Long-term effects of severe acute malnutrition during childhood on adult cognitive, academic and behavioural development in African fragile countries: The Lwiro cohort study in Democratic Republic of the Congo.

INTRODUCTION: Little is known about the outcomes of subjects with a history of severe acute malnutrition (SAM). We therefore sought to explore the long-term effects of SAM during childhood on human capital in adulthood in terms of education, cognition, self-esteem and health-related disabilities in daily living. METHODOLOGY: We traced 524 adults (median age of 22) in the eastern Democratic Republic of the Congo, who were treated for SAM during childhood at Lwiro hospital between 1988 and 2007 (median age 41 months). We compared them with 407 community controls of comparable age and sex. Our outcomes of interest were education, cognitive function [assessed using the Mini Mental State Examination (MMSE) for literate participants, or its modified version created by Ertan et al. (MMSE-I) for uneducated participants], self-esteem (measured using the Rosenberg Self-Esteem Scale) and health-related social and functional disabilities measured using the World Health Organization Disability Assessment Schedule (WHODAS). For comparison, we used the Chi-squared test along with the Student's t-test for the proportions and means respectively. RESULTS: Compared with the community controls, malnutrition survivors had a lower probability of attaining a high level of education (p < 0.001), of reporting a high academic performance (p = 0.014) or of having high self-esteem (p = 0.003). In addition, malnutrition survivors had an overall mean score in the cognitive test that was lower compared with the community controls [25.6 compared with 27.8, p = 0.001 (MMSE) and 22.8 compared with 26.3, p < 0.001(MMSE-I)] and a lower proportion of subjects with a normal result in this test (78.0% compared with 90.1%, p < 0.001). Lastly, in terms of health-related disabilities, unlike the community controls, malnutrition survivors had less social disability (p = 0.034), but no difference was observed as regards activities of daily living (p = 0.322). CONCLUSION: SAM during childhood exposes survivors to low human capital as regards education, cognition and behaviour in adulthood. Policy-deciders seeking to promote economic growth and to address various psychological and medico-social disorders must take into consideration the fact that appropriate investment in child health as regards SAM is an essential means to achieve this.

Determinants of motor, language, cognitive, and global developmental delay in children with complicated severe acute malnutrition at the time of discharge: An observational study from Central India.

BACKGROUND: Undernutrition leads to impaired psychosocial and cognitive development. This study explored the developmental status of children with complicated severe acute malnutrition (SAM) and correlated it with various risk factors for SAM. METHODS AND FINDINGS: We recruited 100 children with SAM and no other associated significant health issues during the recovery phase of treatment using the Bayley Scales of Infant and Toddler Development III prior to discharge from the nutritional rehabilitation unit in R D Gardi Medical College, Ujjain, Central India. We also assessed composite developmental scores, developmental age equivalents, and average differences in developmental age. Risk factors for developmental delay were identified in children with complicated SAM. The results revealed that 75%, 75%, and 63% of children with SAM exhibited delay in motor (mean score: 78.22), language (mean score: 83.97), and cognitive (mean score: 78.06) domains, respectively. A total of 63% children exhibited delay by an average of 4-7 months in the total developmental age. The proportion of children with delay in motor, language, and cognitive domains was determined. An increased risk of global developmental delay was observedin children with a low birth weight (adjusted odds ratio [aOR]: 18.06, 95%CI: 2.08-156.56; P = 0.009), having working mothers (aOR: 17.54, 95%CI: 3.02-102.59; P = 0.001), weight-for-age less than three standard deviations (aOR: 6.09, 95%CI: 1.08-34.10; P = 0.04), and presence of severe anemia (aOR: 16.34, 95%CI: 2.94-90.73; P = 0.001). CONCLUSIONS: The results indicated that children with SAM exhibit developmental delay across all domains. Identifying multiple modifiable risk factors for developmental delay in children with SAM will be helpful in devising early interventional strategies in low-middle income countries; however, the exact timing of such interventions should be investigated.

Nutrition rehabilitation of children with severe acute malnutrition: Revisiting studies undertaken by the National Institute of Nutrition.

Severe acute malnutrition (SAM) in children under five years is an important public health problem due to associated high mortality and long-term health consequences. Research on the dietary causes of SAM, especially the role and relative importance of dietary protein, in the aetiology of oedematous malnutrition, has led to considerable debates and controversies. The present article revisits some of the debates in this field, where the researchers at the National Institute of Nutrition (NIN), Hyderabad, India, with their pioneering work, have contributed to the global literature on the various facets of the disease. Highlighting the importance of energy as a bigger problem than protein malnutrition is a noteworthy contribution of NIN's research. It is, however, important to examine the protein quality of the diets in light of the new information on the lysine requirements. The article argues that the currently dominating hypothesis of free radical theory requires a critical review of the supporting evidence. Over the past few decades, the research has focused on low-cost diets using locally available foods. The article also argues that solutions based on local foods, being acceptable and sustainable, need to be strengthened for their effective delivery through the existing nutrition programmes. Recent evidence shows that the use of ready-to-use therapeutic foods (RUTF) with high micronutrient density may be linked with higher mortality possibly due to the high iron content, which could be counterproductive. There are several unaddressed concerns regarding the potential long-term impact of consumption of RUTF in children with SAM. More evidence and a cautious approach are, therefore, needed before implementing these solutions.

A quantitative cross-sectional survey of psychosocial stimulation and counselling interventions at nutritional rehabilitation units in Southern Malawi.

Background: Inpatient treatment at nutritional rehabilitation units (NRUs) is needed for children who have severe acute malnutrition (SAM) and acute illness, loss of appetite, or severe oedema. World Health Organization guidelines state that nutritional counselling should be done with primary caregivers at NRUs. These recommendations also include psychosocial stimulation interventions to improve developmental outcomes in children with SAM. However, there is limited information about the delivery of these types of interventions for caregivers and children in NRU settings. The primary objective of this research was therefore to obtain data about NRU resources, activities, and protocols relevant to psychosocial stimulation and counselling interventions during inpatient treatment of children with SAM. Methods: A cross-sectional survey was administered by interview at all 16 NRUs in seven districts in Southern Malawi. Participants were health workers, nurses, and nutritionists employed at the respective NRUs. Results: The response rate was 100% across NRUs. Half of participants said that psychosocial stimulation interventions are conducted at their respective NRUs, yet none of the NRUs have protocols for delivery of these interventions. Furthermore, 7/16 (44%) NRUs have no resources for psychosocial stimulation including play materials. Thirteen of 16 (81%) participants said that they feel this type of intervention is very important and 3/16 (19%) participants said that this somewhat important for children with SAM. All NRUs provide counselling to caregivers about breastfeeding and nutrition; 15/16 (94%) also give counselling about water, sanitation and hygiene. Conclusions: Ultimately, results from this survey highlighted that there is a need to invest in comprehensive interventions to improve developmental and nutritional outcomes in these vulnerable children requiring admission to NRUs.

Progress of children with severe acute malnutrition in the malnutrition treatment centre rehabilitation program: evidence from a prospective study in Jharkhand, India.

BACKGROUND: In Jharkhand, Malnutrition Treatment Centres (MTCs) have been established to provide care to children with severe acute malnutrition (SAM). The study examined the effects of facility- and community based care provided as part the MTC program on children with severe acute malnutrition. METHOD: A cohort of 150 children were enrolled and interviewed by trained investigators at admission, discharge, and after two months on the completion of the community-based phase of the MTC program. Trained investigators collected data on diet, morbidity, anthropometry, and utilization of health and nutrition services. RESULTS: We found no deaths among children attending the MTC program. Recovery was poor, and the majority of children demonstrated poor weight gain, with severe wasting and underweight reported in 52 and 83% of the children respectively at the completion of the community-based phase of the MTC program. The average weight gain in the MTC facility (3.8 ± 5.9 g/kg body weight/d) and after discharge (0.6 ± 2.1 g/kg body weight/d) was below recommended standards. 67% of the children consumed food that met less than 50% of the recommended energy and protein requirement. Children experienced high number of illness episodes after discharge: 68% children had coughs and cold, 40% had fever and 35% had diarrhoea. Multiple morbidities were common: 50% of children had two or more episodes of illness. Caregiver's exposure to MTC's health and nutrition education sessions and meetings with frontline workers did not improve feeding practices at home. The take-home ration amount distributed to children through the supplementary food program was inadequate to achieve growth benefits. CONCLUSIONS: Recovery of children during and after the MTC program was suboptimal. This highlights the need for additional support to strengthen MTC program so that effective care to children can be provided.

Developmental performance of hospitalized severely acutely malnourished under-six children in low- income setting.

BACKGROUND: Retrospective studies show that severe acute malnutrition (SAM) affects child development. However, to what extent SAM affects children of different ages at its acute stage is not well documented. This study was aimed at comparing the developmental performance of severely acutely malnourished children under six with that of age and gender-matched non-malnourished healthy children. METHODS: The developmental performances of 310 children with SAM (male = 155, female = 155); mean age = 30.7 mo; SD = 15.2 mo) admitted to the nutritional rehabilitation unit (NRU) at Jimma University's Hospital was compared with that of 310 age and gender-matched, non-malnourished healthy children (male = 155, female = 155; mean age = 29.6 mo; SD = 15.4 mo) living in Jimma Town in Ethiopia. Two culturally adapted tools were used: (1) the Denver II-Jimma, to assess the children's performance on personal social (PS), fine motor (FM) language (LA), gross motor (GM) skills, and (2) the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE), to assess social-emotional (SE) skills. Multivariable Poisson regression analysis was conducted to compare the developmental performance scores of SAM and non-malnourished children. RESULTS: For one-year-old children, SAM delays their developmental performance on GM, FM, PS and LA by 300%, 200%, 140% and 71.4% respectively. For three-years-old children, SAM delays their developmental performance on GM by 80%, on FM and LA by 50% each, and on PS by 28.6%. Of the skills assessed on Denver II-Jimma, GM is the most, and PS is the least affected. Younger SAM children are more affected than older ones on all the domains of development. The delay in FM, GM, LA and PS generally decreases with an increase in age. Social-emotional behavior problems seem to be most pronounced in the very young and older age ranges. CONCLUSIONS: SAM has a differential age effect on the different dimensions of development in children under 6 years of age.

Monitoring and discharging children being treated for severe acute malnutrition using mid-upper arm circumference: secondary data analysis from rural Gambia.

Background: Severe acute malnutrition (SAM) is a major public health problem. Mid-upper arm circumference (MUAC) is widely used to admit children to treatment programmes. However, insufficient data supporting MUAC discharge criterion limits its use as a stand-alone tool. Our aim was to evaluate MUAC for monitoring nutritional recovery and discharge. Methods: This was a secondary analysis of clinical data from children 6-59 months-old treated for SAM from January 2003 to December 2013 at the Nutritional Rehabilitation Unit in rural Gambia. Weight, weight-for-height z-score (WHZ) and MUAC response to treatment were assessed. Treatment indicators and regression models controlled for admission measurement and age were compared by discharge MUAC and WHZ. Results: Four hundred and sixty-three children with marasmus were included. MUAC, WHZ and weight showed parallel responses to treatment. MUAC≥125 mm as a discharge criterion performed well, showing good prediction of default and referral to hospital, acceptable duration of stay, and a higher absolute MUAC measure compared to WHZ≥-2.00, closely related to lower risk of mortality. Conclusions: MUAC can be used as a standalone tool for monitoring nutritional recovery. MUAC≥125 mm performs well as a discharge criterion; however, follow-up data is needed to assess its safety. Further research is needed on children meeting MUAC discharge criterion but with WHZ≤2.0.

Correlates of thymus size and changes during treatment of children with severe acute malnutrition: a cohort study.

BACKGROUND: The impairment of immune functions associated with malnutrition may be one reason for the high mortality in children with severe acute malnutrition (SAM), and thymus atrophy has been proposed as a marker of this immunodeficiency. The aim of this study was to identify nutritional and clinical correlates of thymus size in children with SAM, and predictors of change in thymus size with nutritional rehabilitation. METHODS: In an observational study among children aged 6-59 months admitted with SAM in Uganda, we measured thymus area by ultrasound on hospital admission to treatment with F75 and F100, on hospital discharge and after 8 weeks of nutritional rehabilitation with ready-to-use therapeutic food, as well as in well-nourished healthy children. We investigated anthropometric, clinical, biochemical and treatment-related correlates of area and growth of the thymus. RESULTS: Eighty-five children with SAM with a median age of 16.5 months were included. On admission 27% of the children had a thymus undetectable by ultrasound. Median thymus area was 1.3 cm2 in malnourished children, and 3.5 cm2 in healthy children (p < 0.001). Most anthropometric z-scores, hemoglobin and plasma phosphate correlated positively with thymus area. Thymus area correlated negatively with caretaker-reported severity of illness, plasma α-1 acid glycoprotein, and C-reactive protein >5 mg/L. At follow-up after 8 weeks, median thymus area had increased to 2.5 cm2 (p < 0.001). Increase in thymus area during treatment was associated with simultaneous increase in mid-upper-arm circumference, with 0.29 cm2 higher increase in thymus area per cm larger increment in MUAC (p = 0.03). Children whose F-75 had partially been replaced by rice porridge during their hospital admission had less increase in thymus area after 8 weeks. CONCLUSION: Malnutrition and inflammation are associated with thymus atrophy, and thymus area seems positively associated with plasma phosphate. Substituting therapeutic formula with unfortified rice porridge with the aim of alleviating diarrhea may impair regain of thymus size with nutritional rehabilitation. This calls for research into possible effects of phosphate status on thymus size and other immunological markers. TRIAL REGISTRATION: The study is based on data from the FeedSAM study, ISRCTN55092738 .

Recovery rate and associated factors of children age 6 to 59 months admitted with severe acute malnutrition at inpatient unit of Bahir Dar Felege Hiwot Referral hospital therapeutic feeding unite, northwest Ethiopia.

BACKGROUND: Despite numerous advances made in improving child health and the clinical management protocols for treating severe acute malnutrition at treatment centers, evidences concerning the treatment outcomes are scarce. Therefore, this study was conducted to assess the recovery rate and associated factors of severely acute malnourished children of age 6 to 59 months admitted to inpatient therapeutic feeding unit at Felege Hiwot Referral Hospital. METHODS: We conducted a hospital-based cross-sectional study including 401 severely malnourished children who were admitted from September 2012 to January 2016. Bivariable and a Multivariable logistic regression model were fitted to identify factors associated with recovery rate. Adjusted Odds ratio with its 95% CI was reported and P-value less than 0.05 was considered as significant. RESULTS: Fifty eight percent (58.4%) (95%CI: 53.1-64.1) of admitted children were recovered with a mean recovery time of 18 (±6.3) days. Being female, children who were fully and partially vaccinated, who had better MUAC measurement, who stayed longer in the hospital, and children who took routine vitamin-A supplementation had better recovery rate. However, children who had co-morbidity at admission, had human immune virus (HIV) and Tuberculosis (TB) infection, and who had edema were less likely to recover. INTERPRETATION: Recovery rate was low as compared to international SPHERE cutoff points (> 75% recovery rate). Interventions that could address the outlined factors would be helpful to improve treatment recovery rate of admitted children.