Sheila Isanaka

Introduction: The risk of adverse birth outcomes, such as low birth weight (0.05). Conclusion: There was no statistically significant difference in birth weight, maternal weight gain or anaemia by prenatal nutritional supplementation strategy. However, statistical power in the trial was limited. A combination of strategies may be required to make large improvements in birth and pregnancy outcomes in rural Niger.

Introduction: Patient-centred task-shifting models may be a promising strategy in the community-based management of severe acute malnutrition (SAM) to alleviate pressure on health systems and increase access to treatment in low-resource settings. The engagement of caregivers in clinical and anthropometric surveillance has not been evaluated. Objectives: We examined the effect of caregiver training on their knowledge and confidence in at-home clinical and anthropometric surveillance of children with uncomplicated SAM in Sokoto, Nigeria. Methods: We used data from a cross-over cluster-randomised trial (n clusters=10) comparing a monthly follow-up schedule with caregiver training to standard weekly follow-up for the outpatient management of children 6–59 months with uncomplicated SAM. Caregivers in the monthly follow-up group received a one-time training on at-home clinical surveillance and mid-upper arm circumference (MUAC) measurement. Intention-to-treat analyses assessed mean differences in knowledge and confidence scores within the monthly follow-up group and between groups at enrolment, post-training, programme discharge and 3 months post-discharge. Accuracy of MUAC measurement and classification was compared in the monthly follow-up group to study staff at enrolment post-training, programme discharge and 3 months post-discharge. Results: Of 3945 enrolled children, 96% were followed to programme discharge and 91% to 3 months post-discharge. Caregivers’ knowledge and confidence scores in clinical surveillance increased significantly in the monthly follow-up group post-training and remained elevated at programme discharge and 3 months post-discharge, compared with pretraining. Agreement in MUAC classification between caregiver and study staff was high (>92% agreement at all time points). Caregivers’ knowledge and confidence scores in clinical surveillance were significantly greater in the monthly follow-up group compared with the weekly follow-up group at all time points. Discussion: These findings confirm caregiver training increases knowledge and confidence in at-home clinical and anthropometric surveillance in the management of children with uncomplicated SAM, encouraging the continued consideration for task-shifting models in the community-based management of SAM in similar settings. Trial registration number: NCT03140904 .

Introduction: We aimed to determine the impact of antenatal interventions to optimise maternal nutrition and infection management on birth outcomes in Ethiopia. Methods: We conducted a pragmatic, open-label, 2×2 factorial randomised clinical effectiveness study among pregnant women enrolled <24 weeks gestation in 12 rural health centres in Amhara, Ethiopia. Eligible health centres were randomised to deliver an enhanced nutrition package (ENP) (iron-folic acid, iodised salt and targeted micronutrient fortified balanced energy protein (BEP) supplementation for undernourished women) or routine nutrition care (iron-folic acid only). Individual women were randomised to receive an enhanced infection management package (EIMP) (genitourinary tract infection screening-treatment and enhanced deworming) or routine infection care (syndromic management). The primary outcomes were birth weight and length; secondary outcomes were gestational age, preterm delivery, small-for-gestational-age, low birth weight, stillbirth, newborn weight-for-age and length-for-age z-scores, newborn head circumference, and maternal anemia. Analysis was intention to treat. Results: From August 2020 to December 2021, 2392 women were randomised (604 ENP+EIMP, 600 ENP alone, 593 EIMP alone and 595 neither package) and followed until June 2022, with 2170 pregnancy outcomes analysed (565 ENP+EIMP, 549 ENP, 525 EIMP, 531 neither). In the ENP arm, 427 (36%) women were eligible for BEP and consumed on average 74 days. The prevalence of genitourinary tract infection was low (4.9%), while parasitic stool infections were common (31%). There was no difference in birth weight (ENP vs not-ENP: adjusted mean difference −4 g (−83 to 75); EIMP vs not-EIMP: 18 g (−35 to 70); ENP+EIMP vs neither: 14 g (−81 to 109)) or birth length (ENP: −0.3 cm (−1.1 to 0.5); EIMP: 0.2 cm (−0.1 to 0.5); ENP+EIMP: −0.1 cm (−1.2 to 1.1)) between study arms. In the ENP+EIMP group, the stillbirth rate was lower compared with the arm receiving neither package (7.1/1000 vs 24.7/1000 births; adjusted relative risk: 0.29 (0.09 to 0.94)). The packages did not significantly affect other secondary outcomes. Conclusions: In this pragmatic study implemented within the Ethiopian health system, enhanced nutrition and infection packages did not affect birth weight or length. While stillbirth rates were lower in the group receiving both packages, these findings need to be supported by additional studies. Trial registration number: ISRCTN15116516.

Introduction: Current guidelines for the outpatient treatment of severe acute malnutrition (SAM) recommend the provision of routine medications to all children at admission and prescribed medications as clinically indicated thereafter. The objective of this study was to describe the amount and purpose of medications prescribed during outpatient SAM treatment and explore the effect of routine antibiotics at admission on subsequent medication prescription. Methods: Medications prescribed during outpatient treatment were described by medication category, time from admission, and diagnoses among children with SAM in a placebo-controlled, double-blind trial of 7-day amoxicillin use. Total medications were compared by parent trial intervention arm (amoxicillin vs placebo) and differences assessed using Χ ² and two-sample t-tests. Results: Of the 2399 children enrolled, 74.6% of children received ≥1 prescribed medication during outpatient treatment. Antipyretics/analgesics (44.1% of children), antimalarials (56.6%) and antibiotics (30.0%) were prescribed most frequently. Children who received placebo in the parent trial received fewer total medications (mean difference: −0.80, 95% CI: −0.96 to –0.65) and oral antibiotics (mean difference: −0.96, 95% CI: −0.99 to –0.92) during treatment compared with children who received routine amoxicillin. Conclusions: We found high rates of medication prescription during outpatient treatment for SAM, but fewer total medications and oral antibiotics prescribed to children receiving placebo in the parent trial. Our findings underscore the role of outpatient treatment programmes as an important source of medicine prescription and suggest that provision of antibiotics on a clinically indicated basis for outpatient SAM cases may be a strategy to support prudent antibiotic use in certain settings. Trial registration number: ClinicalTrials.gov Registry ( NCT01613547 ; https://clinicaltrials.gov/ct2/show/NCT01613547 ).

Wasting (ie, a child being too thin for their height) affects at least 45 million children worldwide¹ and is associated with increased child morbidity and mortality.² Despite the effectiveness of community-based management of acute malnutrition, children successfully discharged from treatment continue to face increased risks of relapse, infection, and death following nutritional recovery.^3-6 A recent systematic review showed that the proportion of children who relapse after successful discharge from nutritional treatment for severe acute malnutrition (SAM) may be as high as 37%.³ Other studies indicate postdischarge mortality risk could be as high as 9%.^4,7,8 An increased burden of morbidities (eg, fever, cough, diarrhea) has also been documented following successful discharge from nutritional treatment.^9-12

Background: Infections during pregnancy may increase risk of adverse birth outcomes. In many low-income settings, screening of infections in pregnancy is not routinely performed, and treatment is based on an empirical approach. We aimed to describe the prevalence and etiology of genitourinary...

Background: In the outpatient management of severe wasting, routine antibiotic therapy is recommended for all children upon admission regardless of whether clinical signs of infection are present. Indicated antibiotic therapy, where antibiotics are provided only upon presentation of clinical signs of infection, may be considered for its potential to allow for more prudent antibiotic use and greater program coverage, reducing the risk of antibiotic resistance as well as costs and logistical burdens associated with treatment. We therefore conducted a cost-effectiveness analysis to measure the effects of indicated antibiotic therapy compared to routine antibiotic therapy in terms of incremental cost-per-life-year saved in Niger. Methods: We used a cohort model to conduct a cost-effectiveness analysis from a healthcare system perspective to project and weigh the lifetime discounted costs and effects of indicated antibiotic therapy compared to routine antibiotic therapy in the treatment of uncomplicated severe wasting in children in Niger. We calculated incremental cost-effectiveness ratios (ICERs) in terms of treatment-related healthcare costs per discounted life-years saved (LYS), and conducted program coverage scenario and sensitivity analyses to assess model uncertainty. Results: The ICER for indicated antibiotic therapy compared to routine antibiotic therapy was $8.5/LYS, which is under the cost-effectiveness threshold for Niger. The probability of the indicated strategy being optimal was 76.1% when program coverage was equal to coverage associated with routine therapy but was 100% likely to be optimal in probabilistic sensitivity analysis scenarios where indicated program coverage improved 5 percentage points. Conclusions: Indicated antibiotic therapy likely represents a cost-effective strategy, particularly if indicated treatment can result in expanded coverage. With the risk of increasing antibiotic resistance worldwide, antibiotic stewardship and simplified treatment protocols for severe wasting using indicated antibiotic therapy may represent good value for money in some low risk populations.