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Background: Early childhood development provides an important foundation for the development of human capital. Although there is a clear relation between stunting and child development outcomes, less information is available about the developmental and behavioural outcomes of children with severe acute malnutrition (SAM). Particularly an important research gap exists in Sub-Saharan Africa where there is a high prevalence of SAM and a high rate of co-occurring HIV (human immune deficiency virus) infection. Our first objective was to assess the prevalence and severity of developmental and behavioural disorders on a cohort of children admitted to an inpatient nutritional rehabilitation centre in Malawi. Our second objective was to compare the developmental and behavioural profiles of children with the two main phenotypes of SAM: kwashiorkor and marasmus. Methods: This was a cross-sectional observational study including all children hospitalized with complicated SAM in Blantyre, Malawi over an 8-month period from February to October 2015. At discharge, children were assessed with the well-validated Malawi Developmental Assessment Tool (MDAT) for gross motor, fine motor, language and social development. In children ≥24 months, emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ). Results: 150 children (55% boys) with SAM were recruited; mean age of 27.2 months (standard deviation 17.9), 27 children (18%) had pre-existing neurodisabilities (ND) and 34 (23%) had a co-occurring human immune deficiency virus (HIV) infection. All children with SAM experienced profound delays in the gross and fine motor, language and social domains. Linear regression analysis demonstrated that children with kwashiorkor scored 0.75 standard deviations lower (95% confidence interval -1.43 to -0.07) on language MDAT domain than children with marasmus when adjusted for covariates. The prosocial behaviour score of the SDQ was low in children with SAM, indicating a lack of sensitive behaviour in social interactions. Conclusions: Children with SAM have severe developmental delays after a hospital admission. Our results indicate that there might be a significant difference in developmental attainment between children with kwashiorkor and with marasmus. Future studies exploring longer-term outcomes and testing possible intervention strategies are urgently needed.

BACKGROUND: Early childhood development provides an important foundation for the development of human capital. Although there is a clear relation between stunting and child development outcomes, less information is available about the developmental and behavioural outcomes of children with severe acute malnutrition (SAM). Particularly an important research gap exists in Sub-Saharan Africa where there is a high prevalence of SAM and a high rate of co-occurring HIV (human immune deficiency virus) infection. Our first objective was to assess the prevalence and severity of developmental and behavioural disorders on a cohort of children admitted to an inpatient nutritional rehabilitation centre in Malawi. Our second objective was to compare the developmental and behavioural profiles of children with the two main phenotypes of SAM: kwashiorkor and marasmus. METHODS: This was a cross-sectional observational study including all children hospitalized with complicated SAM in Blantyre, Malawi over an 8-month period from February to October 2015. At discharge, children were assessed with the well-validated Malawi Developmental Assessment Tool (MDAT) for gross motor, fine motor, language and social development. In children ≥24 months, emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ). RESULTS: 150 children (55% boys) with SAM were recruited; mean age of 27.2 months (standard deviation 17.9), 27 children (18%) had pre-existing neurodisabilities (ND) and 34 (23%) had a co-occurring human immune deficiency virus (HIV) infection. All children with SAM experienced profound delays in the gross and fine motor, language and social domains. Linear regression analysis demonstrated that children with kwashiorkor scored 0.75 standard deviations lower (95% confidence interval -1.43 to -0.07) on language MDAT domain than children with marasmus when adjusted for covariates. The prosocial behaviour score of the SDQ was low in children with SAM, indicating a lack of sensitive behaviour in social interactions. CONCLUSIONS: Children with SAM have severe developmental delays after a hospital admission. Our results indicate that there might be a significant difference in developmental attainment between children with kwashiorkor and with marasmus. Future studies exploring longer-term outcomes and testing possible intervention strategies are urgently needed.

The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75). In this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6–60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ≤ 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates. The proportion of children with acidic stool (pH ≤5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p

Background With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (, A retrospective examination of major risk factors associated with in-hospital deaths in children with severe malnutrition has identified admission features that could help distinguish those at highest risk., Editors' Summary Background. Severe malnutrition is thought to be responsible, at least in part, for a large proportion of the many millions of deaths every year among children below the age of five years. The World Health Organization (WHO) has developed guidelines for management of the severely malnourished child in the hospital. These guidelines outline ten initial steps for routine care, followed by treatment of associated conditions and rehabilitation. However, death rates among children admitted to hospital with severe malnutrition are worryingly high, commonly 20% or sometimes even higher. Many hospitals have reported that following introduction of the WHO guidelines, the death rates have been cut, but not to a level that the WHO defines as acceptable (5% or lower). Why Was This Study Done? In the region where this study was done, an area on the coast of Kenya, East Africa, malnutrition is very common. The local hospital, Kilifi District Hospital, currently reports a death rate of approximately 19% among children admitted with severe malnutrition, even with implementation of the WHO guidelines. A group of researchers based at the hospital wanted to see if they could identify those children who were most likely to die. Their aim was to see which aspects of the children's medical condition put them at highest risk. This information would be useful in ensuring that high-risk children received the most appropriate care. What Did the Researchers Do and Find? The researchers studied all severely malnourished children over three months of age who were admitted to the Kilifi District Hospital between September 2000 and June 2002. The children were treated according to the WHO guidelines, and the research group collected data on the condition of the children after treatment (their “outcomes”), as well as for relevant clinical signs and symptoms. The study involved 920 children, of whom 176 died in hospital (a death rate of 19%). They then examined the data to see which characteristics on admission were associated with early death (less than 48 h) and later deaths. They found that four clinical features, which could be easily ascertained at the bedside on admission, were associated with a large proportion of the early deaths. These four signs were slow heart rate, weak pulse volume, depressed consciousness level, and a delayed capillary refilling time (as tested by pressing a fingernail bed to blanche the finger, releasing it, and observing the time taken to reperfuse the capillaries—or recolor the nailbed). The researchers proposed that these findings, together with a number of other features that were associated with the later deaths could be used to identify three groups of patients differing in their need for emergency care: a high-risk group (with any of the four signs listed above, or hypoglycemia, and among whom mortality was 34%); a moderate-risk group (among whom mortality was 23%); and a low-risk group (mortality 7%). What Do These Findings Mean? First, the death rate amongst these children was very high even though WHO guidelines were used to guide management. The signs reported here as indicators of poor outcome may prove useful in future in identifying high-risk individuals to ensure they receive the right treatment. However, the indicators proposed here would need further evaluation before current guidelines for treatment of the severely malnourished child could be changed. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030500. • Information on severe malnutrition is available from the World Health Organization • Management guidelines from the WHO can also be downloaded in many languages • UNICEF, the United Nations Children's Fund, provides relevant resources and statistics as well as information about its programs addressing malnutrition worldwide • Information from Médecins Sans Frontières (MSF) on acute malnutrition worldwide and MSF's response to current emergencies

Background Children with moderate acute malnutrition (MAM) have an increased risk of mortality, infections and impaired physical and cognitive development compared to well-nourished children. In parts of Ethiopia not considered chronically food insecure there are no supplementary feeding programmes (SFPs) for treating MAM. The short-term outcomes of children who have MAM in such areas are not currently described, and there remains an urgent need for evidence-based policy recommendations. Methods We defined MAM as mid-upper arm circumference (MUAC) of ≥11.0cm and, SCOPUS: ar.j, info:eu-repo/semantics/published

ObjectiveSevere acute malnutrition (SAM) is a major cause of mortality in children under 5 years and is associated with hepatic steatosis. Bile acids are synthesized in the liver and participate in dietary fat digestion, regulation of energy expenditure, and immune responses. The aim of this work was to investigate whether SAM is associated with clinically relevant changes in bile acid homeostasis.DesignAn initial discovery cohort with 5 healthy controls and 22 SAM-patients was used to identify altered bile acid homeostasis. A follow up cohort of 40 SAM-patients were then studied on admission and 3 days after clinical stabilization to assess recovery in bile acid metabolism. Recruited children were 6-60 months old and admitted for SAM in Malawi. Clinical characteristics, feces and blood were collected on admission and prior to discharge. Bile acids, 7ahydroxy-4-cholesten-3-one (C4) and FGF-19 were quantified.ResultsOn admission, total serum bile acids were higher in children with SAM than in healthy controls and glycine-conjugates accounted for most of this accumulation with median and interquartile range (IQR) of 24.6 mu mol/L [8.6-47.7] compared to 1.9 mu mol/L [1.7-3.3] (p = 0.01) in controls. Total serum bile acid concentrations did not decrease prior to discharge. On admission, fecal conjugated bile acids were lower and secondary bile acids higher at admission compared to pre-discharge, suggesting increased bacterial conversion. FGF19 (Fibroblast growth factor 19), a marker of intestinal bile acid signaling, was higher on admission and was associated with decreased C4 concentrations as a marker of bile acid synthesis. Upon recovery, fecal calprotectin, a marker of intestinal inflammation, was lower.ConclusionSAM is associated with increased serum bile acid levels despite reduced synthesis rates. In SAM, there tends to be increased deconjugation of bile acids and conversion from primary to secondary bile acids, which may contribute to the development of liver disease.

This paper identifies the low-elevation coastal zone populations and developing regions most vulnerable to sea-level rise and other coastal hazards, such as storm surges, coastal erosion, and salt-water intrusion. The focus is on the rural poor in the low-elevation coastal zone, as their economic livelihoods are especially endangered directly by coastal hazards and indirectly through the impacts of climate change on key coastal and near-shore ecosystems. Using geo-spatially referenced malnutrition and infant mortality data for 2000 as a proxy for poverty, this study finds that just 15 developing countries contain over 90 percent of the world’s low-elevation coastal zone rural poor. Low-income countries as a group have the highest incidence of poverty, which declines somewhat for lower-middle-income countries, and then is much lower for upper-middle-income economies. South Asia, East Asia and the Pacific, and Sub-Saharan Africa account for most of the world’s low-elevation coastal zone rural poor, and have a high incidence of poverty among their rural low-elevation coastal zone populations. Although fostering growth, especially in coastal areas, may reduce rural poverty in the low-elevation coastal zone, additional policy actions will be required to protect vulnerable communities from disasters, to conserve and restore key coastal and near-shore ecosystems, and to promote key infrastructure investments and coastal community response capability.

BACKGROUND: Children with severe malnutrition (SAM) present to hospital with an array of complications, resulting in high mortality despite adherence to WHO guidelines. Diagnostic resources in developing countries are limited and bedside tests could help identify high-risk children. Dipstick urinalysis is a bedside screening test for urinary tract infections (UTIs). UTIs are common in SAM and can lead to secondary invasive bacterial sepsis. Very few studies have examined the usefulness of dipstick screening of urine specimens in SAM and none has explored its prognostic value. PATIENTS AND METHODS: A 2-year prospective study on children admitted in Kilifi District Hospital, Kenya, with SAM. Freshly voided, clean catch urine samples were tested using Multistix reagent test strips. Positive samples were sent for culture. RESULTS: Of the 667 children admitted, 498 children (75%) provided urine samples; of these, 119 (24%) were positive for either leucocyte esterase (LE) or nitrites. Culture-proven UTI was detected in 28 children (6% overall). All isolates were coliforms and were >50% were resistant to cotrimoxazole and gentamicin. There was no difference in severity signs between those with positive dipstick and those without. Case fatality was higher among children with a positive dipstick (29% vs 12%). Presence of a positive dipstick was a strong predictor of mortality (adjusted HR 2.5). CONCLUSIONS: A urine dipstick positive for either LE or nitrites is a useful predictor of death in children admitted with SAM. Prospective studies to determine the role of untreated UTI in these deaths are needed before any treatment recommendations can be made.

This paper builds on the global experience and Mali s context to identify an effective nutrition approach as well as costs and benefits of key nutrition programs, as part of a resilience agenda after the crisis. It is intended to help guide the selection of the most cost-effective interventions as well as strategies for scaling these up. The paper looks at both relevant nutrition-specific interventions, largely delivered through the health sector, and at multisectoral nutrition-sensitive interventions delivered through other sectors such as agriculture, social protection, and water and sanitation that have the potential to strengthen nutritional outcomes in Mali. We first estimate that the costs and benefits of implementing 10 nutrition-specific interventions in all regions of Mali would require a yearly public investment of $64 million. The expected benefits are large: annually about 480,000 Disability-adjusted Life Years (DALYs) and more than 14,000 lives would be saved and over 260,000 cases of stunting among children under five would be averted. However, because it is unlikely that the Government of Mali or its partners will find the $64 million necessary to reach full national coverage, we also consider three potential scale-up scenarios based on considerations of their potential for impact, the burden of stunting, resource requirements, and implementation capacity. Using cost-benefit analyses, we propose scale-up scenarios that represent a compromise between the need to move to full coverage and the constraints imposed by limited resources. We identify and cost six nutrition-sensitive interventions that are relevant to Mali s context and for which there are both evidence of positive impact on nutrition outcomes and some cost information. These findings point to a powerful set of nutrition-specific interventions and a candidate list of nutrition-sensitive approaches that represent a highly cost-effective approach to reducing child malnutrition in Mali.

Several developing economies have recently introduced conditional cash transfer programs, which provide money to poor families contingent on certain behavior, usually investments in human capital, such as sending children to school or bringing them to health centers. The approach is both an alternative to more traditional social assistance programs and a demand-side complement to the supply of health and education services. Unlike most development initiatives, conditional cash transfer programs have been subject to rigorous evaluations of their effectiveness using experimental or quasi-experimental methods. Evaluation results for programs launched in Colombia, Honduras, Jamaica, Mexico, Nicaragua, and Turkey reveal successes in addressing many of the failures in delivering social assistance, such as weak poverty targeting, disincentive effects, and limited welfare impacts. There is clear evidence of success from the first generation of programs in Colombia, Mexico, and Nicaragua in increasing enrollment rates, improving preventive health care, and raising household consumption. Many questions remain unanswered, however, including the potential of conditional cash transfer programs to function well under different conditions, to address a broader range of challenges among poor and vulnerable populations, and to prevent the intergenerational transmission of poverty.

Background Protein energy malnutrition is commonly associated with immune dysfunctions and is a major factor in susceptibility to infectious diseases. Methods In this study, we evaluated the impact of protein energy malnutrition on the capacity of monocytes and macrophages to upregulate arginase, an enzyme associated with immunosuppression and increased pathogen replication. Results Our results show that monocytes and macrophages are significantly increased in the bone marrow and blood of mice fed on a protein low diet. No alteration in the capacity of bone marrow derived macrophages isolated from malnourished mice to phagocytose particles, to produce the microbicidal molecule nitric oxide and to kill intracellular Leishmania parasites was detected. However, macrophages and monocytes from malnourished mice express significantly more arginase both in vitro and in vivo. Using an experimental model of visceral leishmaniasis, we show that following protein energy malnutrition, the increased parasite burden measured in the spleen of these mice coincided with increased arginase activity and that macrophages provide a more permissive environment for parasite growth. Conclusions Taken together, these results identify a novel mechanism in protein energy malnutrition that might contributes to increased susceptibility to infectious diseases by upregulating arginase activity in myeloid cells. Electronic supplementary material The online version of this article (doi:10.1186/1743-7075-11-51) contains supplementary material, which is available to authorized users.

This paper estimates country-specific costs and benefits of scaling up key nutrition investments in Nigeria. Building on the methodology established in the global report scaling up nutrition: what will it cost? Authors first estimate the costs and benefits of a nationwide scale up of ten effective nutrition-specific interventions. This will require an annual public investment of $837 million and would yield enormous benefits: over 8.7 million DALYs and 183,000 lives would be saved annually, while more than 3 million cases of stunting among children under five will be averted. As it is unlikely that the Government of Nigeria or its partners will find the $837 million necessary to reach full national coverage, authors also consider five potential scale-up scenarios based on considerations of burden of stunting, potential for impact, resource requirements and capacity for implementation in Nigeria. Using cost-benefit analyses authors propose scale-up scenarios that represent a compromise between the need to move to full coverage and the constraints imposed by limited resources and capacities. This analysis takes an innovative approach to nutrition costing by not only estimating the costs and benefits of nutrition-specific interventions, but also exploring costs for a selected number of nutrition-sensitive interventions implemented outside of the health sector. We identify and cost four candidate nutrition-sensitive interventions with impact potential in Nigeria, including bio-fortification of cassava, aflatoxin control, school-based deworming, and school-based promotion of good hygiene. Overall, these findings point to a candidate list of nutrition-sensitive approaches that represent a cost-effective approach to reducing child malnutrition in Nigeria. Moving forward, these results are intended to help guide decision makers as they plan future efforts to scale-up action against malnutrition in Nigeria and develop nutrition financing plans that bring to bear resources from the health, social protection, education, and agriculture sectors.

This section describes the priority nutrition interventions and cross-cutting approaches that are essential to promote and protect the nutritional status of mothers and children as well as a country's human capital in the short-, medium-, and long-terms. The main thrust of the guidance is that: (1) policies give special attention to the critical 'window of opportunity' represented by the first 1,000 days of life; (2) policies are aligned with the latest international recommendations in nutrition; (3) policies and interventions of key sectors are coordinated to provide synergy of action; and (4) resources allocated for disaster prevention and emergency management are invested in the most cost-effective way. Monitoring is a continuous process of collecting and analyzing information to better understand how well a program is operating against expected outputs and to allow remedial intervention to correct failures. Situation monitoring measures the change or lack of change, in a condition or a set of conditions and includes monitoring of the wider context. Performance monitoring, on the other hand, measures progress in achieving specific results in relation to an implementation plan. Evaluation is a systematic and objective assessment that attempts to determine the worth or significance of an intervention, strategy, or policy. It is used to appraise the effectiveness of an intervention to determine if it meets its goals, to estimate its results or impact, and to identify its costs vs. its benefits. Promote optimal breastfeeding practices. Provide all pregnant women with daily iron-folic acid supplements for at least six months. Provide deforming treatment to pregnant women, preschool-aged children, and school-aged children in areas where hookworms or soil-transmitted helminthes are prevalent. Establish strong links between agricultural, food security, social protection and nutrition policies that can be used to inform a robust communication program regarding maternal diet and critical infant and young child feeding practices. Support diversified agricultural production to increase availability of nutrient-dense foods, particularly those of animal sources.

This toolkit is the first of its kind to provide information on promoting and protecting the nutritional status of mothers and children in crises and emergencies. Latin America and the Caribbean is one of the most vulnerable regions in the world to major crises and emergencies. This toolkit aims to improve the resilience of the most vulnerable in times of intensified nutritional needs, most notably pregnant and lactating mothers as well as children less than two years of age. Its principal objective is to offer countries, when faced with the transition from stable times into and out of crisis, clear guidance on how to safeguard the nutritional status of mothers and children during times of stability, crisis, and emergency. The principal objective of this toolkit is to offer clear guidance, in a single-source compilation, that will assist countries in safeguarding the nutritional status of mothers and children during times of stability, crisis, and emergency. It aims to inform changes in countries' policies and practices and to guide their attempts to deal with persistently high prevalence rates of malnutrition among their poorest, least educated, and indigenous populations. This toolkit has been crafted so that it can be readily used by non-nutrition specialists.

The World Bank and The United Nations Children's Fund (UNICEF) jointly developed this report to calculate the potential human and economic benefits to be gained from increasing nutrition investments in the Kyrgyz Republic. This report provides compelling evidence of the potential to improve health and economic outcomes through scaling up effective nutrition interventions and introducing new proven interventions to reduce the direct causes of under nutrition in order to support the Kyrgyz government's commitment to the well-being and prosperous future of the Kyrgyz people. This situational analysis examines and quantifies the scope of under nutrition in the Kyrgyz Republic by presenting: (1) the epidemiology of under nutrition; (2) an estimate of the health consequences of under nutrition in terms of mortality and disability adjusted life years (DALYs), and the economic losses due to lost workforce and productivity; (3) the health, social protection, and agriculture and food intervention systems relevant to delivering interventions for improving nutrition; (4) the current coverage of nutrition interventions; and (5) the potential economic gains achievable by scaling up effective nutrition interventions. The current context is very favorable for scaling up nutrition interventions in the Kyrgyz Republic. Investing in nutrition has increasingly proven to have excellent development and health returns. The international development community has recognized (1) the need to scale up nutrition interventions; (2) the potential for public-private partnerships; and, (3) a growing consensus around a common framework for action. Reducing under nutrition worldwide is a priority for the World Bank and UNICEF, and also critical to achieving the Millennium Development Goals (MDGs).

Although Sub-Saharan Africa has some of the worst nutrition indicators in the world, nutrition remains a low priority on the policy agendas of many African governments. This despite the fact that proven interventions are known and available and that investment in them is considered a cost-effective strategy for poverty reduction. This case study is one in a series seeking to understand (1) what keeps African governments from committing fully to reducing malnutrition, and (2) what is required for full commitment. It documents how the Ghanaian government has addressed the issue of malnutrition since Independence, examines what political and institutional factors have prevented full commitment, and identifies what conditions have moved the nutrition agenda forward at different points in time. The primary objective of this study as well as the series as a whole is to help African governments, development partners, and nutrition and health practitioners identify, understand and address the political and institutional obstacles preventing sustainable progress in nutrition.

This review of public expenditures on Social Protection (SP) in Nicaragua is based on the analytical framework of Social Risk Management (SRM) developed by the World Bank. The concept of managing social risk comes from the notion that certain groups in society are vulnerable to unexpected shocks which threaten their livelihood and/or survival. Social protection focuses on the poor since they are more vulnerable to the risks and normally do not have the instruments to handle these risks. This prevents the poor from taking more risky activities that usually yield higher returns and that could help them overcome gradually their poverty situation. Social risk management involves policies and programs aimed at reducing key risks, breaking inter-generational cycle of poverty and vulnerability. Risk management consists in the choice of appropriate risk prevention, mitigation and coping strategies to minimize the adverse impact of social risks. Social protection under SRM is defined as public interventions to assist individuals, households and communities to better manage risk and provide support to the critically poor. Thus Social protection should provide: a safety net, particularly for the poor that are likely to fall in the cracks of established programs; and a springboard for the poor to bounce out of poverty.

The report seeks to analyze what has been learned about how agricultural interventions influence nutrition outcomes in low-and middle-income countries, focusing on the target populations of the millennium development goals-people living on less than a dollar a day. It also sets out to synthesize lessons from past efforts to improve the synergies between agriculture and nutrition outcomes. The report identifies a number of developments in agriculture and nutrition that have transformed the context in which nutrition is affected by agriculture. The relationship between agriculture and human nutrition is far more complex than the relationship between food production and food consumption or the economic relationship between food supply and food demand. Expanding agriculture's purview and capacity to embrace those contributing factors and determinants of nutrition that are traditionally the province of other disciplines or improving agriculture's interface with other, nonagricultural sectors, suggest themselves as possible ways forward. The limitations of production-focused agricultural programs and interventions in delivering improved nutrition impacts have been recognized by some in the agricultural community for decades. In the early 1980s a number of international development agencies undertook programs that sought to orient agricultural production to nutrition-related objectives, and over time a substantial body of literature developed around the analysis of the programs' results.