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Background/objectives Stunted children often have poor appetite, which may limit their response to nutritional interventions. We investigated the effect of a nutritional intervention on the appetite status of stunted children. Methods A longitudinal prospective intervention study was conducted with 50 stunted (length for age; LAZ Results Over the period of nutritional intervention, the mean appetite score increased from 49 to 60 in the stunted children and was associated with increased food consumption. Over the intervention period, both egg and milk consumption increased (40.3–49.6 g and 83.8–138.5 ml, respectively). Conclusions Assessment of appetite status using EACST appears to be a useful tool for monitoring a nutritional intervention in stunted children. This tool may be useful for programs in managing child stunting in low-income countries and an important way to assess the efficacy of a nutritional intervention in these children.

BACKGROUND:Multiple factors constrain the trajectories of child cognitive development, but the drivers that differentiate the trajectories are unknown. We examine how multiple early life experiences differentiate patterns of cognitive development over the first 5 years of life in low-and middle-income settings.METHODS:Cognitive development of 835 children from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) multisite observational cohort study was assessed at 6, 15, 24 (Bayley Scales of Infant and Toddler Development), and 60 months (Wechsler Preschool and Primary Scale of Intelligence). Markers of socioeconomic status, infection, illness, dietary intake and status, anthropometry, and maternal factors were also assessed. Trajectories of development were determined by latent class-mixed models, and factors associated with class membership were examined by discriminant analysis.RESULTS:Five trajectory groups of cognitive development are described. The variables that best discriminated between trajectories included presence of stimulating and learning resources in the home, emotional or verbal responsivity of caregiver and the safety of the home environment (especially at 24 and 60 months), proportion of days (0–24 months) for which the child had diarrhea, acute lower respiratory infection, fever or vomiting, maternal reasoning ability, mean nutrient densities of zinc and phytate, and total energy from complementary foods (9–24 months).CONCLUSIONS:A supporting and nurturing environment was the variable most strongly differentiating the most and least preferable trajectories of cognitive development. In addition, a higher quality diet promoted cognitive development while prolonged illness was indicative of less favorable patterns of development.

Reliable and validated tools for measuring appetite of children in South Asia are not available. This study aimed to develop and validate a tool for assessing appetite level of under-five children. Based on literature review and findings from focus group discussions (FGDs), an initial 27-item interview-based tool, the "Early Childhood Appetite and Satiety Tool (ECAST)" was developed in Bangladesh. Fourteen FGDs were carried out in rural and urban settings and constructs for inclusion were derived from the themes and coding of FGDs and appetite assessment tools used in Western contexts. For structural validation, the ECAST-27-was administered on 150 mothers/primary caregivers of children aged 6-59 months, living in urban and rural areas. To validate the association with other variables, the ECAST was administered on mothers of children aged 12-24 months in the community (N = 50), and two groups of wasted, hospitalized children (Weight-for-length, Z score -2SD) [group1: twenty acutely ill children aged 6-59 months; group 2: twenty children in nutritional rehabilitation aged 18-24 months]. Reliability of ECAST was estimated using Cronbach's alpha and Pearson's correlation coefficient. Kaiser-Meyer-Olkin = 0.73 and the Bartlett's test of sphericity, χ

Growth in young children is controlled through the release of several hormonal signals, which are affected by diet, infection, and other exposures. Stunting is clearly a growth disorder, yet limited evidence exists documenting the association of different growth biomarkers with child stunting. This study explored the association between different growth biomarkers and stunting in Bangladeshi children. A quasi-experimental study was conducted among 50 stunted (length-for-age Z-score (LAZ) &lt, &minus, 2 SD) and 50 control (LAZ &ge, 2 SD) children, aged 12&ndash, 18 months, residing in a Bangladeshi slum. The enrolled stunted children received an intervention package, which included food supplementation for three months, psychosocial stimulation for six months, and routine clinical care on community nutrition center at the study field site. The controls received routine clinical care only. All children were clinically screened over the study period. Length, weight, fasting blood and fecal biomarkers were measured. All biomarkers levels were similar in both groups except for oxyntomodulin at enrolment. Leptin (adjusted odds ratio, AOR: 4.0, p &lt, 0.01), leptin&ndash, adiponectin ratio (AOR 5.07 &times, 108, p &lt, 0.01), insulin-like growth factor-1 (IGF-1) (AOR 1.02, p &lt, 0.05), and gamma interferon (IFN-&gamma, ) (AOR 0.92, p &lt, 0.05) levels were independently associated with stunting at enrolment. Serum leptin, leptin&ndash, adiponectin ratio, interleukin-6 (IL-6), IL-10, tumor necrosis factor-alpha (TNF-&alpha, ), and fecal alpha-1-antitrypsin (AAT) levels increased significantly (p &lt, 0.001), while IFN-&gamma, levels significantly decreased among stunted children after six months of intervention. Leptin, leptin&ndash, adiponectin ratio, IGF-1, and IFN-&gamma, are independently associated with stunting in Bangladeshi children. This trial was registered at clinicaltrials.gov as NCT02839148.

Background Undernutrition and poor cognitive development affect many children in developing countries. Good nutrition and health care are essential for optimal child development and growth. Objectives We assessed the impact of peer counseling combined with psychosocial stimulation on feeding practices and child growth and development in slums in Bangladesh. Methods We performed a community-based cluster randomized controlled trial in selected slums; 350 mother–infant pairs were allocated to receive peer counseling on feeding practices plus psychosocial stimulation (PC + PCS; n = 175) or usual health messages (control; n = 175) using restricted randomization. Data were collected at enrollment and 1, 3, 5, 7, 9, and 12 mo after delivery. We collected data on infant and young child feeding practices and anthropometric measurements from birth until 12 mo to assess the main outcomes, including feeding practices and growth. We used the Bayley Scale III at 12 mo to assess child development. The effects of the PC + PCS intervention were assessed by using regression models. Results More mothers in the PC + PCS group than in the control group reported early initiation of breastfeeding (in the first hour: 89% compared with 78%, respectively; P

Background In August 2017, after a large influx of forcibly displaced Myanmar nationals (FDMN) in Cox’s Bazar, Bangladesh diarrhea treatment centers (DTCs) were deployed. This study aims to report the clinical, epidemiological, and laboratory characteristics of the hospitalized patients. Methods The study followed cross-sectional design. In total 1792 individuals were studied. Other than data, a single, stool specimen was subjected to one step rapid visual diagnostic test for Vibrio cholerae. The provisionally diagnosed specimens of cholera cases were inoculated into Cary-Blair Transport Medium; then sent to the laboratory of icddr,b in Dhaka to isolate the colony as well as perform antibiotic susceptibility tests. Data were analyzed by STATA and analyses included descriptive as well as analytic methods. Results Of the total 1792 admissions in 5 DTCs, 729 (41%) were from FDMN settlements; children Conclusion No diarrhea outbreak was detected, but preparedness for surges and response readiness are warranted in this emergency and crisis setting.

Information on the association between stunting and child development is limited from low‐income settings including Bangladesh where 36% of children under‐ 5 are stunted. This study aimed to explore differences in early childhood development (ECD) between stunted (length‐for‐age z‐score [LAZ]

This study aimed to evaluate the impact of peer counselling on early initiation of breastfeeding (EIBF) and exclusive breastfeeding (EBF) rates for mother–infant pairs living in urban slums, Dhaka, Bangladesh. This randomized controlled trial enrolled 350 mother–infant pairs from selected slums between September 2014 and July 2016. The women assigned to intervention group received peer counselling from locally recruited, trained community female volunteers starting in third trimester of pregnancy until 6 months after delivery; control group received no intervention. EIBF, any liquids given after birth, and EBF were compared between groups. Follow‐up was scheduled at enrolment, following childbirth, and every 2 months up to 6 months after delivery. Multiple logistic regressions were used to assess the effect peer counselling and other associated factors on EIBF and EBF practices. EIBF rate was higher in the intervention group than in the control group (89.1% vs. 77.4%, p = .005). More mothers in intervention group were exclusively breastfeeding at 5 months than mothers in the control group (73% vs. 27%, p

OBJECTIVES Typhoid fever is one of the major causes of morbidity and mortality in typhoid endemic countries like Bangladesh. However, data on the clinical and microbiological profile as well as factors associated with complications of typhoid in Bangladesh are scarce. We intended to characterise the clinical and microbiological profile of culture-proven typhoid fever and to identify factors associated with complications. METHODOLOGY Retrospective analysis of clinical data from 431 patients with culture-confirmed typhoid fever admitted to Dhaka hospital of International Centre for Diarrhoeal Disease Research, Bangladesh, between January 2010 and December 2014. Clinical and microbiological profiles of the patients including age, sex, and duration of illness prior to hospital admission, haematological parameters and the antimicrobial resistance profile of the infecting isolate, duration of hospital stay and defervescence time were examined by logistic regression to identify the factors associated with complications. RESULT About one of three patients were children under 5 years, and 21.5% of them were severely malnourished. During hospitalisation, 17.4% patients developed complications; mainly encephalopathy (6.7%), ileus (6.5%) and pneumonia (3.5%). Among culture-positive cases, 28.3% isolates showed multidrug resistant (MDR) and more than 90% of isolates were resistant to nalidixic acid and had intermediate sensitivity to ciprofloxacin. Five isolates were resistant to azithromycin; all isolates were sensitive to cefixime and ceftriaxone. Complication was independently associated with duration of fever before admission (adjusted odds ratio: 0.85; 95% CI: 0.074-0.97; P < 0.05), thrombocytopenia on admission (AOR: 2.84; 95% CI: 01.06-7.57; P < 0.05), duration of hospital stay (AOR: 1.34; 95% CI: 1.15-1.57; P < 0.01) and defervescence time (AOR: 0.83; 95% CI: 0.70-0.99; P < 0.05). CONCLUSION The high prevalence of typhoid fever among under-five children and complications among hospitalised patients are matters of concern. Sensitivity of Salmonella Typhi to ceftriaxone and cefixime was better than to other conventional antibiotics. Shorter duration of fever and thrombocytopenia on admission can be considered as early signs of complications.

Globally more than 150 million children under age 5 years were stunted in 2018, primarily in low- and middle-income countries (LMICs), and the impact of early-onset, persistent stunting has not been well explored. To explore the association between early-onset persistent stunting in children and cognitive development at 5 years of age, and to identify the factors associated with early-onset stunting.Children from the MAL-ED cohort study were followed from birth to 5 years of age in six LMICs. The Wechsler Preschool Primary Scales of Intelligence (WPPSI) was used to assess cognitive abilities (fluid reasoning) at 5 years and was adapted for each culture. Stunting was categorized as early-onset persistent (first stunted at 1-6 months and persisting at 60 months), early-onset recovered (first stunted at 1-6 months and not stunted at 60 months), late-onset persistent (first stunted at 7-24 months and persisting at 60 months), late-onset recovered (first stunted at 7-24 months and not stunted at 60 months), and never (never stunted). Mixed effects linear models were used to estimate the relationship between stunting status and cognitive development. Children with early-onset persistent stunting had significantly lower cognitive scores (-2.10 (95% CI: -3.85, -0.35)) compared with those who were never stunted. Transferrin receptor (TfR) was also negatively associated with cognitive development (-0.31 (95% CI: -0.49, -0.13)), while the HOME inventory, an index of quality of the home environment (0.46 (95% CI: 0.21, 0.72)) and socio-economic status (1.50 (95% CI: 1.03, 1.98)) were positively associated with cognitive development.Early-onset persistent stunting was associated with lower cognitive development in children at 5 years of age in this cohort of children.

Background Globally more than 150 million children under age 5 years were stunted in 2018, primarily in low- and middle-income countries (LMICs), and the impact of early-onset, persistent stunting has not been well explored. To explore the association between early-onset persistent stunting in children and cognitive development at 5 years of age, and to identify the factors associated with early-onset stunting. Methods and findings Children from the MAL-ED cohort study were followed from birth to 5 years of age in six LMICs. The Wechsler Preschool Primary Scales of Intelligence (WPPSI) was used to assess cognitive abilities (fluid reasoning) at 5 years and was adapted for each culture. Stunting was categorized as early-onset persistent (first stunted at 1–6 months and persisting at 60 months), early-onset recovered (first stunted at 1–6 months and not stunted at 60 months), late-onset persistent (first stunted at 7–24 months and persisting at 60 months), late-onset recovered (first stunted at 7–24 months and not stunted at 60 months), and never (never stunted). Mixed effects linear models were used to estimate the relationship between stunting status and cognitive development. Children with early-onset persistent stunting had significantly lower cognitive scores (-2.10 (95% CI: -3.85, -0.35)) compared with those who were never stunted. Transferrin receptor (TfR) was also negatively associated with cognitive development (-0.31 (95% CI: -0.49, -0.13)), while the HOME inventory, an index of quality of the home environment (0.46 (95% CI: 0.21, 0.72)) and socio-economic status (1.50 (95% CI: 1.03, 1.98)) were positively associated with cognitive development. Conclusions Early-onset persistent stunting was associated with lower cognitive development in children at 5 years of age in this cohort of children.

Background Maternal depression is associated with poor child development and growth in low-income countries. This paper evaluates the effect of a community-based trial providing psychosocial stimulation and food supplements to severely malnourished children on maternal depressive symptoms in Bangladesh. Methods Severely underweight (weight-for-age Z-score

Bangladesh is one of the poorest countries of the world with the highest population density. The Bangladesh government recognizes the educational and financial benefits of early childhood development (ECD) and has incorporated ECD into the national plan of action. However, ECD activities are not fully established in the country and there have been few evaluations. In this paper, we present ECD programs that are integrated into health and nutrition services in Bangladesh. We present four evaluation reports of such programs and we also include seven published research projects showing evidence that such integrations are feasible. We provide short reviews on coverage, methodology, and effects of the published reports and share our experience of challenges faced and steps taken to solve them. Overall, very few programs are based on scientific evidence and fewer are even evaluated. The research projects so far conducted are promising and there is sufficient evidence on feasibility of integrating ECD activities into nutrition and health programs. Suggestions are made on measures to overcome the implementation problems and on suitable methods to establish high-quality ECD programs in Bangladesh and in other low- and middle-income countries.

OBJECTIVE:: The aim of the present study was to assess the effects of community-based follow-up care food supplementation and/or psychosocial stimulation on the recovery of severely underweight children. PATIENTS AND METHODS:: A total of 507 severely underweight children (weight-for-age z score

Young children with severe malnutrition usually have poor mental development. Psychosocial stimulation may reduce their cognitive deficit, but it is not usually provided. The aim of the study was to incorporate stimulation into the routine treatment of severely malnourished children in a nutrition unit and evaluate the impact on their growth and development.Time-lagged controlled study.Nutritional Rehabilitation Unit (NRU) in ICDDR,B Dhaka Hospital.Severely malnourished children, aged 6-24 months, admitted to the NRU were enrolled. All received standard nutritional care. A control group of 43 children was studied initially, followed by an intervention group of 54 children. The intervened mothers and children participated in daily group meetings and individual play sessions for 2 weeks in hospital and were visited at home for 6 months. Children's growth was measured and development assessed using the Bayley Scales of Infant Development.Twenty-seven children were lost to the study. In the remaining children, both groups had similar developmental scores and anthropometry initially. After 6 months, the intervention group had improved more than the controls did by a mean of 6.9 (P0.001; 95% CI: 3.9, 10.0) mental and 3.1 (P=0.024; 95% CI: 0.4, 5.7) motor raw scores and a mean of 0.4 (P=0.029; 95% CI: 0.1, 0.8) weight-for-age z scores, controlling for background variables.Psychosocial stimulation integrated into treatment of severely malnourished children in hospital, followed by home visits for 6 months, was effective in improving children's growth and development and should be an integral part of their treatment.

Purpose: There is paucity of research investigating oropharyngeal dysphagia (OPD) in young children with cerebral palsy (CP), and most studies explore OPD in high-resource countries. This study aimed at determining the proportion and severity of OPD in preschool children with CP in Bangladesh, compared to Australia. Method: Cross-sectional, comparison of two cohorts. Two hundred and eleven children with CP aged 18–36 months, 81 in Bangladesh (mean = 27.6 months, 61.7% males), and 130 in Australia (mean = 27.4 months, 62.3% males). The Dysphagia Disorders Survey (DDS) – Part 2 was the primary OPD outcome for proportion and severity of OPD. Gross motor skills were classified using the Gross Motor Function Classification System (GMFCS), motor type/distribution. Results: (i) Bangladesh sample: proportion OPD = 68.1%; severity = 10.4 SD = 7.9. Australia sample: proportion OPD = 55.7%; severity = 7.0 SD = 7.5. (ii) There were no differences in the proportion or severity of OPD between samples when stratified for GMFCS (OR = 2.4, p = 0.051 and β = 1.2, p = 0.08, respectively). Conclusions: Despite overall differences in patterns of OPD between Bangladesh and Australia, proportion and severity of OPD (when adjusted for the functional gross motor severity of the samples) were equivalent. This provides support for the robust association between functional motor severity and OPD proportion/severity in children with CP, regardless of the resource context.Implications for RehabilitationThe proportion and severity of OPD according to gross motor function level were equivalent between high- and low-resource countries (LCs).Literature from high-resource countries may be usefully interpreted by rehabilitation professionals for low-resource contexts using the GMFCS as a framework.The GMFCS is a useful classification in LCs to improve earlier detection of children at risk of OPD and streamline management pathways for optimal nutritional outcomes.Rehabilitation professionals working in LCs are likely to have a caseload weighted towards GMFCS III–V, with less compensatory OPD management options available (such as non-oral nutrition through tubes). The proportion and severity of OPD according to gross motor function level were equivalent between high- and low-resource countries (LCs). Literature from high-resource countries may be usefully interpreted by rehabilitation professionals for low-resource contexts using the GMFCS as a framework. The GMFCS is a useful classification in LCs to improve earlier detection of children at risk of OPD and streamline management pathways for optimal nutritional outcomes. Rehabilitation professionals working in LCs are likely to have a caseload weighted towards GMFCS III–V, with less compensatory OPD management options available (such as non-oral nutrition through tubes).

Appetite in children is an important determinant of nutritional intake and growth. The information used by caregivers to understand children's appetite can help inform infant and young child feeding promotion and appetite assessment. We conducted a qualitative study to (a) explore maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by type of caregiver, level of maternal experience, and urban versus rural context. We used purposive sampling to recruit mothers and alternate caregivers into 14 total focus group discussions (six to eight participants in each group; N = 95) in both urban and rural settings in Bangladesh. To understand children's appetite, caregivers monitor children's dietary patterns, emotional signs, and physical and verbal cues. Healthy appetite was observed by willingness to eat diverse foods, finish offered portions, and by acceptance of foods without excessive prompting. Child illness was cited for a cause of low appetite, which was manifested through fussiness, and avoiding commonly consumed foods. Mothers described a limited set of feeding practices (offering diverse foods, playing, and cheering children with videos) to encourage consumption when children lacked appetite. Mothers' stress related to work was noted as a barrier to identifying appetite cues. Urban mothers described a lower access to instrumental social support for child feeding but informational support than mothers in the rural setting. Understanding caregivers' perceptions of children's appetite may inform strategies to improve responsive feeding and tool development to assess changes in appetite as early indicators of change in health or nutrition status among high‐risk children.

Background 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. Method 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. Results 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 Conclusions 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.

Psychosocial stimulation (PS) and food supplementation (FS) improve development of malnourished children. This study evaluates the effects of a community-based approach of PS and FS on growth and development of severely malnourished children.Severely underweight hospitalised children aged 6-24 months (n = 507) were randomly allocated on discharge to five groups: (i) PS, (ii) FS, (iii) PS+FS, (iv) clinic-control and (v) hospital-control. PS included play sessions and parental counselling on child development. This was done at each fortnightly follow-up visit, that is, every second week, for 6 months at community clinics. FS included distribution of cereal-based food packets (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplementation, health-education and growth monitoring. Children's development was assessed using revised version of Bayley Scales of Infant Development at baseline and after 3 and 6 months of intervention. Anthropometry was measured using standard procedure.Comparing groups with any stimulation with those with no stimulation there was a significant effect of stimulation on children's mental development index (group*session interaction P = 0.037, effect size = 0.37 s.d.) and weight-for-age Z-score (group*session interaction P = 0.02, effect size=0.26 s.d.). Poor levels of development and nutritional status were sustained, however, due to their initial very severe malnutrition. There was no effect on motor development and linear growth.Children receiving any stimulation showed a significant benefit to mental development and growth in weight. More intensive intervention with longer duration is needed to correct their poor developmental levels and nutritional status.

Lactulose/mannitol (L/M) intestinal permeability tests were completed to compare the intestinal function of severely underweight children recovering from diarrhea and other illnesses and of nonmalnourished children from the same communities, and to evaluate the effects of food supplementation, with or without psychosocial stimulation, on the changes in intestinal function among the underweight children.Seventy-seven malnourished children completed intestinal permeability studies at baseline and 3 months after receiving 1 of the following randomly assigned treatment regimens: group-C--fortnightly follow-up at community-based follow-up units, including growth monitoring and promotion, health education, and micronutrient supplementation, n = 17; group-SF--same as group-C plus supplementary food (SF) to provide 150 to 300 kcal/day, n = 23; group-PS--same as group-C plus psychosocial stimulation (PS), n = 17; or group-SF + PS--same as group-C plus SF and PS, n = 20. Seventeen nonmalnourished children were included as comparison subjects.The malnourished children's mean ± SD initial age was 13.1 ± 4.0 months, their mean weight-for-age z score was -3.82 ± 0.61, and their median (interquartile range) urinary L/M recovery ratio was 0.16 (0.10-0.28). Eighty-four percent of the children had L/M ≥ 0.07, suggestive of impaired intestinal function. The median L/M of the malnourished children was significantly greater than that of 17 relatively well-nourished children (median 0.09; interquartile range 0.05-0.12; P = 0.001). There were no significant differences in baseline characteristics of the severely malnourished children by treatment group. Following treatment, the L/M ratio improved in all of the groups (P0.001), but there were no significant differences in these changes by treatment group. There was a significant positive association between weight gain and the magnitude of improvement in L/M ratio (r = 0.30, P = 0.012).Intestinal mucosal function, as measured by sugar permeability, is impaired among severely underweight children. Intestinal permeability improves in relation to weight gain, but intestinal mucosal recovery is not specifically related to the types or amount of food supplementation or PS provided in this trial.

Protein-energy malnutrition (PEM) is a serious health problem among young children in Bangladesh. PEM increases childhood morbidity and mortality. Information is needed on the major risk factors for PEM to assist with the design and targeting of appropriate prevention programmes. To compare the underlying characteristics of children, aged 6-24 months, with or without severe underweight, reporting to the Dhaka Hospital of ICDDR,B in Bangladesh, a case-control study was conducted among 507 children with weight-for-age z-score (WAZ)-3 and 500 comparison children from the same communities with WAZ-2.5. There were no significant differences between the groups in age [overall mean+standard deviation (SD) 12.6 +/- 4.1 months] or sex ratio (44% girls), area of residence, or year of enrollment. Results of logistic regression analysis revealed that severely-underweight children were more likely to have: undernourished mothers [body mass index (BMI)18.5, adjusted odds ratio (AOR) = 3.8, 95% confidence interval (CI) 2.6-5.4] who were aged19 years (AOR = 3.0, 95% CI 1.9-4.8) and completed5 years of education (AOR = 2.7, 95% CI 1.9-3.8), had a history of shorter duration of predominant breastfeeding (4 months, AOR = 2.3, 95% CI 1.6-3.3), discontinued breastfeeding (AOR = 2.0, 95% CI 1.1-3.5), and had higher birth-order (3 AOR = 1.8, 95% CI 1.2-2.7); and fathers who were rickshaw-pullers or unskilled day-labourers (AOR = 4.4; 95% CI 3.1-6.1) and completed5 years of education (AOR = 1.5; 95% CI 1.1-2.2), came from poorer families (monthly income of Tk5,000, AOR = 2.7, 95% CI 1.9-3.8). Parental education, economic and nutritional characteristics, child-feeding practices, and birth-order were important risk factors for severe underweight in this population, and these characteristics can be used for designing and targeting preventive intervention programmes.

Children with severe acute malnutrition, defined as weight-for-height70% of the reference median or bilateral pedal oedema or mid-arm circumference110 mm having complications, were managed in the Nutrition Unit of the Chittagong Medical College Hospital (CMCH) following the guidelines of the World Health Organization, with support from Concern Worldwide Bangladesh and ICDDR,B. In total, 171 children aged less than five years (mean +/- SD age 23.5 +/- 15.3 months) were admitted during June 2005-May 2006. Of them, 66% were aged less than two years, and 84.2% belonged to households with a monthly income of less than US$ 40. The main reason for bringing children by their families to the hospital was associated major illnesses: bronchopneumonia (33%), oedema (24%), diarrhoea (11%), pulmonary tuberculosis (9%), or other conditions, such as meningitis, septicaemia, and infections of the skin, eye, or ear. The exit criteria from the Nutrition Unit were: (a) for children admitted without oedema, an absolute weight gain ofor = 500 andor = 700 g for children aged less than two years and 2-5 years respectively; and for children admitted with oedema, complete loss of oedema and weight-for-height70% of the reference median, and (b) the mother or caretaker has received specific training on appropriate feeding and was motivated to follow the advice given. Of all the admitted children, 7.6% of parents insisted for discharging their children early due to other urgent commitments while 11.7% simply left with their children against medical advice. Of the 138 remaining children, 88% successfully graduated from the Nutrition Unit with a mean weight gain of 10.6 g/kg per day (non-oedematous children) and loss of -1.9 g/kg per day (oedematous children), 86% graduated in less than three weeks, and the case-fatality rate was 10.8%. The Nutrition Unit of CMCH also functions as a training centre, and 197 health functionaries (82 medical students, 103 medical interns, and 12 nurses) received hands-on training on management of severe malnutrition. The average cost of overall treatment was US$ 14.6 per child or approximately US$ 1 per child-day (excluding staff-cost). Food and medicines accounted for 42% and 58% of the total cost respectively. This study demonstrated the potential of addressing severe acute malnutrition (with complications) effectively with minimum incremental expenditure in Bangladesh. This public-private approach should be used for treating severe acute malnutrition in all healthcare facilities and the treatment protocol included in the medical and nursing curricula.