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  • Use of MUAC as the sole discharge criterion from community-based management of severe acute malnutrition in Burkina Faso.

    Isanaka, S; Hanson, KE; Frison, S; Andersen, CT; Cohuet, S; Grais, RF (Wiley-Blackwell, 2018-09-08)
    The use of mid upper arm circumference (MUAC) measurement to screen and determine eligibility for admission to therapeutic feeding programs has been established, but evidence and programmatic experience to inform guidance on the use of MUAC as a discharge criterion is limited. We present results from a large scale nutritional program using MUAC for admission and discharge and compare program outcomes and response to treatment when determining eligibility for discharge by proportional weight gain vs. discharge by MUAC. The study population included all children admitted to the Ministry of Health therapeutic feeding program supported by Médecins Sans Frontières in northern Burkina Faso from September 2007 to December 2011 (n = 50,841). Recovery was high overall using both discharge criteria, with low risks of death, non-response and transfer to inpatient care and high daily gains in weight, MUAC, WHZ and height. When discharge was made by MUAC only, recovery increased, while all adverse program outcomes and length of stay decreased, with increasing MUAC on admission. MUAC-based programming, where MUAC is integrated into program screening, admission, and discharge, is one of several new approaches that can be used to target resources to the most at-risk malnourished children and improve program efficiency and coherency. This analysis provides additional programmatic experience on the use of MUAC-based discharge criterion, but more work may be needed to inform optimal discharge thresholds across settings.
  • Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programs

    Whitfield, KC; Bourassa, MW; Adamolekun, B; Bergeron, G; Bettendorff, L; Brown, KH; Cox, L; Fattal-Valevski, A; Fischer, PR; Frank, EL; Hiffler, L; Hlaing, LM; Jefferds, ME; Kapner, H; Kounnavong, S; Mousavi, MPS; Roth, DE; Tsaloglou, MN; Wieringa, F; Combs, GF (Wiley, 2018-08-27)
    Thiamine is an essential micronutrient that plays a key role in energy metabolism. Many populations worldwide may be at risk of clinical or subclinical thiamine deficiencies, due to famine, reliance on staple crops with low thiamine content, or food preparation practices, such as milling grains and washing milled rice. Clinical manifestations of thiamine deficiency are variable; this, along with the lack of a readily accessible and widely agreed upon biomarker of thiamine status, complicates efforts to diagnose thiamine deficiency and assess its global prevalence. Strategies to identify regions at risk of thiamine deficiency through proxy measures, such as analysis of food balance sheet data and month-specific infant mortality rates, may be valuable for understanding the scope of thiamine deficiency. Urgent public health responses are warranted in high-risk regions, considering the contribution of thiamine deficiency to infant mortality and research suggesting that even subclinical thiamine deficiency in childhood may have lifelong neurodevelopmental consequences. Food fortification and maternal and/or infant thiamine supplementation have proven effective in raising thiamine status and reducing the incidence of infantile beriberi in regions where thiamine deficiency is prevalent, but trial data are limited. Efforts to determine culturally and environmentally appropriate food vehicles for thiamine fortification are ongoing.
  • Estimating program coverage in the treatment of severe acute malnutrition: a comparative analysis of the validity and operational feasibility of two methods

    Isanaka, S; Hedt-Gauthier, BL; Grais, RF; Allen, BGS (BioMed Central, 2018-07-03)
    Many health programs can assess coverage using standardized cluster survey methods, but estimating the coverage of nutrition programs presents a special challenge due to low disease prevalence. Used since 2012, the Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) employs both qualitative and quantitative methods to identify key barriers to access and estimate coverage of therapeutic feeding programs. While the tool has been increasingly used in programs, the validity of certain methodological elements has been the subject of debate.
  • Determinants of dietary practices during pregnancy: A longitudinal qualitative study in Niger

    Rosen, JG; Clermont, A; Kodish, SR; Seck, AM; Salifou, A; Grais, RF; Isanaka, S (Wiley-Blackwell, 2018-06-28)
    Undernutrition is associated with maternal morbidity and poor pregnancy outcomes. This qualitative study seeks to understand the multilevel factors influencing maternal dietary practices in Niger, including the impact of pregnancy illnesses on diet. Criterion-based, purposive sampling was used to select pregnant women and household members from 24 villages in a rural district of the Maradi Region in south-central Niger. Semistructured interviews (n = 153) and focus group discussions (n = 38) explored 4 primary themes: (a) perceptions of ideal diet during pregnancy, (b) barriers to consuming the ideal diet, (c) coping strategies including dietary responses related to pregnancy illnesses, and (d) changes in perceptions from early to late pregnancy. Longitudinal data collection allowed for repeated interviews of pregnant women to document changes in dietary practices throughout pregnancy. Transcripts were coded using an inductive approach informed by grounded theory methodology. Participants categorized foods into 4 primary dietary taxonomies when discussing ideal maternal diets but cited constraints related to accessibility and availability impeding routine consumption of these foods. Perceptions of "modern," urban foods as healthy, coupled with key structural barriers such as food costs, were identified. Maternal morbidity influenced food consumption, as women reported reducing food intake early in pregnancy in response to illness episodes. Although awareness of optimal foods for supporting healthy pregnancies was moderately high, some misconceptions were observed and multilevel barriers to food security restricted opportunities for consuming these foods. Nutrition-specific and nutrition-sensitive interventions could improve access and availability of acceptable foods for supporting increased dietary intake during pregnancy.
  • Malaria and nutritional status among children with severe acute malnutrition in Niger: a prospective cohort study

    Oldenburg, CE; Guerin, PJ; Berthé, F; Grais, RF; Isanaka, S (Oxford University Press, 2018-03-07)
    The relationship between malaria infection and nutritional status is complex and previous studies suggest malaria may increase the incidence and severity of malnutrition while malnutrition may increase the risk of malaria infection. Here, we report bi-directional associations between malaria and nutritional status among children with uncomplicated severe acute malnutrition (SAM).
  • Effect of Male Involvement on the Nutritional Status of Children Less Than 5 Years: A Cross Sectional Study in a Rural Southwestern District of Uganda

    Kansiime, N; Atwine, D; Nuwamanya, S; Bagenda, F (Hindawi Publishing Corporation, 2017-12-04)
    Undernutrition among children less than 5 years is still a public health concern in most developing countries. Fathers play a critical role in providing support in improving maternal and child health. There is little studied on male involvement and its measurement in child nutrition; therefore, this paper explores the level of male involvement in child feeding and its association with the nutritional status of the children less than 5 years of age.
  • Severe Malnutrition in Infants displaced from Mosul, Iraq

    Haidar, MK; Farhat, JB; Saim, M; Morton, N; Defourny, I (Elsevier, 2017-12)
  • Thiamine Content of F-75 Therapeutic Milk for Complicated Severe Acute Malnutrition: Time for a Change?

    Hiffler, L; Adamolekun, B; Fischer, P; Fattal-Vavleski, A (Wiley-Blackwell, 2017-09-14)
    Since community-based management of severe acute malnutrition has become the standard of care, the clinical profile of severe acutely malnourished patients admitted to hospitals or inpatient therapeutic feeding centers has changed significantly. These patients are usually very ill and often present with several comorbidities, such as shock, sepsis, and pneumonia. Complicated severe acute malnutrition patients are at risk of thiamine insufficiency, and critically ill patients have higher thiamine requirements. The thiamine content of F-75, the therapeutic milk formula used in the early stabilization phase of refeeding in patients with severe acute malnutrition, seems insufficient. Here, we discuss the need and rationale for a substantial increase in the thiamine content of F-75.
  • Effectiveness of Food Supplements in Increasing Fat-Free Tissue Accretion in Children with Moderate Acute Malnutrition: A Randomised 2 × 2 × 3 Factorial Trial in Burkina Faso

    Fabiansen, C; Yaméogo, C; Iuel-Brockdorf, A; Cichon, B; Rytter, M; Kurpad, A; Wells, J; Ritz, C; Ashorn, P; Filteau, S; Briend, A; Shepherd, S; Christensen, V; Michaelsen, K; Friis, H (Public Library of Science, 2017-09-11)
    Children with moderate acute malnutrition (MAM) are treated with lipid-based nutrient supplement (LNS) or corn-soy blend (CSB). We assessed the effectiveness of (a) matrix, i.e., LNS or CSB, (b) soy quality, i.e., soy isolate (SI) or dehulled soy (DS), and (c) percentage of total protein from dry skimmed milk, i.e., 0%, 20%, or 50%, in increasing fat-free tissue accretion.
  • Mortality and Causes of Mortality in Children 6-59 Months of Age Admitted to Inpatient Therapeutic Feeding Centres in Niger

    Tapié de Céleyran, F; Hanson, K; Ferreyra, C; Salse, N; Tshialala, D; Casademont, C; Grais, R; Huerga, H (ENN., 2017-02)
  • Assessment of Regression Models for Adjustment of Iron Status Biomarkers for Inflammation in Children with Moderate Acute Malnutrition in Burkina Faso

    Cichon, B; Ritz, C; Fabiansen, C; Christensen, V; Filteau, S; Friis, H; Kæstel, P (American Society for Nutrition, 2017-01)
    Biomarkers of iron status are affected by inflammation. In order to interpret them in individuals with inflammation, the use of correction factors (CFs) has been proposed.
  • Cost analysis of the treatment of severe acute malnutrition in West Africa

    Isanaka, S; Menzies, NA; Sayyad, J; Ayoola, M; Grais, RF; Doyon, S (Wiley-Blackwell, 2016-12-05)
    We present an updated cost analysis to provide new estimates of the cost of providing community-based treatment for severe acute malnutrition, including expenditure shares for major cost categories. We calculated total and per child costs from a provider perspective. We categorized costs into three main activities (outpatient treatment, inpatient treatment, and management/administration) and four cost categories within each activity (personnel; therapeutic food; medical supplies; and infrastructure and logistical support). For each category, total costs were calculated by multiplying input quantities expended in the Médecins Sans Frontières nutrition program in Niger during a 12-month study period by 2015 input prices. All children received outpatient treatment, with 43% also receiving inpatient treatment. In this large, well-established program, the average cost per child treated was €148.86, with outpatient and inpatient treatment costs of €75.50 and €134.57 per child, respectively. Therapeutic food (44%, €32.98 per child) and personnel (35%, €26.70 per child) dominated outpatient costs, while personnel (56%, €75.47 per child) dominated in the cost of inpatient care. Sensitivity analyses suggested lowering prices of medical treatments, and therapeutic food had limited effect on total costs per child, while increasing program size and decreasing use of expatriate staff support reduced total costs per child substantially. Updated estimates of severe acute malnutrition treatment cost are substantially lower than previously published values, and important cost savings may be possible with increases in coverage/program size and integration into national health programs. These updated estimates can be used to suggest approaches to improve efficiency and inform national-level resource allocation.
  • Admission Profile and Discharge Outcomes for Infants Aged Less than 6 Months Admitted to Inpatient Therapeutic Care in 10 Countries. A Secondary Data Analysis

    Grijalva-Eternod, CS; Kerac, M; McGrath, M; Wilkinson, C; Hirsch, JC; Delchevalerie, P; Seal, AJ (Wiley-Blackwell We regret that this article is behind a paywall., 2016-07-25)
    Evidence on the management of acute malnutrition in infants aged less than 6 months (infants <6mo) is scarce. To understand outcomes using current protocols, we analysed a sample of 24 045 children aged 0-60 months from 21 datasets of inpatient therapeutic care programmes in 10 countries. We compared the proportion of admissions, the anthropometric profile at admission and the discharge outcomes between infants <6mo and children aged 6-60 months (older children). Infants <6mo accounted for 12% of admissions. The quality of anthropometric data at admission was more problematic in infants <6mo than in older children with a greater proportion of missing data (a 6.9 percentage point difference for length values, 95% CI: 6.0; 7.9, P < 0.01), anthropometric measures that could not be converted to indices (a 15.6 percentage point difference for weight-for-length z-score values, 95% CI: 14.3; 16.9, P < 0.01) and anthropometric indices that were flagged as outliers (a 2.7 percentage point difference for any anthropometric index being flagged as an outlier, 95% CI: 1.7; 3.8, P < 0.01). A high proportion of both infants <6mo and older children were discharged as recovered. Infants <6mo showed a greater risk of death during treatment (risk ratio 1.30, 95% CI: 1.09; 1.56, P < 0.01). Infants <6mo represent an important proportion of admissions to therapeutic feeding programmes, and there are crucial challenges associated with their care. Systematic compilation and analysis of routine data for infants <6mo is necessary for monitoring programme performance and should be promoted as a tool to monitor the impact of new guidelines on care.
  • Amoxicillin for Severe Acute Malnutrition in Children

    Isanaka, S; Adehossi, E; Grais, R (Massachusetts Medical Society, 2016-07-14)
  • Thiamine Deficiency in Tropical Pediatrics: New Insights into a Neglected but Vital Metabolic Challenge

    Hiffler, L; Rakotoambinina, B; Lafferty, N; Martinez Garcia, D (Frontiers Media, 2016-06-14)
    In humans, thiamine is a micronutrient prone to depletion that may result in severe clinical abnormalities. This narrative review summarizes current knowledge on thiamine deficiency (TD) and bridges the gap between pathophysiology and clinical presentation by integrating thiamine metabolism at subcellular level with its function to vital organs. The broad clinical spectrum of TD is outlined, with emphasis on conditions encountered in tropical pediatric practice. In particular, TD is associated with type B lactic acidosis and classic forms of beriberi in children, but it is often unrecognized. Other severe acute conditions are associated with hypermetabolism, inducing a functional TD. The crucial role of thiamine in infant cognitive development is also highlighted in this review, along with analysis of the potential impact of TD in refeeding syndrome during severe acute malnutrition (SAM). This review aims to increase clinical awareness of TD in tropical settings where access to diagnostic tests is poor, and advocates for an early therapeutic thiamine challenge in resource-limited settings. Moreover, it provides evidence for thiamine as treatment in critical conditions requiring metabolic resuscitation, and gives rationale to the consideration of increased thiamine supplementation in therapeutic foods for malnourished children.
  • Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Uganda

    van der Kam, S; Roll, S; Swarthout, T; Edyegu-Otelu, G; Matsumoto, A; Kasujja, F X; Casademont, C; Shanks, L; Salse-Ubach, N (Public Library of Science, 2016-02-09)
    Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food but also by illnesses and by poor infant and child feeding practices. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here, we report on the trial that took place in Kaabong, a poor agropastoral region of Karamoja, in east Uganda. While the region of Karamoja shows an acute malnutrition rate between 8.4% and 11.5% of which 2% to 3% severe malnutrition, more than half (58%) of the population in the district of Kaabong is considered food insecure.
  • Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Nigeria

    van der Kam, S; Salse-Ubach, N; Roll, S; Swarthout, T; Gayton-Toyoshima, S; Jiya, N M; Matsumoto, A; Shanks, L (Public Library of Science, 2016-02-09)
    Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food and poor infant and child feeding practices but also by illnesses. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here we report on the trial that took place in Goronyo, a rural region of northwest Nigeria with high morbidity and malnutrition rates.
  • Routine Amoxicillin for Uncomplicated Severe Acute Malnutrition in Children

    Isanaka, S; Langendorf, C; Berthé, F; Gnegne, S; Li, N; Ousmane, N; Harouna, S; Hassane, H; Schaefer, M; Adehossi, E; Grais, R F (Massachusetts Medical Society, 2016-02-04)
    High-quality evidence supporting a community-based treatment protocol for children with severe acute malnutrition, including routine antibiotic use at admission to a nutritional treatment program, remains limited. In view of the costs and consequences of emerging resistance associated with routine antibiotic use, more evidence is required to support this practice.
  • Effect of Ready-to-Use Foods for Preventing Child Undernutrition in Niger: Analysis of a Prospective Intervention Study Over 15 Months of Follow-Up

    Prudhon, C; Langendorf, C; Roederer, T; Doyon, S; Mamaty, AA; Woi-Messe, L; Manzo, ML; de Pee, S; Grais, RF (Wiley-Blackwell, 2016-01-17)
    Strategies for preventing undernutrition comprise a range of interventions, including education, provision of complementary food and cash transfer. Here, we compared monthly distributions of two different lipid-based nutrient supplements (LNS), large-quantity LNS (LNS-LQ) and medium-quantity LNS (LNS-MQ) for 15 months on prevention of undernutrition among children 6 to 23 months. Both groups also received cash transfer for the first 5 months of the intervention. We conducted a prospective intervention study in Maradi, Niger, between August 2011 and October 2012. Six and 11 villages were randomly allocated to LNS-LQ/Cash and LNS-MQ/Cash, respectively. Children measuring 60-80 cm were enrolled in the respective groups and followed up monthly. Poisson regression was used to assess differences between interventions and adjust for baseline characteristics, intervention periods and child-feeding practices. The analysis included 2586 children (1081 in the LNS-LQ/Cash group and 1505 in the LNS-MQ/Cash group). This study suggests that provision of LNS-LQ (reference) or LNS-MQ had, overall, similar effect on incidence of severe acute malnutrition (RR = 0.97; 95% CI: 0.67-1.40; P = 0.88), moderate acute malnutrition (RR = 1.20; 95% CI: 0.97-1.48; P = 0.08), severe stunting (RR = 0.94; 95% CI: 0.70-1.26; P = 0.69), moderate stunting (RR = 0.95; 95% CI: 0.76-1.19; P = 0.67) and mortality (RR = 0.83; 95% CI: 0.41-1.65; P = 0.59). Compared with LNS-LQ, LNS-MQ showed a greater protective effect on moderate acute malnutrition among children with good dietary adequacy: RR = 0.72; 95% CI: 0.56-0.94; P = 0.01. These results highlight the need to design context-specific programmes. Provision of LNS-LQ might be more appropriate when food insecurity is high, while when food security is better, distribution of LNS-MQ might be more appropriate.

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