Publications by authors named "Jai Das"

112 Publications

Large-scale food fortification has great potential to improve child health and nutrition.

Curr Opin Clin Nutr Metab Care 2021 Feb 23. Epub 2021 Feb 23.

Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada Centre of Excellence in Women and Child Health and Institute for Global Health & Development, Aga Khan University, Karachi, Pakistan.

Purpose Of Review: Undernutrition, including micronutrient deficiencies, continues to plague children across the world, particularly in low and middle-income countries (LMICs). The situation has worsened alongside the SARS-CoV-2 pandemic because of major systemic disruptions to food supply, healthcare, and employment. Large-scale food fortification (LSFF) is a potential strategy for improving micronutrient intakes through the addition of vitamins and minerals to staple foods and improving the nutritional status of populations at large.

Recent Findings: Current evidence unquestionably supports the use of LSFF to improve micronutrient status. Evidence syntheses have also demonstrated impact on some functional outcomes, including anemia, wasting, underweight, and neural tube defects, that underpin poor health and development. Importantly, many of these effects have also been reflected in effectiveness studies that examine LSFF in real-world situations as opposed to under-controlled environments. However, programmatic challenges must be addressed in LMICs in order for LSFF efforts to reach their full potential.

Summary: LSFF is an important strategy that has the potential to improve the health and nutrition of entire populations of vulnerable children. Now more than ever, existing programs should be strengthened and new programs implemented in areas with widespread undernutrition and micronutrient deficiencies.
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http://dx.doi.org/10.1097/MCO.0000000000000745DOI Listing
February 2021

Nutritional perspectives for the prevention and mitigation of COVID-19.

Nutr Rev 2021 02;79(3):289-300

Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.

Worldwide, there is an array of clinical trials under way to evaluate treatment options against coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2. Concurrently, several nutritional therapies and alternative supportive treatments are also being used and tested to reduce the mortality associated with acute respiratory distress in patients with COVID-19. In the context of COVID-19, improved nutrition that includes micronutrient supplementation to augment the immune system has been recognized as a viable approach to both prevent and alleviate the severity of the infection. The potential role of micronutrients as immune-boosting agents is particularly relevant for low- and middle-income countries, which already have an existing high burden of undernutrition and micronutrient deficiencies. A systematic literature review was performed to identify nutritional interventions that might prevent or aid in the recovery from COVID-19. The PubMed, ScienceDirect, Cochrane, Scopus, Web of Science, and Google Scholar databases were searched electronically from February to April 2020. All abstracts and full-text articles were examined for their relevance to this review. The information gathered was collated under various categories. Deficiencies of micronutrients, especially vitamins A, B complex, C, and D, zinc, iron, and selenium, are common among vulnerable populations in general and among COVID-19 patients in particular and could plausibly increase the risk of mortality. Judicious use of need-based micronutrient supplementation, alongside existing micronutrient fortification programs, is warranted in the current global pandemic, especially in low- and middle-income economies.
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http://dx.doi.org/10.1093/nutrit/nuaa063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454773PMC
February 2021

Specific considerations for research on the effectiveness of multisectoral collaboration: methods and lessons from 12 country case studies.

Global Health 2021 02 1;17(1):18. Epub 2021 Feb 1.

World Health Organization, Geneva, Switzerland.

Background: The success of the Sustainable Development Goals (SDGs) is predicated on multisectoral collaboration (MSC), and the COVID-19 pandemic makes it more urgent to learn how this can be done better. Complex challenges facing countries, such as COVID-19, cut across health, education, environment, financial and other sectors. Addressing these challenges requires the range of responsible sectors and intersecting services - across health, education, social and financial protection, economic development, law enforcement, among others - transform the way they work together towards shared goals. While the necessity of MSC is recognized, research is needed to understand how sectors collaborate, inform how to do so more efficiently, effectively and equitably, and ascertain similarities and differences across contexts. To answer these questions and inform practice, research to strengthen the evidence-base on MSC is critical.

Methods: This paper draws on a 12-country study series on MSC for health and sustainable development, in the context of the health and rights of women, children and adolescents. It is written by core members of the research coordination and country teams. Issues were analyzed during the study period through 'real-time' discussions and structured reporting, as well as through literature reviews and retrospective feedback and analysis at the end of the study.

Results: We identify four considerations that are unique to MSC research which will be of interest to other researchers, in the context of COVID-19 and beyond: 1) use theoretical frameworks to frame research questions as relevant to all sectors and to facilitate theoretical generalizability and evolution; 2) specifically incorporate sectoral analysis into MSC research methods; 3) develop a core set of research questions, using mixed methods and contextual adaptations as needed, with agreement on criteria for research rigor; and 4) identify shared indicators of success and failure across sectors to assess MSCs.

Conclusion: In responding to COVID-19 it is evident that effective MSC is an urgent priority. It enables partners from diverse sectors to effectively convene to do more together than alone. Our findings have practical relevance for achieving this objective and contribute to the growing literature on partnerships and collaboration. We must seize the opportunity here to identify remaining knowledge gaps on how diverse sectors can work together efficiently and effectively in different settings to accelerate progress towards achieving shared goals.
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http://dx.doi.org/10.1186/s12992-021-00664-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848879PMC
February 2021

Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies?

Lancet 2021 Feb 24;397(10273):533-542. Epub 2021 Jan 24.

Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, London, UK; The Geneva Centre of Humanitarian Studies, University of Geneva, Graduate Institute, Geneva 1211, Switzerland. Electronic address:

Armed conflict disproportionately affects the morbidity, mortality, and wellbeing of women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child, and adolescent health and nutrition interventions in ten conflict-affected settings in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. We found that despite large variations in contexts and decision making processes, antenatal care, basic emergency obstetric and newborn care, comprehensive emergency obstetric and newborn care, immunisation, treatment of common childhood illnesses, infant and young child feeding, and malnutrition treatment and screening were prioritised in these ten conflict settings. Many lifesaving women's and children's health (WCH) services, including the majority of reproductive, newborn, and adolescent health services, are not reported as being delivered in the ten conflict settings, and interventions to address stillbirths are absent. International donors remain the primary drivers of influencing the what, where, and how of implementing WCH interventions. Interpretation of WCH outcomes in conflict settings are particularly context-dependent given the myriad of complex factors that constitute conflict and their interactions. Moreover, the comprehensiveness and quality of data remain limited in conflict settings. The dynamic nature of modern conflict and the expanding role of non-state armed groups in large geographic areas pose new challenges to delivering WCH services. However, the humanitarian system is creative and pluralistic and has developed some novel solutions to bring lifesaving WCH services closer to populations using new modes of delivery. These solutions, when rigorously evaluated, can represent concrete response to current implementation challenges to modern armed conflicts.
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http://dx.doi.org/10.1016/S0140-6736(21)00132-XDOI Listing
February 2021

The Impact of the COVID-19 Pandemic on Immunization Campaigns and Programs: A Systematic Review.

Int J Environ Res Public Health 2021 01 22;18(3). Epub 2021 Jan 22.

Division of Women and Child Health, The Aga Khan University, Karachi 74500, Pakistan.

The COVID-19 pandemic has had an impact on health service delivery, including immunization programs, and this review assesses the impact on vaccine coverage across the globe and identifies the potential underlying factors. A systematic search strategy was employed on PubMed, Embase, MedRxiv, BioRxiv, and WHO COVID-19 databases from December 2019 till 15 September 2020. Two review authors independently assessed studies for inclusion, assessed quality, and extracted the data (PROSPERO registration #CRD42020182363). A total of 17 observational studies were included. The findings suggest that there was a reduction in the vaccination coverage and decline in total number of vaccines administered, which led to children missing out on their vaccine doses. An approximately fourfold increase was also observed in polio cases in polio endemic countries. Factors contributing to low vaccine coverage included fear of being exposed to the virus at health care facilities, restriction on city-wide movements, shortage of workers, and diversion of resources from child health to address the pandemic. As the world re-strategizes for the post-2020 era, we should not let a crisis go to waste as they provide an opportunity to establish guidelines and allocate resources for future instances. High-quality supplementary immunization activities and catch-up programs need to be established to address gaps during the pandemic era.
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http://dx.doi.org/10.3390/ijerph18030988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908591PMC
January 2021

Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO-defined non-severe pneumonia and wheeze.

Cochrane Database Syst Rev 2021 01 20;1:CD009576. Epub 2021 Jan 20.

Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.

Background: Worldwide, pneumonia is the leading cause of death amongst children under five years of age, and accounts for approximately two million deaths annually. Pneumonia can be classified according to the World Health Organization (WHO) guidelines. Classification includes assessment of certain clinical signs and symptoms, and the severity of the disease. Treatment is then tailored according to the classification. For non-severe pneumonia, the WHO recommends treatment with oral antibiotics. We used the 2014 WHO definition of non-severe pneumonia for this review: an acute episode of cough, or difficulty in breathing, combined with fast breathing and chest indrawing. The WHO recommends treating non-severe pneumonia with oral antibiotics. Pneumonia is more commonly caused by viruses that do not require antibiotic treatment, but pneumonia caused by bacteria needs management with antibiotics to avoid complications. There is no clear way to quickly distinguish between viral and bacterial pneumonia. It is considered safe to give antibiotics, however, this may lead to the development of antibiotic resistance, and thus, limit their use in future infections. Therefore, it is essential to explore the efficacy of antibiotics for children with WHO-defined non-severe pneumonia and wheeze.

Objectives: To evaluate the efficacy of antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO-defined non-severe pneumonia and wheeze.

Search Methods: We searched CENTRAL, MEDLINE, Embase, four other databases, and two trial registers (December 2020).

Selection Criteria: We included randomised controlled trials (RCTs) evaluating the efficacy of antibiotic therapy versus no antibiotic therapy for children, aged 2 to 59 months, with non-severe pneumonia and wheeze. We defined non-severe pneumonia as 'a cough or difficulty in breathing, with rapid breathing (a respiratory rate of 50 breaths per minute or more for children aged 2 to 12 months, or a respiratory rate of 40 breaths per minute or more for children aged 12 to 59 months), chest indrawing and wheeze'. We excluded trials involving children with severe or very severe pneumonia, and non-RCTs.

Data Collection And Analysis: Our primary outcomes were clinical cure and treatment failure; secondary outcomes were relapse, mortality, and treatment harms. We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. Two review authors independently assessed the search results, extracted data, assessed risk of bias and the certainty of the evidence. We contacted the authors of two included trials and the author of the trial awaiting classification to obtain missing numerical outcome data.

Main Results: We included three trials involving 3256 children aged between 2 to 59 months, who exhibited features of non-severe pneumonia with wheeze. The included trials were multi-centre, double-blind, randomised, placebo-controlled trials carried out in Malawi, Pakistan, and India. The children were treated with a three-day course of amoxicillin or placebo, and were followed up for a total of two weeks. We assessed the included trials at overall low risk of bias for random sequence generation, allocation concealment, blinding, attrition bias, and selective reporting. Only one trial was assessed to be at high risk for blinding of outcome assessors. One trial is awaiting classification Antibiotic therapy may result in a reduction of treatment failure by 20% (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.68 to 0.94; three trials; 3222 participants; low-certainty evidence). Antibiotic therapy probably results in little or no difference to clinical cure (RR 1.02, 95% CI 0.96 to 1.08; one trial; 456 participants; moderate-certainty evidence), and in little or no difference to relapse (RR 1.00, 95% CI 0.74 to 1.34; three trials; 2795 participants; low-certainty evidence), and treatment harms (RR 0.81, 95% CI 0.60 to 1.09; three trials, 3253 participants; low-certainty evidence). Two trials (2112 participants ) reported on mortality; no deaths occurred in either group. One trial reported cases of hospitalisation, diarrhoea (with and without dehydration), rash (without itch), tremors, mild nausea and vomiting.

Authors' Conclusions: We do not currently have enough evidence to support or challenge the continued use of antibiotics for the treatment of non-severe pneumonia. There is a clear need for RCTs to address this question in children aged 2 to 59 months with 2014 WHO-defined non-severe pneumonia and wheeze.
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http://dx.doi.org/10.1002/14651858.CD009576.pub3DOI Listing
January 2021

Machine Learning for Child and Adolescent Health: A Systematic Review.

Pediatrics 2021 Jan 15;147(1). Epub 2020 Dec 15.

Department of Pediatrics and Child Health.

Context: In the last few decades, data acquisition and processing has seen tremendous amount of growth, thus sparking interest in machine learning (ML) within the health care system.

Objective: Our aim for this review is to provide an evidence map of the current available evidence on ML in pediatrics and adolescent medicine and provide insight for future research.

Data Sources: A literature search was conducted by using Medline, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature Plus, Web of Science Library, and EBSCO Dentistry & Oral Science Source.

Study Selection: Articles in which an ML model was assessed for the diagnosis, prediction, or management of any condition in children and adolescents (0-18 years) were included.

Data Extraction: Data were extracted for year of publication, geographical location, age range, number of participants, disease or condition under investigation, study methodology, reference standard, type, category, and performance of ML algorithms.

Results: The review included 363 studies, with subspecialties such as psychiatry, neonatology, and neurology having the most literature. A majority of the studies were from high-income (82%; = 296) and upper middle-income countries (15%; = 56), whereas only 3% ( = 11) were from low middle-income countries. Neural networks and ensemble methods were most commonly tested in the 1990s, whereas deep learning and clustering emerged rapidly in the current decade.

Limitations: Only studies conducted in the English language could be used in this review.

Conclusions: The interest in ML has been growing across various subspecialties and countries, suggesting a potential role in health service delivery for children and adolescents in the years to come.
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http://dx.doi.org/10.1542/peds.2020-011833DOI Listing
January 2021

Researching the delivery of health and nutrition interventions for women and children in the context of armed conflict: lessons on research challenges and strategies from BRANCH Consortium case studies of Somalia, Mali, Pakistan and Afghanistan.

Confl Health 2020 20;14:69. Epub 2020 Oct 20.

Centre for Global Child Health, The Hospital for Sick Children, 686 Bay St, Toronto, ON M5G 0A4 Canada.

Background: The BRANCH Consortium recently conducted 10 mixed-methods case studies to investigate the provision of health and nutrition interventions for women and children in conflict-affected countries, aiming to better understand the dominant influences on humanitarian health actors' programmatic decision-making and how such actors surmount intervention delivery barriers. In this paper, the research challenges encountered and the mitigating strategies employed by the case study investigators in four of the BRANCH case study contexts are discussed: Somalia, Mali, Pakistan and Afghanistan.

Discussion: Many of the encountered research challenges were anticipated, with investigators adopting mitigation strategies in advance or early on, but others were unexpected, with implications for how studies were ultimately conducted and how well the original study aims were met. Insecurity was a fundamental challenge in all study contexts, with restricted geographical access and concerns for personal safety affecting sampling and data collection plans, and requiring reliance on digital communications, remote study management, and off-site team meetings wherever possible. The need to navigate complex local sociopolitical contexts required maximum reliance on local partners' knowledge, expertise and networks, and this was facilitated by early engagement with a wide range of local study stakeholders. Severe lack of reliable quantitative data on intervention coverage affected the extent to which information from different sources could be triangulated or integrated to inform an understanding of the influences on humanitarian actors' decision-making.

Conclusion: Strong local partners are essential to the success of any project, contributing not only technical and methodological capacity but also the insight needed to truly understand and interpret local dynamics for the wider study team and to navigate those dynamics to ensure study rigour and relevance. Maintaining realistic expectations of data that are typically available in conflict settings is also essential, while pushing for more resources and further methodological innovation to improve data collection in such settings. Finally, successful health research in the complex, dynamic and unpredictable contexts of conflict settings requires flexibility and adaptability of researchers, as well as sponsors and donors.
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http://dx.doi.org/10.1186/s13031-020-00315-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574460PMC
October 2020

Prescribing Patterns of Antihypertensive Medications in Low- and Middle-Income Countries: A Systematic Review.

Asia Pac J Public Health 2021 Jan 21;33(1):14-22. Epub 2020 Oct 21.

The Aga Khan University, Karachi, Pakistan.

Hypertension is highly prevalent, but its pharmacological management has not been well evaluated in low- and middle-income countries (LMICs). This review examined the prescribing patterns of antihypertensives in LMICs. Data were extracted from a total of 26 studies spanning the time period 2000 to 2018. In 10 studies, calcium channel blockers (CCBs) were the most frequently prescribed medication for managing hypertension (range = 33% to 72%); in six studies, renin angiotensin system (RAS) blockers (range = 25% to 83%); in five studies, diuretics (range = 39% to 99%); and in five studies, β-blockers (BBs; range = 26% to 49%) were the most commonly prescribed antihypertensive medications. Prescribing sedatives and sublingual administration of captopril for controlling hypertension was also reported in 3 studies. Only 10 studies presented their findings in light of national or international guidelines. This review calls for further antihypertensive utilization and dispensation studies and a better understanding of clinician's perception and practice of hypertension management guidelines in LMICs.
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http://dx.doi.org/10.1177/1010539520965280DOI Listing
January 2021

The Intertwined Relationship Between Malnutrition and Poverty.

Front Public Health 2020 28;8:453. Epub 2020 Aug 28.

Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.

Despite social and economic development, the burden of malnutrition across the globe remains unacceptably high. A vital relationship exists between nutritional status, human capital, and economic standing. Malnutrition adversely affects the physiological and mental capacity of individuals; which in turn hampers productivity levels, making them and their respective countries more susceptible to poverty. A two-way link exists between malnutrition and poverty, creating a vicious cycle with each fueling the other. Malnutrition produces conditions of poverty by reducing the economic potential of the population and likewise, poverty reinforces malnutrition by increasing the risk of food insecurity. The aim of the paper is to describe the interconnection between malnutrition and poverty, and to highlight how both serve as the cause and consequence of each other. The paper also discusses ways to move ahead to tackle these issues in a parallel manner rather than in separate silos.
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http://dx.doi.org/10.3389/fpubh.2020.00453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485412PMC
August 2020

Continuing and ensuring surgical care for children during COVID and post-COVID crisis.

J Pediatr Surg 2021 01 21;56(1):201-202. Epub 2020 Aug 21.

Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.

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http://dx.doi.org/10.1016/j.jpedsurg.2020.08.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442072PMC
January 2021

Systematic review of infant and young child feeding practices in conflict areas: what the evidence advocates.

BMJ Open 2020 09 13;10(9):e036757. Epub 2020 Sep 13.

Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada

Background: Breast feeding in conflict settings is known to be the safest way to protect infant and young children from malnourishment and increased risk of infections. This systematic review assesses the evidence on infant and young child feeding (IYCF) practices in conflict settings.

Methodology: We conducted a search in PubMed and CENTRAL and also searched for grey literature from the year 1980 to August 2019. We included studies conducted in settings inflicted with armed conflict; which comprised settings undergoing conflict, as well as, those within 5 years of its cessation. Studies were included if they discussed IYCF practices, barriers, programmes and guidelines to promote and improve IYCF practices. Two review authors independently evaluated and screened studies for eligibility and extracted data; followed by a descriptive and thematic analysis.

Results: We included 56 studies in our review including 11 published articles and 45 reports from grey literature and broadly classified into four predetermined sections: epidemiology (n=24), barriers/enablers (n=18), programmes/interventions (n=15) and implementation guidelines (n=30). Epidemiological evidence shows that IYCF practices were generally poor in conflict settings with median prevalence of exclusive breast feeding at 25%, continued breast feeding at 29%, bottle feeding at 58.3%, introduction to solid, semisolid or soft foods at 71.1% and minimum dietary diversity at 60.3%.IYCF practices were affected by displacement, stress, maternal malnutrition and mental health, family casualties and free distribution of breast milk substitutes. To improve IYCF, several interventions were implemented; including, training of health workers, educating mothers, community networking and mobilisation, lactation-support service, baby friendly hospital initiative, mother-baby friendly spaces and support groups.

Conclusion: The evidence suggests that IYCF practices are generally poor in conflict inflicted settings. However, there is potential for improvement by designing effective interventions, responsibly disseminating, monitoring and implementing IYCF guidelines as prescribed by WHO development partners, government and non-government organisations with dedicated funds and investing in capacity development.
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http://dx.doi.org/10.1136/bmjopen-2020-036757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488834PMC
September 2020

Optimum Degree of Head Elevation/Reverse Trendelenburg Position for Sinus Surgery: Systematic Review.

Am J Rhinol Allergy 2020 Aug 27:1945892420954794. Epub 2020 Aug 27.

Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.

Background: This review aims to evaluate the effect of Reverse Trendelenburg Position (RTP) on bleeding and Boezaart score and to determine the optimum degree of head elevation through a systematic review and meta-analysis. We conducted a systematic review according to PRISMA guidelines and a literature search was performed on PubMed, Web of Science, Cochrane, Dental and Oral Science, Google scholar and Clinicaltrials.gov and included randomized controlled trials (RCTs) in English language only. We extracted all relevant data and conducted quality assessment using Cochrane risk of Bias tool (Version 2). We also performed quality assessment of the outcomes using GRADE. Meta-analysis for all the outcomes using conducted on RevMan version 5.3.

Results: The search identified 629 articles and three RCTs that met our inclusion criteria. Two were included in the meta-analysis. A total of 124 patients were assessed for bleeding during sinus surgery and there was a significant reduction in total blood loss in RTP (10-15°) when compared to horizontal position by 134 ml (Mean Difference (MD): -134.23; 95% confidence interval (CI): -184.13 to -67.27). RTP also had a significant reduction in bleeding per minute by 1.07 ml/min (MD: -1.07; 95%CI: (-1.69 to -0.44), while the Boezaart score was significantly lower in the RTP group (MD: -0.69; 95%CI: -0.94 to -0.43) when compared to horizontal position.

Conclusion: Though with limited evidence RTP for ESS reduces total blood loss, blood loss per minute and improves visualization. Further studies are needed to assess the actual impact and optimal degree of head elevation.
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http://dx.doi.org/10.1177/1945892420954794DOI Listing
August 2020

Effects of Lifestyle Modification Interventions to Prevent and Manage Child and Adolescent Obesity: A Systematic Review and Meta-Analysis.

Nutrients 2020 Jul 24;12(8). Epub 2020 Jul 24.

Centre for Global Child Health, the Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.

The objective of this review was to assess the impact of lifestyle interventions (including dietary interventions, physical activity, behavioral therapy, or any combination of these interventions) to prevent and manage childhood and adolescent obesity. We conducted a comprehensive literature search across various databases and grey literature without any restrictions on publication, language, or publication status until February 2020. We included randomized controlled trials and quasi-experimental studies from both high income countries (HIC) and low-middle-income countries (LMICs). Participants were children and adolescents from 0 to 19 years of age. Studies conducted among hospitalized children and children with any pre-existing health conditions were excluded from this review. A total of 654 studies (1160 papers) that met the inclusion criteria were included in this review. A total of 359 studies targeted obesity prevention, 280 studies targeted obesity management, while 15 studies targeted both prevention and management. The majority of the studies (81%) were conducted in HICs, 10% of studies were conducted in upper middle income countries, while only 2% of the studies were conducted in LMICs. The most common setting for these interventions were communities and school settings. Evidence for the prevention of obesity among children and adolescents suggests that a combination of diet and exercise might reduce the BMI -score (MD: -0.12; 95% CI: -0.18 to -0.06; 32 studies; 33,039 participants; I 93%; low quality evidence), body mass index (BMI) by 0.41 kg/m (MD: -0.41 kg/m; 95% CI: -0.60 to -0.21; 35 studies; 47,499 participants; I 98%; low quality evidence), and body weight (MD: -1.59; 95% CI: -2.95 to -0.23; 17 studies; 35,023 participants; I 100%; low quality evidence). Behavioral therapy alone (MD: -0.07; 95% CI: -0.14 to -0.00; 19 studies; 8569 participants; I 76%; low quality evidence) and a combination of exercise and behavioral therapy (MD: -0.08; 95% CI: -0.16 to -0.00; 9 studies; 7334 participants; I 74%; low quality evidence) and diet in combination with exercise and behavioral therapy (MD: -0.13; 95% CI: -0.25 to -0.01; 5 studies; 1806 participants; I 62%; low quality evidence) might reduce BMI -score when compared to the control group. Evidence for obesity management suggests that exercise only interventions probably reduce BMI -score (MD: -0.13; 95% CI: -0.20 to -0.06; 12 studies; 1084 participants; I 0%; moderate quality evidence), and might reduce BMI (MD: -0.88; 95% CI: -1.265 to -0.50; 34 studies; 3846 participants; I 72%) and body weight (MD: -3.01; 95% CI: -5.56 to -0.47; 16 studies; 1701 participants; I 78%; low quality evidence) when compared to the control group. and the exercise along with behavioral therapy interventions (MD: -0.08; 95% CI: -0.16 to -0.00; 8 studies; 466 participants; I 49%; moderate quality evidence), diet along with behavioral therapy interventions (MD: -0.16; 95% CI: -0.26 to -0.07; 4 studies; 329 participants; I 0%; moderate quality evidence), and combination of diet, exercise and behavioral therapy (MD: -0.09; 95% CI: -0.14 to -0.05; 13 studies; 2995 participants; I 12%; moderate quality evidence) also probably decreases BMI -score when compared to the control group. The existing evidence is most favorable for a combination of interventions, such as diet along with exercise and exercise along with behavioral therapy for obesity prevention and exercise alone, diet along with exercise, diet along with behavioral therapy, and a combination of diet, exercise, and behavioral therapy for obesity management. Despite the growing obesity epidemic in LMICs, there is a significant dearth of obesity prevention and management studies from these regions.
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http://dx.doi.org/10.3390/nu12082208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468898PMC
July 2020

Challenges to delivering pediatric surgery services in the midst of COVID 19 crisis: experience from a tertiary care hospital of Pakistan.

Pediatr Surg Int 2020 Nov 20;36(11):1267-1273. Epub 2020 Jul 20.

Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.

Covid-19 pandemic has significantly challenged the healthcare delivery across the world. Surgery departments across the country responded to this challenge by halting all non-emergency procedures. This delay in diagnosis and management of surgical disease could result in significant mortality and morbidity among the most vulnerable population-the children. In this manuscript, we discuss the measures adopted as well as the challenges faced by the pediatric surgery department at Aga Khan University Hospital, Karachi (AKUH), Pakistan, which is a private, not-for-profit entity and providing optimum surgical care to the patients. We also underscore the need for global strategies for tackling such crisis.
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http://dx.doi.org/10.1007/s00383-020-04721-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370874PMC
November 2020

Food supplements to reduce stunting in Pakistan: a process evaluation of community dynamics shaping uptake.

BMC Public Health 2020 Jul 2;20(1):1046. Epub 2020 Jul 2.

Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.

Background: There is an increasing interest in use of food supplements to prevent childhood stunting, however the evidence on the process indicators is scarce. We in this study explore the barriers to the effective implementation of food supplementation programs and the possible mitigation strategies which can guide the design of future programs.

Methods: We undertook a process evaluation of a stunting prevention food supplementation pilot program in rural Pakistan that distributed Wheat Soy Blend (WSB) to pregnant & lactating women, and Lipid-based Nutrient Supplement (LNS) and micronutrient powder (MNP) to < 5 years children. We used a mixed methods approach through a quantitative survey of 800 households and conducted 18 focused group discussion (FGDs) (with male and female caregivers), 4 FGDs (with Community Health Workers (CHWs)) and 22 key informant interviews (with district stakeholders) to evaluate the community side factors affecting uptake through five parameters: value, acceptability, receipt of supplement, usage and correct dosage.

Results: The findings show that proportionately few beneficiaries consumed the full dose of supplements, despite reasonable knowledge amongst caregivers. Sharing of supplements with other household member was common, and the full monthly stock was usually not received. Qualitative findings suggest that caregivers did not associate food supplements with stunting prevention. WSB was well accepted as an extra ration, LNS was popular due its chocolaty taste and texture, whereas MNP sprinkles were perceived to be of little value. The cultural food practices led to common sharing, whereas interaction with CHWs was minimal for nutrition counselling. Qualitative findings also indicate CHWs related programmatic constraints of low motivation, multi-tasking, inadequate counselling skills and weak supervision.

Conclusion: We conclude that the community acceptability of food supplements does not translate into optimal consumption. Hence a greater emphasis is needed on context specific demand creation and focusing on the supply side constraints with improved logistical planning, enhanced motivation and supervision of community workers with involvement of multiple stakeholders. While, similar studies are needed in varying contexts to help frame universal guidelines.

Trial Registration: ClinicalTrials.gov Identifier: NCT02422953 . Registered on April 22, 2015.
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http://dx.doi.org/10.1186/s12889-020-09103-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331235PMC
July 2020

Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan.

Confl Health 2020 10;14:38. Epub 2020 Jun 10.

Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.

Introduction: Since decades, the health system of Afghanistan has been in disarray due to ongoing conflict. We aimed to explore the direct effects of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing these services.

Method: We conducted a quantitative analysis of secondary data on RMNCAH&N indicators and undertook a supportive qualitative study to help understand processes and contextual factors. For quantitative analysis, we stratified the various provinces of Afghanistan into minimal-, moderate- and severe conflict categories based on battle-related deaths from Uppsala Conflict Data Program (UCDP) and through accessibility of health services using a Delphi methodology. The coverage of RMNCAH&N indicators across the continuum of care were extracted from the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Survey (MICS). The qualitative data was captured by conducting key informant interviews of multi-sectoral stakeholders working in government, NGOs and UN agencies.

Results: Comparison of various provinces based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators including antenatal care (OR: 0.42, 95%CI: 0.32-0.55), facility delivery (OR: 0.42, 95%CI: 0.32-0.56), skilled birth attendance (OR: 0.43, 95%CI: 0.33-0.57), DPT3 (OR: 0.26, 95% CI: 0.20-0.33) and oral rehydration therapy (OR: 0.37, 95% CI: 0.25-0.55) was significantly lower for severe conflict provinces when compared to minimal conflict provinces. The qualitative analysis identified various factors affecting decision making and service delivery including insecurity, cultural norms, unavailability of workforce, poor monitoring, lack of funds and inconsistent supplies. Other factors include weak stewardship, capacity gap at the central level and poor coordination at national, regional and district level.

Conclusion: RMNCAH&N service delivery has been significantly hampered by conflict in Afghanistan over the last several years. This has been further compromised by poor infrastructure, weak stewardship and poor capacity and collaboration at all levels. With the potential of peace and conflict resolution in Afghanistan, we would underscore the importance of continued oversight and integrated implementation of sustainable, grass root RMNCAH&N services with a focus on reaching the most marginalized.
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http://dx.doi.org/10.1186/s13031-020-00285-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288441PMC
June 2020

Impact of conflict on maternal and child health service delivery - how and how not: a country case study of conflict affected areas of Pakistan.

Confl Health 2020 27;14:32. Epub 2020 May 27.

Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.

Introduction: In conflict affected countries, healthcare delivery remains a huge concern. Pakistan is one country engulfed with conflict spanning various areas and time spans. We aimed to explore the effect of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing the prioritization and implementation in conflict affected areas of Pakistan (Balochistan and FATA).

Method: We conducted a secondary quantitative and a primary qualitative analysis. For the quantitative analysis, we stratified the various districts/agencies of Balochistan and FATA into the conflict categories of minimal-, moderate- and severe based on accessibility to health services through a Delphi methodology with local stakeholders and implementing agencies and also based on battle-related deaths (BRD) information from Uppsala Conflict Data Program (UCDP). The coverage of RMNCAH&N indicators across the continuum of care were extracted from the demographic and health surveys (DHS) and district health information system (DHIS). We conducted a stratified descriptive analysis and multivariate analysis using STATA version 15. The qualitative data was captured by conducting key informant interviews of stakeholders working in government, NGOs, UN agencies and academia. All the interviews were audiotaped which were transcribed, translated, coded and analyzed on Nvivo software version 10.

Results: The comparison of the various districts based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators in Balochistan were significantly lower in severe- conflict districts when compared to minimal conflict districts, while there was no significant difference between moderate and severe conflict areas. There was no reliable quantitative data available for FATA. Key factors identified through qualitative analysis, which affected the prioritization and delivery of services included planning at the central level, lack of coordination amongst various hierarchies of the government and various stakeholders. Other factors included unavailability of health workforce especially female workers, poor quality of healthcare services, poor data keeping and monitoring, lack of funds and inconsistent supplies. Women and child health is set at a high priority but capacity gap at service delivery, resilience from health workers, insecurity and poor infrastructure severely hampers the delivery of quality healthcare services.

Conclusion: Conflict has severely hampered the delivery of health services and a wholesome effort is desired involving coordination amongst various stakeholders. The multiple barriers in conflict contexts cannot be fully mitigated, but efforts should be made to negate these as much as possible with good governance, planning, efficiency and transparency in utilization of available resources.
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http://dx.doi.org/10.1186/s13031-020-00271-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254751PMC
May 2020

Do recipients of cash transfer scheme make the right decisions on household food expenditure? A study from a rural district in Pakistan.

J Pak Med Assoc 2020 May;70(5):796-802

Community Health Solutions, Karachi, Pakistan.

Objectives: To assess spending by beneficiaries of Benazir Income Support Programme on monthly food commodities, and contribution of the cash grant programme on purchase of nutritious foods.

Methods: The descriptive cross-sectional survey of households enrolled in the Benazir Income Support Programme was conducted during July and August, 2013, in Matiari district of the Sindh province of Pakistan. Monthly household food expenditure on food commodities and use of the cash grant on type of food purchased was assessed through structured interviews of the beneficiaries. Results were computed in 2013 Pak rupees and converted to 2018 United States dollar. Women beneficiaries were also interviewed on decision-making regarding the use of the cash grant and on household food expenditure.

Results: The survey comprised 421 households. with a mean monthly expenditure on food of Rs 7,577, r 80.73 dollars. Women made decisions on food spending in only 135(32%) households, but in 235(56%) households, women were the primary decision-makers on cash grant spending.

Conclusions: Unconditional cash grant did not meaningfully translate into the purchase of nutritious foods even though it played an important role in increasing women's agency.
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http://dx.doi.org/10.5455/JPMA.16884DOI Listing
May 2020

Vitamin C supplementation for prevention and treatment of pneumonia.

Cochrane Database Syst Rev 2020 04 27;4:CD013134. Epub 2020 Apr 27.

Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.

Background: According to the Global Burden of Disease Study 2015, lower respiratory tract infection is the leading cause of infectious disease death, and the fifth most common cause of death overall. Vitamin C has a role in modulating resistance to infectious agents, therefore vitamin C supplementation may be important in preventing and treating pneumonia.

Objectives: To assess the impact of vitamin C supplementation to prevent and treat pneumonia in children and adults.

Search Methods: We searched CENTRAL, MEDLINE, Embase, PubMed, CINAHL, LILACS, Web of Science, and two trials registers to 4 March 2020. We also checked references to identify additional studies. We did not apply any publication status or language filters.

Selection Criteria: We included randomised controlled trials (RCTs) and quasi-RCTs (studies using allocation methods that are not random, e.g. date of birth, medical record number) assessing the role of vitamin C supplementation in the prevention and treatment of pneumonia in children and adults compared to control or placebo.

Data Collection And Analysis: We used standard methodological procedures expected by Cochrane.

Main Results: We included seven studies in the review and identified two ongoing studies. The seven included studies involved a total of 2774 participants; five studies were RCTs and two were quasi-RCTs. The included studies were conducted in high-income countries (UK, USA and Chile) and lower-middle-income countries (Bangladesh and Pakistan). Four studies were conducted in hospital inpatient settings, two in schools, and one in a military training centre. Three studies included children under five years of age, two school-aged children, one adult participants, and one older participants aged 60 to 90 years. Two studies assessed the effect of vitamin C supplementation for pneumonia prevention; four studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment; and one study assessed the role of vitamin C for both prevention and treatment of pneumonia. For pneumonia prevention, the included studies provided supplementation in doses of 500 mg daily for 14 weeks, 2 g daily for 8 weeks, and 2 g daily for 12 weeks. For pneumonia treatment, the included studies provided vitamin C supplementation in doses of 125 mg daily (until discharge), 200 mg for 4 weeks, and 200 mg until discharge, as an adjunct to the pneumonia treatment. We assessed the included studies as at overall either high or unclear risk of bias for random sequence generation, allocation concealment, and blinding. We judged the quality of the evidence as very low. Three studies assessed the effect of vitamin C supplementation for pneumonia prevention; we judged the quality of the evidence as very low. We are uncertain about the effect of vitamin C supplementation on pneumonia incidence (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.06 to 3.61; 2 studies, 736 participants; I² = 75%; very low-quality evidence) and adverse events (urticaria) (RR 3.11, 95% CI 0.13 to 76.03; 1 study, 674 participants; very low-quality evidence). No included studies reported our other primary outcomes (pneumonia prevalence and mortality) or any of our secondary outcomes. Five studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment; we judged the quality of the evidence as very low. One study reported a decrease in the duration of illness in the vitamin C supplementation group (3.4 days ± 2.54) compared to the control group (4.5 days ± 2.35), and one study reported a decrease in number of days required for improvement in oxygen saturation (1.03 days ± 0.16 versus 1.14 days ± 1.0) and respiratory rate (3.61 days ± 1.50 versus 4.04 days ± 1.62) in the vitamin C supplementation group compared to the control group. We are uncertain of the effect of vitamin C supplementation on mortality due to pneumonia (RR 0.21, 95% CI 0.03 to 1.66; 1 study, 57 participants; very low-quality evidence). One study reported that the mean duration of hospital stay was 6.75 days amongst children in the vitamin C supplementation group and 7.75 days in the control group; another study reported a lower mean duration of hospital stay in the vitamin C supplementation group compared to the control group (109.55 hours ± 27.89 versus 130.64 hours ± 41.76).

Authors' Conclusions: Due to the small number of included studies and very low quality of the existing evidence, we are uncertain of the effect of vitamin C supplementation for the prevention and treatment of pneumonia. Further good-quality studies are required to assess the role of vitamin C supplementation in the prevention and treatment of pneumonia.
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http://dx.doi.org/10.1002/14651858.CD013134.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192369PMC
April 2020

Impact of Infant and Young Child Feeding (IYCF) Nutrition Interventions on Breastfeeding Practices, Growth and Mortality in Low- and Middle-Income Countries: Systematic Review.

Nutrients 2020 Mar 10;12(3). Epub 2020 Mar 10.

Division of Women and Child Health, Aga Khan University Hospital, Karachi 74800, Pakistan.

Undernutrition is associated with 45% of total infant deaths, totalling 2.7 million globally per year. The vast majority of the burden is felt in low- and middle-income countries (LMICs). This review aims to assess the effectiveness of infant and young child feeding (IYCF) interventions. We searched multiple databases including Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE. Title/abstract screening and full-text screening and data extraction filtered 77 studies for inclusion. Breastfeeding education interventions ( = 38) showed 20% increase in rates of early initiation of breastfeeding, 102% increase in exclusive breastfeeding (EBF) at 3 months and 53% increase in EBF at 6 months and 24% decreases in diarrheal diseases. Complementary feeding education intervention (n=12) showed a 0.41 standard deviation (SD) increase in WAZ, and 0.25 SD in HAZ in food secure setting. Complementary food provision with or without education (n=17) showed a 0.14 SD increase in HAZ and 36% decrease in stunting. Supplementary food interventions (n=12) showed a significant 0.15 SD increase in WHZ. Subgroup analyses showed healthcare professional led interventions were largely more effective, especially on breastfeeding outcomes. We believe this is a comprehensive review of the existing literature on IYCF studies in LMICs. Though breastfeeding education is well supported in its effectiveness on breastfeeding practices, limited evidence exists for growth outcomes. Supplementation interventions seem to have better effects at improving growth. However, more research is required to reach more substantial conclusions.
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http://dx.doi.org/10.3390/nu12030722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146402PMC
March 2020

Effects of Preconception Care and Periconception Interventions on Maternal Nutritional Status and Birth Outcomes in Low- and Middle-Income Countries: A Systematic Review.

Nutrients 2020 Feb 26;12(3). Epub 2020 Feb 26.

Department of Pediatrics, the Aga Khan University, Karachi 74800, Pakistan.

Pregnancy in adolescence and malnutrition are common challenges in low- and middle-income countries (LMICs), and are associated with many complications and comorbidities. The preconception period is an ideal period for intervention as a preventative tactic for teenage pregnancy, and to increase micronutrient supplementation prior to conception. Over twenty databases and websites were searched and 45 randomized controlled trials (RCTs) or quasi-experimental interventions with intent to delay the age at first pregnancy ( = 26), to optimize inter-pregnancy intervals ( = 4), and supplementation of folic acid ( = 5) or a combination of iron and folic acid ( = 10) during the periconception period were included. The review found that educational interventions to delay the age at first pregnancy and optimizing inter-pregnancy intervals significantly improved the uptake of contraception use (RR = 1.71, 95% CI = 1.42-2.05; two studies, = 911; I = 0%) and (RR = 2.25, 95% CI = 1.29-3.93; one study, = 338), respectively. For periconceptional folic acid supplementation, the incidence of neural tube defects were reduced (RR = 0.53; 95% CI = 0.41-0.77; two studies, = 248,056; I = 0%), and iron-folic acid supplementation improved the rates of anemia (RR = 0.66, 95% CI = 0.53-0.81; six studies; = 3430, I = 88%), particularly when supplemented weekly and in a school setting. Notwithstanding the findings, more robust RCTs are required from LMICs to further support the evidence.
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http://dx.doi.org/10.3390/nu12030606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146400PMC
February 2020

Impact of Dietary Interventions during Pregnancy on Maternal, Neonatal, and Child Outcomes in Low- and Middle-Income Countries.

Nutrients 2020 Feb 19;12(2). Epub 2020 Feb 19.

Department of Pediatrics, Aga Khan University, Karachi 74800, Pakistan.

Optimal nutrition plays a crucial role in pregnancy. Maternal malnutrition is a risk factor for maternal, fetal, and neonatal complications and is more prevalent in low and middle-income countries (LMICs). This review aims to study the effectiveness of antenatal macronutrient nutritional interventions on maternal, neonatal, and child outcomes. We searched the CENTRAL, PubMed, Embase, and other databases for randomized controlled trials and quasi-experimental designs on healthy pregnant women in LMICs. We also searched grey literature and reports from Google Scholar, Web of Science, and websites of different organizations. Title/abstract screening, full-text screening, and data extraction filtered 15 studies for inclusion. Balanced energy protein (BEP) supplementation ( = 8) studies showed a reduced incidence of perinatal mortality, stillbirths, low birth weight (LBW) infants, small for gestational age (SGA) babies and increased birth weight. Food distribution programs (FDPs) ( =5) witnessed reduced rates of SGA, stunting, wasting, and increased birth weight and birth length. Studies on intervention for obesity prevention ( = 2) showed reductions in birth weight. Other findings were statistically insignificant. Subgroup analyses were conducted to study the effectiveness of supplementation between regions, location, the timing of supplementation and nutritional status; however, there were a limited number of studies in each subgroup. Data from our review supports the antenatal supplementation of BEP and FDP for the prevention of adverse maternal, neonatal, and child outcomes that can be utilized for future policymaking. However, more research is required before recommending obesity prevention programs.
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http://dx.doi.org/10.3390/nu12020531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071393PMC
February 2020

Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Nutrients 2020 Jan 21;12(2). Epub 2020 Jan 21.

Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada.

Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming.
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http://dx.doi.org/10.3390/nu12020289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071447PMC
January 2020

Effectiveness of Interventions for Managing Acute Malnutrition in Children under Five Years of Age in Low-Income and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Nutrients 2020 Jan 1;12(1). Epub 2020 Jan 1.

Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan.

Childhood malnutrition is a major public health concern, as it is associated with significant short- and long-term morbidity and mortality. The objective of this review was to comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization (WHO) protocol using facility- and community-based approaches, as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use, and vitamin A supplementation. We searched relevant electronic databases until 11 February 2019, and performed a meta-analysis. This review summarizes findings from a total of 42 studies (48 papers), including 35,017 children. Limited data show some benefit of integrated community-based screening, identification, and management of SAM and MAM on improving recovery rate. Facility-based screening and management of uncomplicated SAM has no effect on recovery and mortality, while the effect of therapeutic milk F100 for SAM is comparable to RUTF for weight gain and mortality. Local food and whey RUSF are comparable to standard RUSF for recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate and probably improves weight gain and reduces mortality. Limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM.
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http://dx.doi.org/10.3390/nu12010116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019612PMC
January 2020

Effects of Preventive Nutrition Interventions among Adolescents on Health and Nutritional Status in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis.

Nutrients 2019 Dec 23;12(1). Epub 2019 Dec 23.

Centre for Global Child Health, the Hospital for Sick Children, Toronto, ON M5G 0A4, Canada.

The objective of this review was to assess the impact of preventive nutrition interventions on health and nutritional status of adolescents aged 10-19 years in low- and middle-income countries (LMICs). We searched the databases until 5 February 2019 without any restrictions on publication, date, language, or publication status. A total of 10 studies (15 papers) including 10,802 participants assessing the impact of micronutrient supplementation/fortification were included in this review. We did not find any study assessing the impact of nutrition education and counseling or macronutrient supplementation among adolescents. Among primary outcomes, we are uncertain of the effect of iron supplementation with or without folic acid on anemia (daily supplementation; relative risk (RR): 1.04, 95% confidence interval (CI) 0.42, 2.57; one study; 1160 participants; low-quality evidence; weekly supplementation; RR: 1.07, 95% CI: 0.46, 2.52; one study; 1247 participants; low-quality evidence). We are also uncertain of the effect of various micronutrient supplementation/fortification on body mass index (BMI) (calcium/vitamin D supplementation; (MD: -0.01 kg/m; 95% CI: -1.20, 1.17; two studies; 730 participants; I 94%; very-low-quality evidence, iron supplementation with or without folic acid; MD: 0.47 kg/m; 95% CI: -0.17, 1.11; two studies; 652 participants; I 37%; very-low-quality evidence, zinc supplementation; MD: 0.35 kg/m; 95% CI: -0.15, 0.85; one study; 382 participants; very-low-quality evidence) and multiple micronutrient (MMN) fortification; MD: 0.23 kg/m, 95% CI: -0.11, 0.57; two studies; 943 participants; I 22%; very-low-quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Among secondary outcomes, iron supplementation with or without folic acid may improve hemoglobin concentrations, and calcium/vitamin D supplementation may improve serum 25(OH)D levels, while calcium only supplementation and calcium and vitamin D supplementation may marginally improve total body bone mineral density (BMD). We are uncertain of the effect of MMN fortification on hemoglobin concentrations, calcium supplementation on total body bone mineral content (BMC), calcium + vitamin D supplementation on total body BMC, and zinc supplementation on zinc levels. There is limited evidence of micronutrient supplementation/fortification among adolescents, especially adolescent boys, on health and nutritional status in LMICs. These findings should be interpreted with caution due to the low quality and limited number of studies.
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http://dx.doi.org/10.3390/nu12010049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019616PMC
December 2019

Food fortification with multiple micronutrients: impact on health outcomes in general population.

Cochrane Database Syst Rev 2019 12 18;12:CD011400. Epub 2019 Dec 18.

The Hospital for Sick Children, Centre for Global Child Health, Toronto, Canada.

Background: Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

Objectives: To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

Search Methods: We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

Selection Criteria: We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

Data Collection And Analysis: Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

Main Results: We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

Authors' Conclusions: The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.
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http://dx.doi.org/10.1002/14651858.CD011400.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6917586PMC
December 2019

Approaches to the management of pediatric ovarian masses in the 21st century: Systematic review and meta-analysis.

J Pediatr Surg 2020 Mar 25;55(3):357-368. Epub 2019 Oct 25.

Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, UK.

Background: Laparoscopy is increasingly being adopted for the treatment of ovarian pathologies in adults. However, its implementation for the management of pediatric ovarian masses varies and the evidence, to date, has not been comprehensively analyzed. This review aims to compare laparoscopic and open surgical management of pediatric ovarian masses.

Methods: We searched PubMed, Cochrane Library and Google Scholar from the year 2000 till April 2017. Studies selected for this included those on epidemiological trends of pediatric ovarian lesions, assessing outcomes of laparoscopic management and comparison of laparoscopic and open surgical techniques for pediatric ovarian masses. A meta-analysis comparing outcomes of both modalities was performed using standard methodology.

Results: A total of 44 studies met the inclusion criteria of which 15 were on histological types of ovarian lesions, 24 assessed laparoscopic management only and five compared laparoscopy with open surgery for pediatric ovarian masses. Nonneoplastic lesions were the most common ranging from 36.5% to 73.7%, with cystic lesions being the most prevalent. Neoplastic lesions ranged between 26.3% and 63.5%, with germ cell tumors being the most common, while malignancy ranged between 3.5% and 10.8%. Laparoscopic management was generally advocated for managing benign lesions with a cautious approach for suspicion of malignant lesions. In comparison to open surgery, laparoscopic surgery had shorter operating time (MD = -33.24 min, 95% CI = -34.29 to -32.19, p < 0.0001), less intraop bleeding (MD = - 61.46 ml, 95% CI = -62.69 to -60.24, p < 0.0001), and reduced length of hospital stay (MD = -2.78 days, 95% CI= -2.82 to -2.74, p<0.0001). Complication rates were equivocal between the two approaches. Spillage rates could not be assessed.

Conclusion: Limited evidence suggests that laparoscopic approach to presumptively benign ovarian masses have better outcomes when compared to open surgery with regards to operating time, blood loss and hospital stay. However, complication rates were similar between the two approaches. Studies with rigorous scientific methods are needed for a definitive recommendation, especially in resource limiting settings. However malignant lesions should still be managed with an open surgical approach to avoid upstaging of disease status.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.003DOI Listing
March 2020

Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan.

JAMA Netw Open 2019 11 1;2(11):e1914819. Epub 2019 Nov 1.

Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.

Importance: Current studies examining the effects of Afghanistan's conflict transition on the performance of health systems, health service delivery, and health outcomes are outdated and small in scale and do not span all essential reproductive, maternal, newborn, and child health interventions.

Objective: To evaluate associations of conflict severity with improvement of health system performance, use of health services, and child nutrition outcomes in Afghanistan during the 2003 to 2018 reconstruction period.

Design, Setting, And Participants: This population-based survey study included a sequential cross-sectional analysis of individual-level panel data across 2 periods (2003-2010 and 2010-2018) and a difference-in-differences design. Surveys included the 2003 to 2004 and 2010 to 2011 Multiple Indicator Cluster Surveys and the 2018 Afghanistan Health Survey. Afghanistan's 2013 National Nutrition Survey was used to assess nutritional outcomes, and the annual Balanced Scorecard data sets were used to evaluate health system performance. Participants included girls and women aged 12 to 49 years and children younger than 5 years who completed nationally representative household surveys. All analyses were conducted from January 1 through April 30, 2019.

Exposures: Provinces were categorized as experiencing minimal-, moderate-, and severe-intensity conflict using battle-related death data from the Uppsala Conflict Data Program.

Main Outcomes And Measures: Health intervention coverage was examined using 10 standard indicators: contraceptive method (any or modern); antenatal care by a skilled health care professional; facility delivery; skilled birth attendance (SBA); bacille Calmette-Guérin vaccination (BCG); diphtheria, pertussis, and tetanus vaccination (DPT3) or DPT3 plus hepatitis B and poliomyelitis (penta); measles vaccination; care-seeking for acute respiratory infection; oral rehydration therapy for diarrhea; and the Composite Coverage Index. The health system performance was analyzed using the following standard Balanced Scorecard composite domains: client and community, human resources, physical capacity, quality of service provision, management systems, and overall mission. Child stunting, wasting, underweight, and co-occurrence of stunting and wasting were estimated using World Health Organization growth reference cutoffs.

Results: Responses from 64 815 women (mean [SD] age, 31.0 [8.5] years) were analyzed. Provinces with minimal-intensity conflict had greater gains in contraceptive use (mean annual percentage point change [MAPC], 1.3% vs 0.5%; P < .001), SBA (MAPC, 2.7% vs 1.5%; P = .005), BCG vaccination (MAPC, 3.3% vs -0.5%; P = .002), measles vaccination (MAPC, 1.9% vs -1.0%; P = .01), and DPT3/penta vaccination (MAPC, 1.0% vs -2.0%; P < .001) compared with provinces with moderate- to severe-intensity conflict after controlling for confounders. Provinces with severe-intensity conflict fared significantly worse than those with minimal-intensity conflict in functioning infrastructure (MAPC, -1.6% [95% CI, -2.4% to -0.8%]) and the client background and physical assessment index (MAPC, -1.0% [95% CI, -0.8% to 2.7%]) after adjusting for confounders. Child wasting was significantly worse in districts with greater conflict severity (full adjusted β for association between logarithm of battle-related deaths and wasting, 0.33 [95% CI, 0.01-0.66]; P = .04).

Conclusions And Relevance: Associations between conflict and maternal and child health in Afghanistan differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict. These findings may be helpful for planning and prioritizing efforts to reach the United Nations' Sustainable Development Goals in Afghanistan.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.14819DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902774PMC
November 2019

Addressing childhood undernutrition and development through education and lipid-based supplements.

Lancet Glob Health 2019 09;7(9):e1160-e1161

Division of Women and Child Health, Aga Khan University, Karachi 74800, Pakistan.

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http://dx.doi.org/10.1016/S2214-109X(19)30341-9DOI Listing
September 2019