Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort

Abstract

Background: Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries.

Methods: We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates.

Findings: We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions.

Interpretation: Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support.

Funding: Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.

Keywords: Africa; Children; Growth; Hospital; Kwashiorkor; Length; Malnutrition; Post-discharge; Stunting; Vulnerability; Wasting; Weight; “Acute illness”; “South asia”.

Fig. 1

Post-discharge growth of children by nutritional group as classified at hospital admission: a) Length-for-age z-score (LAZ); b) Weight-for-age z-score (WAZ); c) Mid-upper arm circumference z-scores (MUACZ), d) Weight-for-length z-score (WLZ) in children who are not wasted (NW), moderately wasted (MW), severely wasted (SW) or have nutritional oedema (NO). Growth trajectories were fitted with locally estimated scatterplot smoothing (LOESS) curves; line color indicates nutritional groups as per legend; colored shaded areas represent the standard error of the mean. Grey dotted line shows average z-score of community participants.

Fig. 2

Alluvial plots detailing the change in nutritional classification of children from discharge (center) to 180-days post discharge (left) for: a) Stunting, based on LAZ; b) Underweight, based on WAZ; c) Wasting, based on MUACZ. Wasting based on WLZ is presented in Supplementary Fig. S9. Classification is as follows: None ≥ −2 z-score (dark grey); Moderate < −2 to ≥ −3 z-score (light grey); Severe < −3 z-score (orange). Each flow line depicts how an individual child changes between initial group at admission (x-axis, left) and their nutritional classification at discharge (center), and 180-days post-discharge (right). Y-axis presents stacked child counts. Tables detail the number and percentage of children in each trajectory pattern seen between discharge and 180-days. NW, no wasting; MW, moderately wasted; SW, severely wasted; NO, nutritional oedema. LAZ, length-for-age z-score; WAZ, weight-for-age z-score, MUACZ, mid upper arm circumference z-score; WLZ, weight-for-length z-score.

Fig. 3

Forest plots present the association between each post-discharge growth metric and clinical variables or exposure domains. Plotted coefficients for a) common syndromes diagnosed at admission (i.e., anaemia, diarrhoea, severe pneumonia, and sepsis) and b) exposure domains and other clinical variables (i.e., HIV status, birth size, chronic medical condition, and prior hospitalisation). Stars indicate variables that significantly improved model fit compared to the ‘base’ models (Significance threshold, p < 0.025). The ‘base’ piecewise mixed models included a single knot point at 45-days post-discharge with adjustment for age, and sex with random slopes per participants and random intercepts for sites with participants nested within. Full model results for LAZ, WAZ, MUACZ, and WLZ are presented in Supplementary Tables S20–S47, respectively. LAZ, length-for-age z-score; WAZ, weight-for-age z-score; MUACZ, mid-upper arm circumference z-scores; WLZ, weight-for-length z-score.