Journal Article > ReviewFull Text
JAMA Netw Open. 1 May 2023; Volume 6 (Issue 5); e2315077.; DOI:10.1001/jamanetworkopen.2023.15077
Bliznashka L, Rattigan SM, Sudfeld CR, Isanaka S
JAMA Netw Open. 1 May 2023; Volume 6 (Issue 5); e2315077.; DOI:10.1001/jamanetworkopen.2023.15077
IMPORTANCE
Children treated for acute malnutrition remain at increased risk of relapse, infection, and mortality after programmatic recovery. Global guidelines for the management of acute malnutrition currently provide no recommendations to sustain recovery following treatment discharge.
OBJECTIVE
To inform guideline development by evaluating the evidence on postdischarge interventions to improve outcomes within 6 months after discharge.
EVIDENCE REVIEW
In this systematic review, 8 databases were searched from inception through December 2021 and included randomized and quasi-experimental studies investigating interventions delivered after discharge from nutritional treatment for children aged 0 to 59 months. Outcomes were relapse, deterioration to severe wasting, readmission, sustained recovery, anthropometry, all-cause mortality, and morbidity within 6 months after discharge. The risk of bias was assessed using Cochrane tools, and the certainty of the evidence was evaluated with the GRADE approach.
FINDINGS
Of 7124 records identified, 8 studies, conducted in 7 countries between 2003 and 2019 with 5965 participants, were included. The study interventions included antibiotic prophylaxis (n?=?1), zinc supplementation (n?=?1), food supplementation (n?=?2), psychosocial stimulation (n?=?3), unconditional cash transfers (n?=?1), and an integrated biomedical, food supplementation, and malaria prevention package (n?=?1). Risk of bias was moderate or high for half the studies. Only unconditional cash transfers were associated with reduced relapse, while the integrated package was associated with improved sustained recovery. Zinc supplementation, food supplementation, psychosocial stimulation, and unconditional cash transfers were associated with improvements in postdischarge anthropometry, while zinc supplementation was associated with reductions in multiple postdischarge morbidities.
CONCLUSIONS AND RELEVANCE
In this systematic review of postdischarge interventions to reduce relapse and improve other postdischarge outcomes among children treated for acute malnutrition, evidence was limited. Biomedical, cash, and integrated interventions showed promise in improving certain postdischarge outcomes for children treated for moderate or severe acute malnutrition in single studies. Further evidence on the efficacy, effectiveness, and operational feasibility of postdischarge interventions in other contexts is needed to inform global guidance development.
Children treated for acute malnutrition remain at increased risk of relapse, infection, and mortality after programmatic recovery. Global guidelines for the management of acute malnutrition currently provide no recommendations to sustain recovery following treatment discharge.
OBJECTIVE
To inform guideline development by evaluating the evidence on postdischarge interventions to improve outcomes within 6 months after discharge.
EVIDENCE REVIEW
In this systematic review, 8 databases were searched from inception through December 2021 and included randomized and quasi-experimental studies investigating interventions delivered after discharge from nutritional treatment for children aged 0 to 59 months. Outcomes were relapse, deterioration to severe wasting, readmission, sustained recovery, anthropometry, all-cause mortality, and morbidity within 6 months after discharge. The risk of bias was assessed using Cochrane tools, and the certainty of the evidence was evaluated with the GRADE approach.
FINDINGS
Of 7124 records identified, 8 studies, conducted in 7 countries between 2003 and 2019 with 5965 participants, were included. The study interventions included antibiotic prophylaxis (n?=?1), zinc supplementation (n?=?1), food supplementation (n?=?2), psychosocial stimulation (n?=?3), unconditional cash transfers (n?=?1), and an integrated biomedical, food supplementation, and malaria prevention package (n?=?1). Risk of bias was moderate or high for half the studies. Only unconditional cash transfers were associated with reduced relapse, while the integrated package was associated with improved sustained recovery. Zinc supplementation, food supplementation, psychosocial stimulation, and unconditional cash transfers were associated with improvements in postdischarge anthropometry, while zinc supplementation was associated with reductions in multiple postdischarge morbidities.
CONCLUSIONS AND RELEVANCE
In this systematic review of postdischarge interventions to reduce relapse and improve other postdischarge outcomes among children treated for acute malnutrition, evidence was limited. Biomedical, cash, and integrated interventions showed promise in improving certain postdischarge outcomes for children treated for moderate or severe acute malnutrition in single studies. Further evidence on the efficacy, effectiveness, and operational feasibility of postdischarge interventions in other contexts is needed to inform global guidance development.
Journal Article > ResearchFull Text
Matern Child Nutr. 21 July 2022; Online ahead of print; e13400.; DOI:10.1111/mcn.13400
Bliznashka L, Grantz KH, Botton J, Berthé F, Garba S, et al.
Matern Child Nutr. 21 July 2022; Online ahead of print; e13400.; DOI:10.1111/mcn.13400
This study aimed to quantify the burden of relapse following successful treatment for uncomplicated severe acute malnutrition (SAM) and to identify associated risk factors in rural Niger. We used data from 1490 children aged 6-59 months discharged as recovered from an outpatient nutritional programme for SAM and followed for up to 12 weeks after admission. Post-discharge SAM relapse was defined as weight-for-height Z-score <-3, mid-upper arm circumference (MUAC) <115 mm or bipedal oedema after having been discharged as recovered. Post-discharge hospitalisation was defined as admission to inpatient SAM treatment or hospitalisation for any cause after having been discharged as recovered. We used multivariate log-binomial models to identify independent risk factors. After programmatic discharge, 114 (8%) children relapsed to SAM and 89 (6%) were hospitalised. Factors associated with SAM relapse were discharge during the lean season (relative risk [RR] = 1.80 [95% confidence interval [CI] = 1.22-2.67]) and larger household size (RR = 1.56 [95% CI = 1.01-2.41]), whereas older child age (RR = 0.94 [95% CI = 0.88-1.00]), higher child MUAC at discharge (RR = 0.93 [95% CI = 0.87-1.00]) and maternal literacy (RR = 0.54 [95% CI = 0.29-0.98]) were protective factors. Discharge during the lean season (RR = 2.27 [95% CI = 1.46-3.51]) was independently associated with post-discharge hospitalisation. Future nutritional programmes in the context of Niger may consider modification of anthropometric discharge criteria or the provision of additional home support or follow-up during the lean season as potential interventions to prevent relapse. More research including post-discharge follow-up is needed to better understand the sustainability of treatment outcomes after discharge and the type of intervention that may best sustain recovery over time.
Clinical Trial Registration: ClinicalTrials.gov number, NCT01613547.
Clinical Trial Registration: ClinicalTrials.gov number, NCT01613547.
Journal Article > ResearchFull Text
PLOS Med. 2 May 2022; Volume 19 (Issue 5); e1003984.; DOI:10.1371/journal.pmed.1003984
Sudfeld CR, Bliznashka L, Salifou A, Guindo O, Soumana I, et al.
PLOS Med. 2 May 2022; Volume 19 (Issue 5); e1003984.; DOI:10.1371/journal.pmed.1003984
BACKGROUND
It is estimated that over 250 million children under 5 years of age in low- and middle-income countries (LMICs) do not reach their full developmental potential. Poor maternal diet, anemia, and micronutrient deficiencies during pregnancy are associated with suboptimal neurodevelopmental outcomes in children. However, the effect of prenatal macronutrient and micronutrient supplementation on child development in LMIC settings remains unclear due to limited evidence from randomized trials.
METHODS AND FINDINGS
We conducted a 3-arm cluster-randomized trial (n = 53 clusters) that evaluated the efficacy of (1) prenatal multiple micronutrient supplementation (MMS; n = 18 clusters) and (2) lipid-based nutrient supplementation (LNS; n = 18 clusters) as compared to (3) routine iron-folic acid (IFA) supplementation (n = 17 clusters) among pregnant women in the rural district of Madarounfa, Niger, from March 2015 to August 2019 (ClinicalTrials.gov identifier NCT02145000). Children were followed until 2 years of age, and the Bayley Scales of Infant and Toddler Development III (BSID-III) were administered to children every 3 months from 6 to 24 months of age. Maternal report of WHO gross motor milestone achievement was assessed monthly from 3 to 24 months of age. An intention-to-treat analysis was followed. Child BSID-III data were available for 559, 492, and 581 singleton children in the MMS, LNS, and IFA groups, respectively. Child WHO motor milestone data were available for 691, 781, and 753 singleton children in the MMS, LNS, and IFA groups, respectively. Prenatal MMS had no effect on child BSID-III cognitive (standardized mean difference [SMD]: 0.21; 95% CI: −0.20, 0.62; p = 0.32), language (SMD: 0.16; 95% CI: −0.30, 0.61; p = 0.50) or motor scores (SMD: 0.18; 95% CI: −0.39, 0.74; p = 0.54) or on time to achievement of the WHO gross motor milestones as compared to IFA. Prenatal LNS had no effect on child BSID-III cognitive (SMD: 0.17; 95% CI: −0.15, 0.49; p = 0.29), language (SMD: 0.11; 95% CI: −0.22, 0.44; p = 0.53) or motor scores (SMD: −0.04; 95% CI: −0.46, 0.37; p = 0.85) at the 24-month endline visit as compared to IFA. However, the trajectory of BSID-III cognitive scores during the first 2 years of life differed between the groups with children in the LNS group having higher cognitive scores at 18 and 21 months (approximately 0.35 SD) as compared to the IFA group (p-value for difference in trajectory <0.001). Children whose mothers received LNS also had earlier achievement of sitting alone (hazard ratio [HR]: 1.57; 95% CI: 1.10 to 2.24; p = 0.01) and walking alone (1.52; 95% CI: 1.14 to 2.03; p = 0.004) as compared to IFA, but there was no effect on time to achievement of other motor milestones. A limitation of our study is that we assessed child development up to 2 years of age, and, therefore, we may have not captured effects that are easier to detect or emerge at older ages.
CONCLUSIONS
There was no benefit of prenatal MMS on child development outcomes up to 2 years of age as compared to IFA. There was evidence of an apparent positive effect of prenatal LNS on cognitive development trajectory and time to achievement of selected gross motor milestones.
TRIAL REGISTRATION
ClinicalTrials.gov NCT02145000
It is estimated that over 250 million children under 5 years of age in low- and middle-income countries (LMICs) do not reach their full developmental potential. Poor maternal diet, anemia, and micronutrient deficiencies during pregnancy are associated with suboptimal neurodevelopmental outcomes in children. However, the effect of prenatal macronutrient and micronutrient supplementation on child development in LMIC settings remains unclear due to limited evidence from randomized trials.
METHODS AND FINDINGS
We conducted a 3-arm cluster-randomized trial (n = 53 clusters) that evaluated the efficacy of (1) prenatal multiple micronutrient supplementation (MMS; n = 18 clusters) and (2) lipid-based nutrient supplementation (LNS; n = 18 clusters) as compared to (3) routine iron-folic acid (IFA) supplementation (n = 17 clusters) among pregnant women in the rural district of Madarounfa, Niger, from March 2015 to August 2019 (ClinicalTrials.gov identifier NCT02145000). Children were followed until 2 years of age, and the Bayley Scales of Infant and Toddler Development III (BSID-III) were administered to children every 3 months from 6 to 24 months of age. Maternal report of WHO gross motor milestone achievement was assessed monthly from 3 to 24 months of age. An intention-to-treat analysis was followed. Child BSID-III data were available for 559, 492, and 581 singleton children in the MMS, LNS, and IFA groups, respectively. Child WHO motor milestone data were available for 691, 781, and 753 singleton children in the MMS, LNS, and IFA groups, respectively. Prenatal MMS had no effect on child BSID-III cognitive (standardized mean difference [SMD]: 0.21; 95% CI: −0.20, 0.62; p = 0.32), language (SMD: 0.16; 95% CI: −0.30, 0.61; p = 0.50) or motor scores (SMD: 0.18; 95% CI: −0.39, 0.74; p = 0.54) or on time to achievement of the WHO gross motor milestones as compared to IFA. Prenatal LNS had no effect on child BSID-III cognitive (SMD: 0.17; 95% CI: −0.15, 0.49; p = 0.29), language (SMD: 0.11; 95% CI: −0.22, 0.44; p = 0.53) or motor scores (SMD: −0.04; 95% CI: −0.46, 0.37; p = 0.85) at the 24-month endline visit as compared to IFA. However, the trajectory of BSID-III cognitive scores during the first 2 years of life differed between the groups with children in the LNS group having higher cognitive scores at 18 and 21 months (approximately 0.35 SD) as compared to the IFA group (p-value for difference in trajectory <0.001). Children whose mothers received LNS also had earlier achievement of sitting alone (hazard ratio [HR]: 1.57; 95% CI: 1.10 to 2.24; p = 0.01) and walking alone (1.52; 95% CI: 1.14 to 2.03; p = 0.004) as compared to IFA, but there was no effect on time to achievement of other motor milestones. A limitation of our study is that we assessed child development up to 2 years of age, and, therefore, we may have not captured effects that are easier to detect or emerge at older ages.
CONCLUSIONS
There was no benefit of prenatal MMS on child development outcomes up to 2 years of age as compared to IFA. There was evidence of an apparent positive effect of prenatal LNS on cognitive development trajectory and time to achievement of selected gross motor milestones.
TRIAL REGISTRATION
ClinicalTrials.gov NCT02145000
Journal Article > ResearchFull Text
Am J Clin Nutr. 6 December 2021; Volume 115 (Issue 3); 738-748.; DOI:10.1093/ajcn/nqab404
Bliznashka L, Sudfeld CR, Garba S, Guindo O, Soumana I, et al.
Am J Clin Nutr. 6 December 2021; Volume 115 (Issue 3); 738-748.; DOI:10.1093/ajcn/nqab404
BACKGROUND
Prenatal multiple micronutrient supplementation (MMS) and lipid-based nutrient supplementation (LNS) can improve birth outcomes relative to iron-folic acid supplementation (IFA); however, effects on child postnatal growth remain unclear.
OBJECTIVE
To compare the effect of prenatal MMS, medium-quantity LNS (MQ-LNS), and IFA on child growth up to 2 years of age.
DESIGN
We conducted a cluster-randomized controlled trial of prenatal nutritional supplementation in Madarounfa, Niger. Villages were randomly assigned for pregnant women to receive IFA (17 villages, 1105 women), MMS (18 villages, 1083 women) or MQ-LNS (18 villages, 1144 women). Pregnant women received nutritional supplements weekly until delivery, and children were followed up monthly from 6-8 weeks to 24 months of age. We assessed the effect of prenatal MMS and MQ-LNS compared to IFA and the effect of prenatal MMS compared to MQ-LNS on child length-for-age Z-scores (LAZ), weight-for-age Z-scores (WAZ), and weight-for-length Z-scores (WLZ) at 24 months of age using generalized linear models. In secondary analyses, we used mixed effects models to assess the trajectory of anthropometric Z-scores longitudinally from 6-8 weeks to 24 months.
RESULTS
Compared to IFA, MMS and MQ-LNS had no effect on child LAZ, WAZ, or WLZ at 24 months of age (P-values >0.05). Children in the MQ-LNS arm had significantly higher MUAC at 24 months than children in the MMS arm: mean difference 0.50 cm (95% CI 0.10, 0.91). WAZ and WLZ trajectories were more negative in the MQ-LNS arm compared to IFA and MMS, with lower Z-scores from 14 to 20 months of age. However, WAZ and WLZ trajectories converged after 20 months of age, and there were no differences by 24 months of age.
CONCLUSIONS
Prenatal MMS and MQ-LNS had limited effect on anthropometric measures of child growth up to 24 months of age as compared to IFA in rural Niger.
Prenatal multiple micronutrient supplementation (MMS) and lipid-based nutrient supplementation (LNS) can improve birth outcomes relative to iron-folic acid supplementation (IFA); however, effects on child postnatal growth remain unclear.
OBJECTIVE
To compare the effect of prenatal MMS, medium-quantity LNS (MQ-LNS), and IFA on child growth up to 2 years of age.
DESIGN
We conducted a cluster-randomized controlled trial of prenatal nutritional supplementation in Madarounfa, Niger. Villages were randomly assigned for pregnant women to receive IFA (17 villages, 1105 women), MMS (18 villages, 1083 women) or MQ-LNS (18 villages, 1144 women). Pregnant women received nutritional supplements weekly until delivery, and children were followed up monthly from 6-8 weeks to 24 months of age. We assessed the effect of prenatal MMS and MQ-LNS compared to IFA and the effect of prenatal MMS compared to MQ-LNS on child length-for-age Z-scores (LAZ), weight-for-age Z-scores (WAZ), and weight-for-length Z-scores (WLZ) at 24 months of age using generalized linear models. In secondary analyses, we used mixed effects models to assess the trajectory of anthropometric Z-scores longitudinally from 6-8 weeks to 24 months.
RESULTS
Compared to IFA, MMS and MQ-LNS had no effect on child LAZ, WAZ, or WLZ at 24 months of age (P-values >0.05). Children in the MQ-LNS arm had significantly higher MUAC at 24 months than children in the MMS arm: mean difference 0.50 cm (95% CI 0.10, 0.91). WAZ and WLZ trajectories were more negative in the MQ-LNS arm compared to IFA and MMS, with lower Z-scores from 14 to 20 months of age. However, WAZ and WLZ trajectories converged after 20 months of age, and there were no differences by 24 months of age.
CONCLUSIONS
Prenatal MMS and MQ-LNS had limited effect on anthropometric measures of child growth up to 24 months of age as compared to IFA in rural Niger.