evidence-based blog of Filippo Dibari

Posts Tagged ‘weight-for-height’

Associations of Suboptimal Growth with All-Cause and Cause-Specific Mortality in Children under Five Years: A Pooled Analysis of Ten Prospective Studies

In Under-nutrition on June 3, 2016 at 3:38 pm

Olofin I, McDonald CM, Ezzati M, Flaxman S, Black RE, et al. (2013) Associations of Suboptimal Growth with All-Cause and Cause-Specific Mortality in Children under Five Years: A Pooled Analysis of Ten Prospective Studies. PLoS ONE 8(5): e64636.





Child undernutrition affects millions of children globally. We investigated associations between suboptimal growth and mortality by pooling large studies.


Pooled analysis involving children 1 week to 59 months old in 10 prospective studies in Africa, Asia and South America. Utilizing most recent measurements, we calculated weight-for-age, height/length-for-age and weight-for-height/length Z scores, applying 2006 WHO Standards and the 1977 NCHS/WHO Reference. We estimated all-cause and cause-specific mortality hazard ratios (HR) using proportional hazards models comparing children with mild (−2≤Z<−1), moderate (−3≤Z<−2), or severe (Z<−3) anthropometric deficits with the reference category (Z≥−1).


53 809 children were eligible for this re-analysis and contributed a total of 55 359 person-years, during which 1315 deaths were observed. All degrees of underweight, stunting and wasting were associated with significantly higher mortality. The strength of association increased monotonically as Z scores decreased. Pooled mortality HR was 1.52 (95% Confidence Interval 1.28, 1.81) for mild underweight; 2.63 (2.20, 3.14) for moderate underweight; and 9.40 (8.02, 11.03) for severe underweight. Wasting was a stronger determinant of mortality than stunting or underweight. Mortality HR for severe wasting was 11.63 (9.84, 13.76) compared with 5.48 (4.62, 6.50) for severe stunting. Using older NCHS standards resulted in larger HRs compared with WHO standards. In cause-specific analyses, all degrees of anthropometric deficits increased the hazards of dying from respiratory tract infections and diarrheal diseases. The study had insufficient power to precisely estimate effects of undernutrition on malaria mortality.


All degrees of anthropometric deficits are associated with increased risk of under-five mortality using the 2006 WHO Standards. Even mild deficits substantially increase mortality, especially from infectious diseases.

The Effect of Adding Ready-to-Use Supplementary Food to a General Food Distribution on Child Nutritional Status and Morbidity: A Cluster-Randomized Controlled Trial

In Under-nutrition on February 5, 2014 at 11:18 am

by Lieven Huybregts, Freddy Houngbé, Cécile Salpéteur, Rebecca Brown, Dominique Roberfroid, Myriam Ait-Aissa, Patrick Kolsteren.

PLOS Medicine | 1 September 2012 | Volume 9 | Issue 9

(download the paper)




Recently, operational organizations active in child nutrition in developing countries have suggested that blanket feeding strategies be adopted to enable the prevention of child wasting. A new range of nutritional supplements is now available, with claims that they can prevent wasting in populations at risk of periodic food shortages. Evidence is lacking as to the effectiveness of such preventive interventions. This study examined the effect of a ready-to-use supplementary food (RUSF) on the prevention of wasting in 6- to 36-mo-old children within the framework of a general food distribution program.

Methods and Findings

We conducted a two-arm cluster-randomized controlled pragmatic intervention study in a sample of 1,038 children aged 6 to 36 mo in the city of Abeche, Chad. Both arms were included in a general food distribution program providing staple foods. The intervention group was given a daily 46 g of RUSF for 4 mo. Anthropometric measurements and morbidity were recorded monthly. Adding RUSF to a package of monthly household food rations for households containing a child assigned to the intervention group did not result in a reduction in cumulative incidence of wasting (incidence risk ratio: 0.86; 95% CI: 0.67, 1.11; p = 0.25). However, the intervention group had a modestly higher gain in height-for-age (+0.03 Z-score/mo; 95% CI: 0.01, 0.04; p<0.001). In addition, children in the intervention group had a significantly higher hemoglobin concentration at the end of the study than children in the control group (+3.8 g/l; 95% CI: 0.6, 7.0; p = 0.02), thereby reducing the odds of anemia (odds ratio: 0.52; 95% CI: 0.34, 0.82; p = 0.004). Adding RUSF also resulted in a significantly lower risk of self-reported diarrhea (−29.3%; 95% CI: 20.5, 37.2; p<0.001) and fever episodes (−22.5%; 95% CI: 14.0, 30.2; p<0.001). Limitations of this study include that the projected sample size was not fully attained and that significantly fewer children from the control group were present at follow-up sessions.


Providing RUSF as part of a general food distribution resulted in improvements in hemoglobin status and small improvements in linear growth, accompanied by an apparent reduction in morbidity.


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Predictors of stunting, wasting and underweight among Tanzanian children born to HIV-infected women

In Under-nutrition on October 24, 2012 at 7:52 am

McDonald CMKupka RManji KPOkuma JBosch RJAboud SKisenge RSpiegelman DFawzi WWDuggan CP.

Eur J Clin Nutr. 2012 Oct 3


Background/Objectives: Children born to human immunodeficiency virus (HIV)-infected women are susceptible to undernutrition, but modifiable risk factors and the time course of the development of undernutrition have not been well characterized.

The objective of this study was to identify maternal, socioeconomic and child characteristics that are associated with stunting, wasting and underweight among Tanzanian children born to HIV-infected mothers, followed from 6 weeks of age for 24 months.

Subjects/Methods: Maternal and socioeconomic characteristics were recorded during pregnancy, data pertaining to the infant’s birth were collected immediately after delivery, morbidity histories and anthropometric measurements were performed monthly. Multivariate Cox proportional hazards methods were used to assess the association between potential predictors and the time to first episode of stunting, wasting and underweight.

Results: A total of 2387 infants (54.0% male) were enrolled and followed for a median duration of 21.2 months. The respective prevalence of prematurity (<37 weeks) and low birth weight (<2500 g) was 15.2% and 7.0%; 11.3% of infants were HIV-positive at 6 weeks. Median time to first episode of stunting, wasting and underweight was 8.7, 7.2 and 7.0 months, respectively. Low maternal education, few household possessions, low infant birth weight, child HIV infection and male sex were all independent predictors of stunting, wasting and underweight. In addition, preterm infants were more likely to become wasted and underweight, whereas those with a low Apgar score at birth were more likely to become stunted.

Conclusions: Interventions to improve maternal education and nutritional status, reduce mother-to-child transmission of HIV, and increase birth weight may lower the risk of undernutrition among children born to HIV-infected women.

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An effectiveness trial showed lipid-based nutrient supplementation but not corn–soya blend offered a modest benefit in weight gain among 6- to 18-month-old underweight children in rural Malawi

In Under-nutrition on August 28, 2012 at 8:44 pm

by Chrissie M Thakwalakwa, Per Ashorn, Mpumulo Jawati, John C Phuka, Yin Bun Cheung and Kenneth M Maleta

Public Health Nutrition / Volume 15 / Issue 09 / September 2012 , pp 1755-1762


 Objective To determine if supplementation with corn–soya blend (CSB) or lipid-based nutrient supplement (LNS) improved the weight gain of moderately underweight infants and children when provided through the national health service.

Design A randomised, controlled, assessor-blinded clinical trial. Infants and children were randomised to receive for 12 weeks an average daily ration of 71 g CSB or 43 g LNS, providing 1188 kJ and 920 kJ, respectively, or no supplement (control). Main outcome was weight gain. Secondary outcomes included changes in anthropometric indices and incidence of serious adverse events. Intention-to-treat analyses were used.

Setting Kukalanga, Koche, Katema and Jalasi health centres in Mangochi District, rural Malawi.

Subjects Underweight (weight-for-age Z-score <−2) infants and children aged 6–15 months (n 299).

Results Mean weight gain was 630 g, 680 g and 750 g in control, CSB and LNS groups, respectively (P = 0·21). When adjusted for baseline age, children receiving LNS gained on average 90 g more weight (P = 0·185) and their weight-for-length Z-score increased 0·22 more (P = 0·049) compared with those receiving no supplementation. No statistically significant differences were observed between the CSB and control groups in mean weight and length gain.

Conclusions LNS supplementation provided during the lean season via through the national health service was associated with a modest increase in weight. However, the effect size was lower than that previously reported under more controlled research settings.

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Save the Children (NGO) about treatment of Acute Malnutrition: Minimum Reporting Package User Guidelines

In Under-nutrition on August 21, 2012 at 10:46 am

(download the entire doc)

“These minimum Reporting Package (MRP) User Guidelines are intended to outline the definitions, reporting categories and performance indicators for monitoring and reporting on three feeding programmes using the MRP software.

“The programmes are: targeted Supplementary Feeding Programmes (SFPs), Outpatient Therapeutic Programmes (OTPs) and Stabilisation Centres (SCs).

“There is also guidance on interpreting and taking action on programme performance indicators.

“The audience for the guidelines are nutrition programme coordinators and M&E staff of NGOs involved in the monitoring and reporting process.”

On this blog you can find more information about management of acute malnutrition, and ready to use foods for undernutrition treatment.
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The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review

In Under-nutrition on August 19, 2012 at 11:55 am

Picot J, Hartwell D, Harris P, Mendes D, Clegg AJ, Takeda A

Health Technology Assessment 2012; Vol. 16: No. 19

(download the entire paper)



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.


To evaluate the effectiveness of interventions to treat infants and children aged < 5 years who have SAM.

Data source:

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.


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.


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.


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.

Context-specific choice of food aid items (USAID)

In Under-nutrition on August 12, 2012 at 10:22 am

(click directly on the flowchart for an enlarged view)

In a recent document (2011), USAID, in collaboration with the UN Global Nutrition Cluster, UNHCR WFP and other organizations, suggest which type of programme and food commodities are more adequate.

However, it was concluded that there is no one food product that can meet every kind of programming goal, and no one programming approach that fits all needs.

The same panel  developed decision trees and few flow charts to help policy makers and donors in taking more informed decisions about programmes and choice of food-products.

The original program guidance is available here, whereas another version of the same, visible above, was adjusted in one chapter of my PhD thesis.

Randomized, Double-Blind, Placebo-Controlled Trial Evaluating the Need for Routine Antibiotics as Part of the Outpatient Management of Severe Acute Malnutrition

In Under-nutrition on August 11, 2012 at 11:23 am

by Mark J. Manary, Kenneth Maleta, Indi Trehan
Food and Nutrition Technical Assistance II Project (FANTA-2) Bridge, FHI
360, March 2012

(download the entire document)

The Food and Nutrition Technical Assistance (FANTA) Project undertook a clinical trial comparing nutritional recovery and mortality outcomes in children with severe acute malnutrition (SAM) receiving 1 week of amoxicillin, cefdinir, or placebo, in addition to usual peanut-based ready-to-use therapeutic food (RUTF) therapy. This report documents the outcomes of the trial, which clearly showed the benefit of using antibiotics in the outpatient treatment of SAM without medical complications in a setting with high levels of kwashiorkor and HIV infection.

Effects of psychosocial stimulation on improving home environment and child-rearing practices: results from a community-based trial among severely malnourished children in Bangladesh

In Under-nutrition on August 9, 2012 at 12:45 pm

Nahar BHossain MIHamadani JDAhmed TGrantham-McGregor SPersson LA.

BMC Public Health. 2012 Aug 7;12(1):622. [Epub ahead of print]




Parenting programmes are effective in enhancing parenting practices and child development. This study evaluated the effects of a intervention with psychosocial stimulation (PS) on the quality of the home environment and mothers’ child-rearing practices in a community-based trial with severely malnourished Bangladeshi children.


Severely underweight children (n = 507), 6-24 months of age, were randomly assigned to five groups: PS; food supplementation (FS); PS + FS; clinic-control (CC); and, hospital-control (CH). PS included fortnightly follow-up visits for six months at community clinics where a play leader demonstrated play activities and gave education on child development and child rearing practices. FS comprised cereal-based supplements (150-300 kcal/day) for three months. All groups received medical care, micronutrient supplements and growth monitoring. Mothers were given the Home Observation for Measurement of the Environment (HOME) inventory and a questionnaire on parenting at baseline and after six months to assess the outcome.


322 children completed the study. After six months of intervention the PS + FS and PS groups benefitted in the total HOME score (depending on the comparison group, effect sizes varied from 0.66 to 0.33 SD) The PS + FS and PS groups also benefitted in two HOME subscales: maternal involvement (effect sizes: 0.8 to 0.55 SD) and play materials, (effect sizes: 0.46 to 0.6 SD), and child-rearing practices scores (effect size: 1.5 to 1.1 SD). The PS + FS group benefitted 4.0 points in total HOME score compared with CH, 4.8 points compared with CC and 4.5 points compared with FS (p < 0.001 for all). The PS group benefitted 2.4 points compared with CH (p = 0.035), 3.3 points compared with CC (p = 0.004), and 2.9 points compared with FS (p = 0.006). Child-rearing practice scores of the PS + FS group improved 7.7, 6.4 and 6.6 points and the PS group improved 8.5, 7.2 and 7.4 points more than CH, CC and FS, respectively (p < 0.001 for all).


Child-rearing practices of mothers of severely malnourished children and the quality of their home environment can be improved through community-based psychosocial stimulation with or without food supplementation. This may be of importance to promote child development.

How ready-to-use therapeutic food shapes a new technological regime to treat child malnutrition

In Under-nutrition on August 1, 2012 at 6:23 pm

by José Guimón and Pablo Guimón

from Technological Forecasting and Social Change; Volume 79, Issue 7, September 2012, Pages 1319–1327


Since the turn of the 21st century ready-to-use therapeutic food (RUTF) has emerged as the preferred solution to treat acute malnutrition without complications. RUTF is a more appropriate technology than formerly prevalent powdered milk solutions because it enables outpatient care, simpler treatment protocols and production in the field. In this paper we analyze the forces driving the diffusion of RUTF as an innovation to treat child malnutrition and discuss the main features characterizing the new technological regime that results from its wide adoption. We combine the theoretical discussion and the review of secondary sources with insights from field research in Ethiopia, encompassing personal interviews with relevant parties and direct observation of how RUTF works in practice. This technology assessment exercise enables us to suggest some opportunities for policy intervention.

Another less recent version of the same paper is available here.

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