to similar humanitarian situations. TRIAL REGISTRATION: ISRCTN25360839, registered March 19, 2015.

The role of unconditional cash transfers during a nutritional emergency in Maradi region, Niger: a pre-post intervention observational study.

OBJECTIVE: To assess the effect of an unconditional cash transfer (CT) implemented as part of an emergency response to food insecurity during a declared state of emergency. DESIGN: Pre-post intervention observational study involving two rounds of data collection, i.e. baseline (April 2012) and final survey (September 2012), on the same cohort of 'poor' and 'very poor' households enrolled by Save the Children in an unconditional CT programme. SETTING: Aguié district, Maradi, Niger. SUBJECTS: Households with a non-acutely malnourished child aged 6-36 months (n 412). RESULTS: The study showed that the living standards of 'poor' and 'very poor' households improved, as indicated by a reduction in poverty-related indicators and an improvement in household food security. Anthropometric outcomes for children aged 6-36 months improved significantly, despite a decline in child health and women's well-being and autonomy. Risk factors for becoming acutely malnourished post-intervention were being from a very poor household at baseline, starting the lean season with low weight-for-height Z-score (WHZ <-1) and the presence of co-morbidity. CONCLUSIONS: The results of the study are consistent with the published evidence regarding the general impact of CT and suggest it is plausible that giving cash during an emergency can help safeguard living standards of the very poor and poor. While improvements in childhood nutrition status were seen it is not possible to attribute these to the CT programme. However, knowledge of the risk factors for acute malnutrition in a particular setting can be used to influence the design of future CT interventions for which a controlled trial would be recommended if feasible.

The practical challenges of evaluating a blanket emergency feeding programme in northern Kenya.

A blanket supplementary feeding programme for young children was implemented for four months in five northern districts of Kenya from January 2010 because of fears of food insecurity exacerbated by drought. An attempt to evaluate the impact of the food on children's anthropometric status was put in place in three districts. The main aim of the analysis was to assess the quality of the data on the cohort of children studied in the evaluation and to propose methods by which it could be improved to evaluate future blanket feeding programmes. Data on the name, age, sex, weight and height of a systematic sample of children recruited at 61 food distribution sites were collected at the first, second and third rounds and again at an extra, fifth food distribution, offered only to the evaluation subjects. Of the 3,544 children enrolled, 483 (13.63%) did not collect a fifth ration. Of the 2,640 children who were considered by their name to be the same at the first and fifth food distribution (13% were different), data on only 902 children (34.17%) were considered acceptable based on their age (an arbitrary ±3 months different) and their length or height (between >-1 or ≤4 cm different) at the two instances they were seen. Data on nearly two thirds of children were of questionable quality. The main reasons for the poor quality data were inconsistencies in estimating age or because caretakers may have brought different children. Recommendations are made about how to improve data quality including ensuring that entry to a blanket feeding programme is clearly based on height, not age, to avoid misreporting age; careful identification of subjects at all contacts; and using well-trained, specialist evaluation staff.

Micronutrient supplementation in later life: limited evidence for benefit.

The importance of attaining adequate macronutrient and micronutrient intake throughout the life course is essential for the maintenance of health. Claims have been made for the benefits of micronutrient supplementation in later life, and this review considers the strength of the evidence behind these claims focusing on studies with cardiovascular, cancer, eye health, immune, and cognitive end points. While observational data suggest the presence of a link between dietary micronutrient intake and health outcomes, evidence from large randomized controlled trials does not support the use of antioxidant vitamin or mineral supplements among well-nourished older populations. Moreover, there is evidence of possible adverse affects of micronutrient supplementation. In conclusion, the considerable enthusiasm for the use of micronutrient, especially antioxidant, supplements as anti-aging treatments or as treatments for specific diseases of later life is not supported by the currently available scientific literature.