Severe malnutrition in infants aged <6 months—Outcomes and risk factors in Bangladesh: A prospective cohort study

Abstract

Severe acute malnutrition (SAM) affects ~4 million infants under 6 months (u6m) worldwide, but evidence underpinning their care is "very low" quality. To inform future research and policy, the objectives of our study were to identify risk factors for infant u6m SAM and describe the clinical and anthropometric outcomes of treatment with current management strategies. We conducted a prospective cohort study in infants u6m in Barisal district, Bangladesh. One group of 77 infants had SAM (weight-for-length Z-score [WLZ] <-3 and/or bipedal oedema); 77 others were "non-SAM" (WLZ ≥-2 to <+2, no oedema, mid-upper-arm circumference ≥125 mm). All were enrolled at 4-8 weeks of age and followed up at 6 months. Maternal education and satisfaction with breastfeeding were among factors associated with SAM. Duration of exclusive breastfeeding was shorter at enrolment (3·9 ± 2.1 vs. 5.7 ± 2.2 weeks, P < 0.0001) and at age 6 months (13.2 ± 8.9 vs. 17.4 ± 7.9 weeks; P = 0.003) among SAM infants. Despite referral, only 13 (17%) reported for inpatient care, and at 6 months, 18 (23%) infants with SAM still had SAM, and 3 (3.9%) died. In the non-SAM group, one child developed SAM, and none died. We conclude that current treatment strategies have limited practical effectiveness: poor uptake of inpatient referral being the main reason. World Health Organization recommendations and other intervention strategies of outpatient-focused care for malnourished but clinically stable infants u6m need to be tested. Breastfeeding support is likely central to future treatment strategies but may be insufficient alone. Better case definitions of nutritionally at-risk infants are also needed.

Water, sanitation and hygiene interventions and the prevention and treatment of childhood acute malnutrition: A systematic review

“…The results are inconsistent, and the quality of studies varied. Several studies were conducted to examine associations between WASH conditions and acute malnutrition and the effect of WASH interventions on preventing this condition; however, results are mixed, and the evidence relies mostly on low‐ to moderate‐quality observational studies (Ambadekar & Zodpey, 2017 ; Ayana et al, 2015 ; Buttenheim, 2008 ; Chisti et al, 2007 ; Dodos et al, 2018 ; Fikree et al, 2000 ; George et al, 2016 ; Iannotti et al, 2009 ; Langford et al, 2011 ; Lin et al, 2013 ; Munirul Islam et al, 2018 ; Nabwera et al, 2018 ; Stobaugh et al, 2018 ; Tomedi et al, 2012 ).…”

“…Two high‐quality studies (du Preez et al, 2011 ; Stobaugh et al, 2018 ) and six low‐quality studies (Arnold et al, 2009 ; Dodos et al, 2018 ; Fikree et al, 2000 ; George et al, 2016 ; Lin et al, 2013 ; Munirul Islam et al, 2018 ) consistently demonstrated no association between measured water quality and prevention of acute malnutrition or improved WHZ.…”

“…Compared with other hygiene interventions, the effect of handwashing interventions alone have been evaluated in a larger number of studies; however, findings regarding the association between handwashing and acute malnutrition was mixed and weak. Whereas one case–control study demonstrated an association with preventing SAM (Ayana et al, 2015 ), four other non‐intervention studies ranging in quality found no association between handwashing and acute malnutrition prevention (Arnold et al, 2009 ; Dodos et al, 2018 ; Munirul Islam et al, 2018 ; Stobaugh et al, 2018 ).…”

“…One low‐quality quasi‐experimental study found an association between the percentage of community using a latrine and improved child WHZ (Buttenheim, 2008 ), indicating the potential importance of community‐level sanitation over household‐level sanitation. Two high‐quality cRCTs (Luby et al, 2018 ; Null et al, 2018 ), two moderate‐quality non‐intervention studies (Ambadekar & Zodpey, 2017 ; Langford et al, 2011 ) and six low‐quality non‐intervention studies (Buttenheim, 2008 ; Chisti et al, 2007 ; De Vita et al, 2019 ; George et al, 2016 ; Headey & Palloni, 2019 ; Munirul Islam et al, 2018 ) consistently demonstrated no association between the presence of an improved latrine at the household and prevention of acute malnutrition or improvement of WHZ.…”

Antimicrobial and micronutrient interventions for the management of infants under 6 months of age identified with severe malnutrition: a literature review

“…Besides shorter-term risks of death and morbidity, there are important long-term consequences for neurodevelopment and adult non-communicable disease ( Tarry-Adkins & Ozanne, 2011 ). The determinants of severe malnutrition in infants U6M are only just beginning to be studied ( Munirul Islam et al, 2018 ). It is not yet clear what proportion of infants are presenting with acute wasting as opposed to following a trajectory from LBW, whether premature or small for gestational age (SGA), and whether this has implications for assessment and treatment.…”