Lay-screeners and Use of WHO Growth Standards Increase Case Finding of Hospitalized Malawian Children with Severe Acute Malnutrition

Abstract Background Weight for length z-score (WLZ) <- 3 is currently used to define severe acute malnutrition (SAM) among infants. However, this approach has important limitations for infants younger than 6 months of age as WLZ cannot be calculated using WHO growth standards if infant length is <45 cm. Moreover, length for age z-score (LAZ) and weight for length z-score (WLZ) are least reliable measures, with high chances of variation, and less chances of detecting undernutrition in under 6 months infants. The objective of the current analysis was to compare WLZ with WAZ and LAZ in a cohort of Indian infants in predicting the deaths between 6 weeks and 6 months of age. Methods The data was from an individually randomized trial conducted in slums of Delhi, India in which infants’ weight and length were measured at 6 weeks of age (at the time of the first immunization visit). Vital status of the infants was documented from 6 weeks to 6 months of age. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, and area under curve (AUC) were calculated for WAZ<-3, WLZ<-3, and LAZ<-3 for deaths between 6 weeks and 6 months of age. Results For deaths occurring between 6 weeks to 6 months of age, the specificity ranged between 85.9-95.9% for all three anthropometric indicators. However, the sensitivity was considerably higher for WAZ; it was 64.6 % for WAZ<-3, 39.1% for LAZ<-3, and 25.0% for WLZ<-3. WAZ <-3 had higher AUC (0.75; 95% CI: 0.68, 0.82) and hence, better discriminated deaths between 6 weeks and 6 months of age than WLZ<-3. The adjusted relative risk (RR 10.6, 95% CI 5.9, 18.9) and the population attributable fraction (PAF 57.9%, 95% CI 38.8, 71.0%) of mortality was highest for WAZ<-3. Conclusions We found WAZ<-3 at 6 weeks of age to be a better predictor of death in the 6 weeks to 6 months of life in comparison to WLZ<-3 and LAZ<-3 and propose that it should be considered to diagnose SAM in this age group.

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Diagnostic Measures for Severe Acute Malnutrition in Indian Infants Under 6 Months of Age: a Secondary Data Analysis

10.21203/rs.3.rs-58666/v1 ◽

2020 ◽

Author(s):

Ranadip Chowdhury ◽

Nitika Nitika ◽

Tarun Shankar Choudhary ◽

Sunita Taneja ◽

Jose Carlos Martines ◽

...

Keyword(s):

Severe Acute Malnutrition ◽

Population Attributable Fraction ◽

Secondary Data ◽

Acute Malnutrition ◽

Adjusted Relative Risk ◽

Z Score ◽

Likelihood Ratios ◽

Predictive Values ◽

Growth Standards ◽

Diagnostic Measures

Abstract Background Weight for length z-score (WLZ) <- 3 is currently used to define severe acute malnutrition (SAM) among infants. However, this approach has important limitations for infants younger than 6 months of age as WLZ cannot be calculated using WHO growth standards if infant length is <45 cm. Moreover, length for age z-score (LAZ) and weight for length z-score (WLZ) are least reliable measures, with high chances of variation, and less chances of detecting undernutrition in under 6 months infants. The objective of the current analysis was to compare WLZ with WAZ and LAZ in a cohort of Indian infants in predicting the deaths between 6 weeks and 6 months of age. Methods The data was from an individually randomized trial conducted in slums of Delhi, India in which infants’ weight and length were measured at 6 weeks of age (at the time of the first immunization visit). Vital status of the infants was documented from 6 weeks to 6 months of age. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios, and area under curve (AUC) were calculated for WAZ<-3, WLZ<-3, and LAZ<-3 for deaths between 6 weeks and 6 months of age. Results For deaths occurring between 6 weeks to 6 months of age, the specificity ranged between 85.9-95.9% for all three anthropometric indicators. However, the sensitivity was considerably higher for WAZ; it was 64.6 % for WAZ<-3, 39.1% for LAZ<-3, and 25.0% for WLZ<-3. WAZ <-3 had higher AUC (0.75; 95% CI: 0.68, 0.82) and hence, better discriminated deaths between 6 weeks and 6 months of age than WLZ<-3. The adjusted relative risk (RR 10.6, 95% CI 5.9, 18.9) and the population attributable fraction (PAF 57.9%, 95% CI 38.8, 71.0%) of mortality was highest for WAZ<-3.Conclusions We found WAZ<-3 at 6 weeks of age to be a better predictor of death in the 6 weeks to 6 months of life in comparison to WLZ<-3 and LAZ<-3 and propose that it should be considered to diagnose SAM in this age group.

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Diagnostic measures for severe acute malnutrition in Indian infants under 6 months of age: a secondary data analysis

BMC Pediatrics ◽

10.1186/s12887-021-02629-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Ranadip Chowdhury ◽

Nitika ◽

Tarun Shankar Choudhary ◽

Sunita Taneja ◽

Jose Martines ◽

...

Keyword(s):

Severe Acute Malnutrition ◽

Population Attributable Fraction ◽

Acute Malnutrition ◽

Adjusted Relative Risk ◽

Z Score ◽

Operating Characteristics ◽

Likelihood Ratios ◽

Predictive Values ◽

Growth Standards ◽

Anthropometric Indicators

Abstract Background Weight for length z-score (WLZ) < − 3 is currently used to define severe acute malnutrition (SAM) among infants. However, this approach has important limitations for infants younger than 6 months of age as WLZ cannot be calculated using WHO growth standards if infant length is < 45 cm. Moreover, length for age z-score (LAZ) and weight for length z-score (WLZ) are least reliable measures, with high chances of variation, and less chances of detecting undernutrition in under 6 months infants. The objective of the current analysis was to compare WLZ with WAZ and LAZ in a cohort of Indian infants in predicting the deaths between 6 weeks and 6 months of age. Methods The data was from an individually randomized trial conducted in slums of Delhi, India in which infants’ weight and length were measured at 6 weeks of age (at the time of the first immunization visit). Vital status of the infants was documented from 6 weeks to 6 months of age. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for WAZ < -3, WLZ < -3, and LAZ < -3 for deaths between 6 weeks and 6 months of age. The receiver operating characteristics curve was calculated for each of the above anthropometric indicators. Results For deaths occurring between 6 weeks to 6 months of age, the specificity ranged between 85.9–95.9% for all three anthropometric indicators. However, the sensitivity was considerably higher for WAZ; it was 64.6% for WAZ < -3, 39.1% for LAZ < -3, and 25.0% for WLZ < -3. WAZ < -3 had higher area under curve (0.75; 95% CI: 0.68, 0.82) and hence, better discriminated deaths between 6 weeks and 6 months of age than WLZ < -3. The adjusted relative risk (RR 10.6, 95% CI 5.9, 18.9) and the population attributable fraction (PAF 57.9, 95% CI 38.8, 71.0%) of mortality was highest for WAZ < -3. Conclusions We found WAZ < -3 at 6 weeks of age to be a better predictor of death in the 6 weeks to 6 months of life in comparison to WLZ < -3 and LAZ < -3 and propose that it should be considered to diagnose SAM in this age group.

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Hypophosphataemia in severe acute malnutrition: a prospective observational study

British Journal Of Nutrition ◽

10.1017/s0007114518003197 ◽

2018 ◽

Vol 121 (3) ◽

pp. 306-311 ◽

Cited By ~ 1

Author(s):

Rana Chanchal ◽

Sarika Gupta ◽

Chandra Kanta ◽

Kalpana Singh ◽

Sciddhartha Koonwar

Keyword(s):

Observational Study ◽

Prospective Observational Study ◽

Severe Acute Malnutrition ◽

Tertiary Care ◽

Uttar Pradesh ◽

North India ◽

Acute Malnutrition ◽

Indian Children ◽

Mortality And Morbidity ◽

Growth Standards

AbstractSevere acute malnutrition (SAM) is a major cause of child mortality and morbidity. Children treated for SAM are at risk of refeeding hypophosphataemia (HP). The study was done to find out the incidence and various predictors of moderate/severe HP in SAM among North Indian children. This prospective observational study was conducted from August 2014 to July 2015 in the inpatients’ department of Department of Paediatrics at King George’s Medical University, Lucknow, Uttar Pradesh, North India, a tertiary care teaching hospital. Before inclusion, ethical approval and written informed consent was obtained. Included in the study were sixty-five children aged 6–59 months of age, who were admitted to the hospital with SAM as per the WHO guidelines. SAM was defined as a mid-upper arm circumference <115 mm and/or weight-for-height/length <–3z-scores of the WHO growth standards and/or have bilateral oedema. Serum P levels were measured on admission and for five consecutive days after starting feed. HP was defined as mild, moderate and severe with a cut-off of 1·19–0·65, 0·65–0·32 and <0·32 mmol/l, respectively. About 60 % children had HP, with 20 % having moderate/severe HP at admission. The proportion of HP increased to 83·1 %, with 38·5 % having moderate/severe HP on day 3 after feeding. It was concluded that HP is a common biochemical abnormality in SAM. Considering its impact on the health of the child, serum P levels should be monitored in patients with SAM who are treated with enteral feeding.

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Active and adaptive case finding to estimate therapeutic program coverage for severe acute malnutrition: a capture-recapture study

BMC Health Services Research ◽

10.1186/s12913-019-4791-9 ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Sheila Isanaka ◽

Bethany L. Hedt-Gauthier ◽

Halidou Salou ◽

Fatou Berthé ◽

Rebecca F. Grais ◽

...

Keyword(s):

Severe Acute Malnutrition ◽

Sampling Procedure ◽

Case Finding ◽

Acute Malnutrition ◽

Important Indicator ◽

Link Type ◽

Capture Recapture ◽

Low Sensitivity ◽

Coverage Estimation ◽

The Impact

Abstract Background Coverage is an important indicator to assess both the performance and effectiveness of public health programs. Recommended methods for coverage estimation for the treatment of severe acute malnutrition (SAM) can involve active and adaptive case finding (AACF), an informant-driven sampling procedure, for the identification of cases. However, as this procedure can yield a non-representative sample, exhaustive or near exhaustive case identification is needed for valid coverage estimation with AACF. Important uncertainty remains as to whether an adequate level of exhaustivity for valid coverage estimation can be ensured by AACF. Methods We assessed the sensitivity of AACF and a census method using a capture-recapture design in northwestern Nigeria. Program coverage was estimated for each case finding procedure. Results The sensitivity of AACF was 69.5% (95% CI: 59.8, 79.2) and 91.9% (95% CI: 85.1, 98.8) with census case finding. Program coverage was estimated to be 40.3% (95% CI 28.6, 52.0) using AACF, compared to 34.9% (95% CI 24.7, 45.2) using the census. Depending on the distribution of coverage among missed cases, AACF sensitivity of at least ≥70% was generally required for coverage estimation to remain within ±10% of the census estimate. Conclusion Given the impact incomplete case finding and low sensitivity can have on coverage estimation in potentially non-representative samples, adequate attention and resources should be committed to ensure exhaustive or near exhaustive case finding. Trial registration ClinicalTrials.gov ID NCT03140904. Registered on May 3, 2017.

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