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Schematic diagram of the 433 malnourished children aged 6 mo to 5 y who participated in the study during the war in Guinea-Bissau in 1998 – 1999. The supplementary feeding program took place from 1 September 1998 to 31 May 1999. Numbers in parentheses indicate subjects who were still eligible for treatment or were receiving supplementary feeding and treatment at the end of the study. Numbers in brackets indicate subjects who were censored because they permanently moved out of the study area or reached 5 y of age before recovery or death. Two children receiving supplementary feeding and treatment permanently moved out of the study area and were censored at day zero as having abandoned treatment. MUAC, midupper arm circumference.
Source publication
Supplementary feeding programs (SFPs) are intended to mitigate the deterioration of nutritional status and the increase in mortality among malnourished children.
We investigated the effect of an SFP on malnourished children in Guinea-Bissau who were returning to their homes after having been displaced within the country because of war in 1998-1999....
Contexts in source publication
Context 1
... once, and of these, 247 (57.0%) received supplementary feeding and medical treatment. Children were censored at death, permanent movement out of the area, attainment of 5 y of age, or 31 May 1999, whichever came first. We cannot know the nutritional status of a child who was absent at a home visit; thus, only time from a home visit at which the nutritional status was registered was attributed to the child. Nutritional status of a child changes over time. The interval between home visits was normally 3 mo. Thus, we censored information about nutritional status after 90 d if a new visit and examination of arm circumference had not been conducted within this period. Deaths due to acts of war or accidents, as reported in a cause-of-death interview, were censored. We used different designs to examine the effect of war and supplementary feeding on the nutritional status of the community. We evaluated the effect of war on the nutrition status of the study population in 2 different designs. First, we investigated how children aged 6 – 35 mo were affected; we compared observed monthly prevalence rates of malnutrition during the war with expected prevalence rates. Second, to investigate changes in the severity of malnutrition among malnourished children, we compared mean MUAC before and during the war. The nutritional status of the children was known only when they were present in Bissau. Migration patterns were different during the war; more time was spent outside Bissau due to periods of fighting. Families with good conditions might have been the first to return to Bissau. Alternatively, families with malnourished or sick children might have returned to Bissau more quickly, as knowledge about the better availability of treatment in Bissau circulated among the IDPs in the interior of Guinea- Bissau. Thus, to explore the potential bias in those who came back first, we compared the cultural and socioeconomic risk factors of malnourished children before and during the war. As we know only the nutritional status of the children present at the last home visit, the effect of the war was examined by using only the children who were present in Bissau. Before the war, the routine surveillance included children up to 3 y of age, and our comparisons are therefore restricted to children aged 6 mo to 3 y. The quality of the supplementary feeding and treatment program was compared with the Sphere Project ’ s minimum standards in disaster response (4). The supplementary feeding was performed in an urban area with 2 h return walk. Thus, coverage should have been 90%, and during treatment, the numbers of deaths, recovered, and abandoned should have been 3%, 75%, and 15%, respectively. In addition, we evaluated compliance. The expected monthly wartime prevalence of malnutrition and mortality associated with malnutrition was estimated by using time series methods to forecast prewar data (January 1995 to May 1998) into wartime (June 1998 to May 1999). We used 2 classes of log-transformed time series models to account for trends, epidemics, and seasonal variations, the latter as either piecewise constant terms or cyclic functions. The variance was modeled with an underlying Poisson process with overdispersion or with an underlying Gaussian process including the monthly estimation SE in the variance. The best forecasting capacity was ob- tained when the monthly estimation error was included in the variance, either multiplicatively as overdispersion in a Poisson regression or additively in a Gaussian regression. The model residual error in both regressions may express autocorrelation. The forecasting capacity of the time series models was evaluated on the basis of their ability to predict prevalence or mortality in the year before the war. We found that a Gaussian regression with no trend and quarterly constant seasonal variation was the best model for forecasting the prevalence of malnutrition the year before the war. Mortality rates the year before the war had the best prediction in a Poisson regression with no trend and a 12-mo cyclic seasonal variation. A more detailed description of the methods is available from the authors. We used 4 cultural and socioeconomic indicators (ethnicity, suburb, schooling of mother, and type of roof) that are associated with childhood survival to construct an index. The index was defined as the sum of positive values [ie, not(Pepel) ѿ not(Bandim) ѿ mother had any schooling ѿ roof was solid]. Because the 2 index groups 0 and 4 were small, they were grouped with index groups 1 and 3, respectively. Missing values were treated as negative values. The expected wartime prevalence and mortality rates were forecasted for each cultural and socioeconomic index group. These rates were then assembled every month during the war into one rate weighted by the distribution of persons (prevalence) or observation time (mortality rates) in each index group. Indexes ( z scores) of anthropometric status were calculated by using a SAS program that was based on the year 2000 growth charts from the Centers for Disease Control and Prevention (CDC) and was downloaded from the CDC website on 26 September 2002 (Internet: www.cdc.gov/nccdphp/dnpa/growth- charts/sas.htm). Analysis was performed by using SAS release 8.02 (SAS Institute Inc, Cary, NC). The distributions of malnourished children present in Bissau before and during the war did not differ with respect to age and type of household ( Table 1 ). However, there were significant differences with respect to ethnicity, district, mother ’ s schooling, and quality of roof. Values of a cultural and socioeconomic index based on these 4 factors differed significantly between the children present during the war and all children present in Bissau from 1 January 1995 to 31 December 1999 (Table 1). The prevalence of malnutrition among children 6 – 35 mo of age before the war (January 1995 to May 1998) was 7.5%, and quarterly constant prevalence ratios (8.5% in February – April, 6.5% in May – July, 6.7% in August – October, and 8.4% in November – January) were the best adjustment for calendar-time variation. The observed and expected prevalence of malnutrition and the ratio of observed to expected prevalence from September 1998 to May 1999 are shown in Figure 1 . In December 1998, the observed prevalence was significantly elevated in comparison with the expected prevalence. A decrease in the observed prevalence of malnourished children began in January 1999. The mortality rate for malnourished children 6 – 35 mo of age did not show any calendar-time trend before the war; the best adjustment for calendar-time variation was a 12-mo cyclic fluc- tuation varying from 2.7 to 5.7 around 3.9 deaths · 10 000 children Ҁ 1 · d Ҁ 1 . During the intervention period, observed mortality rates relative to the expected rates, adjusted for the cultural and socioeconomic distribution observed during the war, showed some variation but were never significantly elevated ( Figure 2 ). The severity of malnutrition among the malnourished children, which was measured as mean MUAC, in the 3 prewar September-to-May periods was 122 mm (95% CI: 122, 122 mm; n ҃ 2198). The mean MUAC during the war was the same: 122 mm (95% CI: 121, 123 mm; n ҃ 470; P ҃ 0.43) (adjusted for repeated measurement and controlled for cultural and socioeconomic index and season). Of the 433 children registered as being malnourished, 5 died and 84 recovered without supplementary feeding or medical treatment ( Figure 3 ). Ninety-four children were eligible for supplementary feeding at the end of the study (31 May 1999). Two hundred forty-seven children received supplementary feeding and medical treatment. Twenty-seven children were still under treatment when the study ended, 2 of the children had died [0.9% ҃ 2/(247 Ҁ 27)], 148 (67%; 95% CI: 61%, 73%) had recovered, and 70 (32%; 95% CI: 26%, 38%) had abandoned treatment (Figure 3). All children with an MUAC 130 mm at the 3-mo home visits were referred for treatment. Coverage, which was expressed as the percentage of children who were referred for treatment and were actually included in the supplementary feeding program, was 74% [247/(433 Ҁ 94 Ҁ 5)]. In the community surveillance, the mean MUAC of the children enrolled in the supplementary feeding program was 121 mm (95% CI: 120, 121 mm), whereas the mean MUAC of the children who did not receive treatment was 124 mm (95% CI: 123, 125 mm) ( P for equal values 0.01; controlled for age ...
Context 2
... once, and of these, 247 (57.0%) received supplementary feeding and medical treatment. Children were censored at death, permanent movement out of the area, attainment of 5 y of age, or 31 May 1999, whichever came first. We cannot know the nutritional status of a child who was absent at a home visit; thus, only time from a home visit at which the nutritional status was registered was attributed to the child. Nutritional status of a child changes over time. The interval between home visits was normally 3 mo. Thus, we censored information about nutritional status after 90 d if a new visit and examination of arm circumference had not been conducted within this period. Deaths due to acts of war or accidents, as reported in a cause-of-death interview, were censored. We used different designs to examine the effect of war and supplementary feeding on the nutritional status of the community. We evaluated the effect of war on the nutrition status of the study population in 2 different designs. First, we investigated how children aged 6 – 35 mo were affected; we compared observed monthly prevalence rates of malnutrition during the war with expected prevalence rates. Second, to investigate changes in the severity of malnutrition among malnourished children, we compared mean MUAC before and during the war. The nutritional status of the children was known only when they were present in Bissau. Migration patterns were different during the war; more time was spent outside Bissau due to periods of fighting. Families with good conditions might have been the first to return to Bissau. Alternatively, families with malnourished or sick children might have returned to Bissau more quickly, as knowledge about the better availability of treatment in Bissau circulated among the IDPs in the interior of Guinea- Bissau. Thus, to explore the potential bias in those who came back first, we compared the cultural and socioeconomic risk factors of malnourished children before and during the war. As we know only the nutritional status of the children present at the last home visit, the effect of the war was examined by using only the children who were present in Bissau. Before the war, the routine surveillance included children up to 3 y of age, and our comparisons are therefore restricted to children aged 6 mo to 3 y. The quality of the supplementary feeding and treatment program was compared with the Sphere Project ’ s minimum standards in disaster response (4). The supplementary feeding was performed in an urban area with 2 h return walk. Thus, coverage should have been 90%, and during treatment, the numbers of deaths, recovered, and abandoned should have been 3%, 75%, and 15%, respectively. In addition, we evaluated compliance. The expected monthly wartime prevalence of malnutrition and mortality associated with malnutrition was estimated by using time series methods to forecast prewar data (January 1995 to May 1998) into wartime (June 1998 to May 1999). We used 2 classes of log-transformed time series models to account for trends, epidemics, and seasonal variations, the latter as either piecewise constant terms or cyclic functions. The variance was modeled with an underlying Poisson process with overdispersion or with an underlying Gaussian process including the monthly estimation SE in the variance. The best forecasting capacity was ob- tained when the monthly estimation error was included in the variance, either multiplicatively as overdispersion in a Poisson regression or additively in a Gaussian regression. The model residual error in both regressions may express autocorrelation. The forecasting capacity of the time series models was evaluated on the basis of their ability to predict prevalence or mortality in the year before the war. We found that a Gaussian regression with no trend and quarterly constant seasonal variation was the best model for forecasting the prevalence of malnutrition the year before the war. Mortality rates the year before the war had the best prediction in a Poisson regression with no trend and a 12-mo cyclic seasonal variation. A more detailed description of the methods is available from the authors. We used 4 cultural and socioeconomic indicators (ethnicity, suburb, schooling of mother, and type of roof) that are associated with childhood survival to construct an index. The index was defined as the sum of positive values [ie, not(Pepel) ѿ not(Bandim) ѿ mother had any schooling ѿ roof was solid]. Because the 2 index groups 0 and 4 were small, they were grouped with index groups 1 and 3, respectively. Missing values were treated as negative values. The expected wartime prevalence and mortality rates were forecasted for each cultural and socioeconomic index group. These rates were then assembled every month during the war into one rate weighted by the distribution of persons (prevalence) or observation time (mortality rates) in each index group. Indexes ( z scores) of anthropometric status were calculated by using a SAS program that was based on the year 2000 growth charts from the Centers for Disease Control and Prevention (CDC) and was downloaded from the CDC website on 26 September 2002 (Internet: www.cdc.gov/nccdphp/dnpa/growth- charts/sas.htm). Analysis was performed by using SAS release 8.02 (SAS Institute Inc, Cary, NC). The distributions of malnourished children present in Bissau before and during the war did not differ with respect to age and type of household ( Table 1 ). However, there were significant differences with respect to ethnicity, district, mother ’ s schooling, and quality of roof. Values of a cultural and socioeconomic index based on these 4 factors differed significantly between the children present during the war and all children present in Bissau from 1 January 1995 to 31 December 1999 (Table 1). The prevalence of malnutrition among children 6 – 35 mo of age before the war (January 1995 to May 1998) was 7.5%, and quarterly constant prevalence ratios (8.5% in February – April, 6.5% in May – July, 6.7% in August – October, and 8.4% in November – January) were the best adjustment for calendar-time variation. The observed and expected prevalence of malnutrition and the ratio of observed to expected prevalence from September 1998 to May 1999 are shown in Figure 1 . In December 1998, the observed prevalence was significantly elevated in comparison with the expected prevalence. A decrease in the observed prevalence of malnourished children began in January 1999. The mortality rate for malnourished children 6 – 35 mo of age did not show any calendar-time trend before the war; the best adjustment for calendar-time variation was a 12-mo cyclic fluc- tuation varying from 2.7 to 5.7 around 3.9 deaths · 10 000 children Ҁ 1 · d Ҁ 1 . During the intervention period, observed mortality rates relative to the expected rates, adjusted for the cultural and socioeconomic distribution observed during the war, showed some variation but were never significantly elevated ( Figure 2 ). The severity of malnutrition among the malnourished children, which was measured as mean MUAC, in the 3 prewar September-to-May periods was 122 mm (95% CI: 122, 122 mm; n ҃ 2198). The mean MUAC during the war was the same: 122 mm (95% CI: 121, 123 mm; n ҃ 470; P ҃ 0.43) (adjusted for repeated measurement and controlled for cultural and socioeconomic index and season). Of the 433 children registered as being malnourished, 5 died and 84 recovered without supplementary feeding or medical treatment ( Figure 3 ). Ninety-four children were eligible for supplementary feeding at the end of the study (31 May 1999). Two hundred forty-seven children received supplementary feeding and medical treatment. Twenty-seven children were still under treatment when the study ended, 2 of the children had died [0.9% ҃ 2/(247 Ҁ 27)], 148 (67%; 95% CI: 61%, 73%) had recovered, and 70 (32%; 95% CI: 26%, 38%) had abandoned treatment (Figure 3). All children with an MUAC 130 mm at the 3-mo home visits were referred for treatment. Coverage, which was expressed as the percentage of children who were referred for treatment and were actually included in the supplementary feeding program, was 74% [247/(433 Ҁ 94 Ҁ 5)]. In the community surveillance, the mean MUAC of the children enrolled in the supplementary feeding program was 121 mm (95% CI: 120, 121 mm), whereas the mean MUAC of the children who did not receive treatment was 124 mm (95% CI: 123, 125 mm) ( P for equal values 0.01; controlled for age ...
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Childhood malnutrition is the leading risk factor for the global burden of disease. Guinea-Bissau is a politically unstable country with high levels of childhood malnutrition and mortality.
To determine the nutritional status of children on three remote islands of the Bijagós Archipelago, Bubaque, Rubane and Soga, and to identify factors associated...
Citations
... Anthropometric measurements using survey data or interviews were the most common method to identify stunting, underweight, and wasting among children [16][17][18][19][20][21][22][23][24][25]. Studies [17,19,23,24,[26][27][28] also assessed prevalence of anemia or malnutrition through assessments of blood samples. The review identified seven papers that discussed the impact of economic crises on nutrition [17,25,[29][30][31][32][33]: six during natural disasters [18,[34][35][36][37][38], including cyclones, earthquakes, flooding and drought, and two during humanitarian crises [27,39]. ...
... Studies [17,19,23,24,[26][27][28] also assessed prevalence of anemia or malnutrition through assessments of blood samples. The review identified seven papers that discussed the impact of economic crises on nutrition [17,25,[29][30][31][32][33]: six during natural disasters [18,[34][35][36][37][38], including cyclones, earthquakes, flooding and drought, and two during humanitarian crises [27,39]. Studies found that the prevalence of child morbidity and mortality was high in crisis situations, with worsened child diet and nutritional status, including higher prevalence of malnutrition and lower birth rates. ...
... Of these, two papers reviewed the overall impact of nutrition interventions [35,40]. Two were categorized as cash-for-nutrition programs [41,42], one as a food-for-work program [28], six as nutrition education interventions [16,24,26,41,43,44], one as a malnutrition screening study [41], two as nutrition policy interventions, and the majority (13) as supplementary feeding programs [18][19][20][21][22][23][24]27,28,36,[44][45][46]. Additionally, four programs were combination interventions, one being cash-for-nutrition with nutrition education and malnutrition screening [41], one as food-for-work with supplementary feeding, and two as supplementary feeding with nutrition education [24,44]. ...
Adequate child nutrition is critical to child development, yet child malnutrition is prevalent in crisis settings. However, the intersection of malnutrition and disasters is sparse. This study reviews existing evidence on nutrition responses and outcomes for infants and young children during times of crisis. The scoping review was conducted via two approaches: a systematic search and a purposive search. For the systematic search, two key online databases, PubMed and Science Direct, were utilized. In total, data from 32 studies were extracted and included in the data extraction form. Additionally, seven guidelines and policy documents were included, based on relevance to this study. Overall, the existing evidence demonstrates the negative impacts of crises on nutritional status, diet intake, anthropometric failure, and long-term child development. On the other hand, crisis-related interventions positively affected nutrition-related knowledge and practices. Further studies should be carried out to explore the sustainability of the interventions and the success of existing guidelines. Since this study focuses only on nutrition among children under three, further studies should likewise consider an extended age range from three to five years.
... 76 The Bandim health project and humanitarian assistance in Guinea Bissau during 1998 and 1999 treated SAM children through community, and outreach approach. 64 They also achieved almost minimum coverage (57%), and recovery rate (59.9%), while the defaulters were reported higher than the minimum (32%). 64 Another reported coverage of similar programme in 1998 among refugees and nondisplaced residents of Guinea Bissau 23 and showed 87% coverage among refugees and 91% among residents. ...
... 64 They also achieved almost minimum coverage (57%), and recovery rate (59.9%), while the defaulters were reported higher than the minimum (32%). 64 Another reported coverage of similar programme in 1998 among refugees and nondisplaced residents of Guinea Bissau 23 and showed 87% coverage among refugees and 91% among residents. 23 The same study reported on food distribution, which reported higher coverage among refugees (41%) as compared with non-displaced residents (16%). ...
... Nutrition assessment, 53 73 disease prevention and management 62 73 general food distribution, 42 SAM/MAM treatment, 73 supplementary feeding, 73 nutrition education 38 62 Continued BMJ Lebanon, 83 Sudan, 85 Kenya, 64 Guinea-Bissau, 64 65 Afghanistan, 84 Syria, 101 Jordan, 109 South Sudan 112 Nutrition assessment, 83 84 101 109 breastfeeding and appropriate IYCF, 64 65 micronutrient supplementation, 64 65 83 101 general food distribution, 64 112 SAM/MAM treatment, 83 85 101 109 supplementary feeding, 65 83 101 109 nutrition education 83 101 Multi-sector programming Inter-Cluster Coordination Group (ICCG Somalia) 88 Nutrition cluster in partnership with the health and WASH clusters 25 88 Integration of services through public primary healthcare (PHC) centres 31 39 40 48 49 66 Nutrition services integration into public education system 99 Burundi, 48 Somalia, 39 88 Sri Lanka, 49 Pakistan, 25 Ethiopia, 31 Guinea-Bissau, 40 DRC, 66 Lebanon 99 ...
Background
Low/middle-income countries (LMICs) face triple burden of malnutrition associated with infectious diseases, and non-communicable diseases. This review aims to synthesise the available data on the delivery, coverage, and effectiveness of the nutrition programmes for conflict affected women and children living in LMICs.
Methods
We searched MEDLINE, Embase, CINAHL, and PsycINFO databases and grey literature using terms related to conflict, population, and nutrition. We searched studies on women and children receiving nutrition-specific interventions during or within five years of a conflict in LMICs. We extracted information on population, intervention, and delivery characteristics, as well as delivery barriers and facilitators. Data on intervention coverage and effectiveness were tabulated, but no meta-analysis was conducted.
Results
Ninety-one pubblications met our inclusion criteria. Nearly half of the publications (n=43) included population of sub-Saharan Africa (n=31) followed by Middle East and North African region. Most publications (n=58) reported on interventions targeting children under 5 years of age, and pregnant and lactating women (n=27). General food distribution (n=34), micronutrient supplementation (n=27) and nutrition assessment (n=26) were the most frequently reported interventions, with most reporting on intervention delivery to refugee populations in camp settings (n=63) and using community-based approaches. Only eight studies reported on coverage and effectiveness of intervention. Key delivery facilitators included community advocacy and social mobilisation, effective monitoring and the integration of nutrition, and other sectoral interventions and services, and barriers included insufficient resources, nutritional commodity shortages, security concerns, poor reporting, limited cooperation, and difficulty accessing and following-up of beneficiaries.
Discussion
Despite the focus on nutrition in conflict settings, our review highlights important information gaps. Moreover, there is very little information on coverage or effectiveness of nutrition interventions; more rigorous evaluation of effectiveness and delivery approaches is needed, including outside of camps and for preventive as well as curative nutrition interventions.
PROSPERO registration number
CRD42019125221.
... Three of the 11 studies used cut-off values for admission that did not resemble to the WHO definition of severe acute malnutrition, namely mid-upper arm circumference <120 mm, mid-upper arm circumference <130 mm and weight-for-height <-2 Z-score. [19][20][21] In the present study, a total of 485 patients were admitted in SAM block during January 2013-December 2017. Among them, 266 patients were successfully discharged from the hospital. ...
... While many studies used WHO 2006 reference standards to define moderate and severe stunting and wasting (labelled 'WHO' in Table 4), others used the National Center for Health Statistics (NCHS)/WHO international growth reference standards (labelled NCHS in Table 4) [23][24][25][26]. Wasting (WFH) was used as an outcome in 15 studies [18][19][20][27][28][29][30][31][32][33][34][35][36][37][38], stunting (HFA) in five studies [32,33,37,39,40], underweight (WFA) in five studies [31,34,37,41,42] and MUAC in five studies [19,28,38,43,44]. Four studies described weight gain [20,28,43,45] and one described linear growth [37]. ...
... Recovery rates of 67-81% were seen in two studies examining take-home selective supplementary feeding for those with mild or moderate malnutrition using millet gruel and corn-soy blend, respectively [27,44]. Rates of over 90% were seen in therapeutic feeding studies using RUTF in those with severe malnutrition [28,43]. ...
Objectives:
Malnutrition contributes to pediatric morbidity and mortality in disasters and complex emergencies, but summary data describing specific nutritional interventions in these settings are lacking. This systematic review aims to characterize such interventions and their effects on pediatric mortality, anthropometric measures, and serum markers of nutrition.
Methods:
A systematic search of OVID Medline, Cochrane Library, and relevant grey literature was conducted. We included all randomized controlled trials and observational controlled studies evaluating effectiveness of nutritional intervention(s) on defined health outcomes in children and adolescents (0-18 years) within a disaster or complex emergency. We extracted study characteristics, interventions, and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.
Results:
31 studies met inclusion criteria. Most were conducted in Africa (17), during periods of conflict or hunger gaps (14), and evaluated micronutrient supplementation (14) or selective feeding (10). Overall study quality was low, with only two high and four moderate quality studies. High- and medium-quality studies demonstrated positive impact of fortified spreads, ready-to-use therapeutic foods, micronutrient supplementation, and food and cash transfers.
Conclusion:
In disasters and complex emergencies, high variability and low quality of controlled studies on pediatric malnutrition limit meaningful data aggregation. If existing research gaps are to be addressed, the inherent unpredictability of humanitarian emergencies and ethical considerations regarding controls may warrant a paradigm shift in what constitutes adequate methods. Periodic hunger-gaps may offer a generalizable opportunity for robust trials, but consensus on meaningful nutritional endpoints is needed. This article is protected by copyright. All rights reserved.
... Of these 25 articles, 11 studies met our eligibility criteria described above. The included articles (n = 11) were published from 1983 to 2012 (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31). The results from the nutrition interventions for children in conflict settings were difficult to compare across studies due to differences in intervention approaches and outcomes; thus, results are presented by type of intervention in Table 3. ...
... Description of studies. Of the 11 included studies, 6 were cross-sectional studies (21, 25-27, 29, 30), 3 were prospective cohort studies (22,23,31), 1 was a retrospective cohort study (24), and 1 was a randomized controlled trial (30). All of the studies included children of both sexes in conflict settings or resettlement or refugee camps. ...
... The majority of the studies identified through our systematic review were conducted in regions of Central and East Africa, including the countries of South Sudan, Democratic Republic of Congo, Rwanda, Somalia, and Burundi, most of which are still facing ongoing violent conflicts, primarily due to civil wars among ethnic groups. Overall, 7 of the 11 nutrition intervention studies identified were conducted in postconflict refugee camp settings either within the country or in resettlement areas in neighboring countries (22)(23)(24)(28)(29)(30)(31). ...
Food and nutrition insecurity becomes increasingly worse in areas affected by armed conflict. Children affected by conflict, or in war-torn
settings, face a disproportionate burden of malnutrition and poor health outcomes. As noted by humanitarian response reviews, there is a need
for a stronger evidence-based response to humanitarian crises. To achieve this, we systematically searched and evaluated existing nutrition
interventions carried out in conflict settings that assessed their impact on children’s nutrition status. To evaluate the impact of nutrition
interventions on children’s nutrition and growth status, we identified published literature through EMBASE, PubMed, and Global Health by
using a combination of relevant text words and Medical Subject Heading terms. Studies for this review must have included children (aged #18 y),
been conducted in conflict or postconflict settings, and assessed a nutrition intervention that measured $1 outcome for nutrition
status (i.e., stunting, wasting, or underweight). Eleven studies met the inclusion and exclusion criteria for this review. Five different nutrition
interventions were identified and showed modest results in decreasing the prevalence of stunting, wasting, underweight, reduction in severe or
moderate acute malnutrition or both, mortality, anemia, and diarrhea. Overall, nutrition interventions in conflict settings were associated with
improved children’s nutrition or growth status. Emergency nutrition programs should continue to follow recent recommendations to expand
coverage and access (beyond refugee camps to rural areas) and ensure that aid and nutrition interventions are distributed equitably in all
conflict-affected populations.
... Supporting citations were limited to two indirect retrospective studies demonstrating that mid-upper arm circumference was an adequate measure of outpatient progress. 38,39 The results of these studies led to the recommendation to eliminate percentage weight gain as a criterion for discharge from outpatient follow-up. ...
Objective
To understand how the World Health Organization’s (WHO’s) guidelines on the inpatient care of children with complicated severe acute malnutrition may be strengthened to improve outcomes.
Methods
In December 2015, we searched Google scholar and WHO’s website for WHO recommendations on severe acute malnutrition management and evaluated the history and cited evidence behind these recommendations. We systematically searched WHO International Clinical Trials Registry Platform, clinicaltrials.gov and the Controlled Trials metaRegister until 10 August 2015 for recently completed, ongoing, or pending trials.
Findings
WHO’s guidelines provide 33 recommendations on the topic. However, 16 (48.5%) of these recommendations were based solely on expert opinion – unsupported by published evidence. Another 11 (33.3%) of the recommendations were supported by the results of directly relevant research – i.e. either randomized trials (8) or observational studies (3). The other six recommendations (18.2%) were based on studies that were not conducted among children with complicated severe malnutrition or studies of treatment that were not identical to the recommended intervention. Trials registries included 20 studies related to the topic, including nine trials of alternative feeding regimens. Acute medical management and follow-up care studies were minimally represented.
Conclusion
WHO’s guidelines on the topic have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with severe malnutrition is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.
... Despite support for broader use of MUAC as a single admission criterion, programmatic experience with MUAC-based admissions is limited. Few reports have been published to share experience from programmes admitting children with SAM to therapeutic feeding using MUAC only (20,22,23) . In these studies, treatment outcomes, including mortality, were similar to those recorded in our study. ...
... In these studies, treatment outcomes, including mortality, were similar to those recorded in our study. A study of the effect of a supplemental food programme in Guinea-Bissau found a mortality of 1 % (23) . Defourny et al. evaluated the use of MUAC < 110 mm as an admission criterion for a TFP in Niger (22) . ...
The present study was performed to describe the operational implications of using mid-upper arm circumference (MUAC) as a single admission criterion for treatment of severe acute malnutrition in South Sudan.
We performed a retrospective analysis of routine programme data of children with severe acute malnutrition aged 6-59 months admitted to a therapeutic feeding programme using weight-for-height Z-score (WHZ) and/or MUAC. To understand the implications of using MUAC as a single admission criterion, we compared patient characteristics and treatment outcomes for children admitted with MUAC<115 mm (irrespective of WHZ) v. children admitted with WHZ<-3 and MUAC≥115 mm.
Of 2205 children included for analysis, 719 (32·6 %) were admitted to the programme with MUAC<115 mm and 1486 (67·4 %) with WHZ<-3 and MUAC≥115 mm. Children who would have been admitted using a single MUAC<115 mm criterion were more severely malnourished and more likely to be female and younger. Compared with children admitted with WHZ<-3 and MUAC≥115 mm, children who would have been admitted using MUAC<115 mm were less likely to recover (54 % v. 69 %) and had higher risk of death (4 % v. 1 %), but responded to treatment with greater weight and MUAC gains. MUAC<115 mm would have failed to identify 33 % of deaths, while 98 % were identified by WHZ<-3 alone and 100 % by MUAC<130 mm.
The study shows that MUAC<115 mm identified more severely malnourished children with a higher risk of mortality but failed to identify a third of the children who died. Admission criteria for therapeutic feeding should be adapted to the programmatic context with consideration for both operational and public health implications.
... Four studies, including an unpublished report, reported on outcomes of children diagnosed on the basis of mid-upper arm circumference only and managed in outpatient care without a comparison group admitted on the basis of weight-for-height (25,28,29,33). The mortality risk for children with severe acute malnutrition was reported in three of the studies and was overall relatively low (≤2.1 %). ...
... The daily gain of mid-upper arm circumference ranged from 0.17 ± 0.16 mm in children admitted with a mid-upper arm circumference <110 mm and treated in a supplementary feeding programme (25) to 0.51 ± 0.3 mm in Burkina Faso in children with a mid-upper arm circumference ≤110 mm and receiving ready-to-use therapeutic food (28). Two of the studies stratified the results by level of mid-upper arm circumference at admission (28,29). In both studies, children admitted with a lower mid-upper arm circumference displayed a greater daily gain in weight and mid-upper arm circumference. ...
... Two observational studies reported outcomes when mid-upper arm circumference was used as a discharge criterion for malnourished children from nutritional rehabilitation programmes (28,29). In Burkina Faso, the time to discharge of children with mid-upper arm circumference <120 mm from an outpatient programme (n = 5689) was reported for the period April to December 2008 when discharge was based on 15% weight gain, and then for the period April to December 2009 when discharge was based on achieving mid-upper arm circumference ≥124 mm (without consideration of weight gain). ...
... A national programme of therapeutic and supplementary feeding during a humanitarian emergency in Burundi seemingly failed to reduce the prevalence of wasting, perhaps because only 55% coverage was achieved [11]. Three different lines of evidence suggested that supplementary feeding programmes during a war in Guinea-Bissau prevented in increase in the prevalence of undernutrition [12]. But even if the evidence of the impact of supplementary feeding programmes is inevitably indirect because having an unfed control group is impossible, the experiences described here offer useful lessons that could be applied to improve the quality of data in future evaluations of blanket feeding programmes in Kenya and elsewhere. ...
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.
... Recent methodological reviews demonstrated that all actual approaches for measuring SEP in low-income countries have their drawbacks. Furthermore, the results of the different methods showed only limited agreement and have restrictions for further processing [59,[61][62][63][64]. Along with previous research undertaken in conflict zones elsewhere in Africa [37,[65][66][67][68][69][70][71][72][73][74][75][76], the present study can be considered as additional evidence of the feasibility of research even in troubled times and zones. Knowledge about the profiles of households that are more resilient to armed conflict could help to better prevent and/or alleviate adverse conflict-related and increasingly civilian-borne socioeconomic effects. ...
Current conceptual frameworks on the interrelationship between armed conflict and poverty are based primarily on aggregated macro-level data and/or qualitative evidence and usually focus on adherents of warring factions. In contrast, there is a paucity of quantitative studies about the socioeconomic consequences of armed conflict at the micro-level, i.e., noncommitted local households and civilians.
We conducted a secondary analysis of data pertaining to risk factors for malaria and neglected tropical diseases. Standardized questionnaires were administered to 182 households in a rural part of western Côte d'Ivoire in August 2002 and again in early 2004. Between the two surveys, the area was subject to intensive fighting in the Ivorian civil war. Principal component analysis was applied at the two time points for constructing an asset-based wealth-index and categorizing the households in wealth quintiles. Based on quintile changes, the households were labeled as 'worse-off', 'even' or 'better-off'. Statistical analysis tested for significant associations between the socioeconomic fates of households and head of household characteristics, household composition, village characteristics and self-reported events associated with the armed conflict. Most-poor/least-poor ratios and concentration indices were calculated to assess equity changes in households' asset possession.
Of 203 households initially included in the first survey, 21 were lost to follow-up. The population in the remaining 182 households shrunk from 1,749 to 1,625 persons due to migration and natural population changes. However, only weak socioeconomic dynamics were observed; every seventh household was defined as 'worse-off' or 'better-off' despite the war-time circumstances. Analysis of other reported demographic and economic characteristics did not clearly identify more or less resilient households, and only subtle equity shifts were noted.However, the results indicate significant changes in livelihood strategies with a significant return to agricultural production and a decrease in the diversity of socioeconomic activities.
Situational constraints and methodological obstacles are inherent in conflict settings and hamper conflict-related socioeconomic research. Furthermore, sensitive methods to assess and meaningfully interpret longitudinal micro-level wealth data from low-income countries are lacking. Despite compelling evidence of socioeconomic dynamics triggered by armed conflicts at the macro-level, we could not identify similar effects at the micro-level. A deeper understanding of household profiles that are more resilient to armed conflict could help to better prevent and/or alleviate adverse conflict-related and increasingly civilian-borne socioeconomic effects.
