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    • What can be done to reduce morbidity and mortality

    2019-05-21

    What can be done to reduce morbidity and mortality in HEU infants? Notably, a third of all mortality in the Botswana trial occurred early, before randomisation. Similarly, in a trial of more than 14 110 infants in Zimbabwe, done in the pre-MTCT-prevention era, HIV-exposed uninfected infants had 50% more hospital admissions than HIV-unexposed infants in the first 4 weeks of life. We suggest that a package of interventions might be required from birth to most effectively reduce morbidity and mortality in HEU infants. HEU infants have no specific follow-up before age 4–6 weeks, despite this being the period of highest risk, and loss to follow-up in MTCT prevention programmes is high. Future trials of alternative vaccination and prophylaxis approaches from birth might be required to improve outcomes for this growing population of infants.
    More than 15 million infants worldwide are born preterm every year, and complications related to preterm birth are a leading cause of death for children younger than 5 years. Incidence of preterm birth is increasing in most countries, with substantial long-term costs to survivors, their families, and society. Breastfeeding by the mother improves a range of short and long-term outcomes, but most preterm infants exhibit poor growth during initial hospital stay and in the post-discharge period. Some evidence suggests that this poor growth is associated with worse neuro-developmental outcomes in later infancy and childhood, but the optimal nutritional strategy and pattern of growth is uncertain. In a trial across 3 hospitals in India, Shuchita Gupta and colleagues examined the effect of introducing complementary feeding (defined as semisolid, soft, or solid foods other than breast, formula, or animal milk) at 4 months compared to 6 months corrected age. This is an area of management with little high quality data, but where the higher nutrient density provided by complementary feeding might theoretically improve measures of growth, body composition, and dhfr inhibitors growth. They show that earlier introduction of complementary feeding had no measurable impact on growth, metabolic or neuro-development at 12 months of age, but did result in an increased rate of hospital admission primarily due to infectious disease. Complementary feeding is a complex intervention with multiple potential biological and behavioural effects over the life-course. Despite counselling and the provision of written materials to parents, less than two thirds of the infants in the study achieved a minimal acceptable diet, leading the authors to comment that innovative approaches are required to supplement the counselling in order to achieve the recommended dietary standards in this population. In this context, the lack of beneficial effect of the intervention is perhaps not surprising since milk (whether breast milk or formula) might have been displaced by complementary feeding with inferior nutritional value. Furthermore, the secondary outcome of a significantly increased rate of hospital admission in the 4 month group (18·1%) compared to the 6 month group (9·4%, risk ratio 1·9, 95% CI 1·0–3·3) in combination with earlier hospital admissions in the 4 month group, suggests the intervention might have resulted in an increased risk of pathogen exposure due to poor hygiene in semi-solid food preparation, although decreased ingestion of beneficial breast milk components in the 4 month group should also be considered. Out of 1677 infants who were eligible at birth, 578 (34%) died prior to discharge, and of those discharged alive, 114 (10%) died before 4 months of age, emphasising that the risk of death from preterm birth is much higher dhfr inhibitors than in higher income country settings. Infants who were enrolled lost 1 weight-for-age Z score (WAZ) between birth and discharge, and a further 1 WAZ between discharge and 40 weeks post-menstrual age. This early and dramatic growth failure occurred at a stage of development when brain growth is rapid and when poor nutritional status (manifested by poor growth) might impair long-term outcomes. However, given the absence of effect of the complementary feeding intervention on growth, it is not surprising that there was no effect on body composition or neuro-development at 12 months corrected age, or on markers of the metabolic syndrome.