Prevalence of malnutrition among children at primary cleft surgery: A cross-sectional analysis of a global database
Authors: Delage Barbara , Kerac Marko , Stieber Erin , Sheeran Pamela 
Published: January 2021

SummaryBackgroundOrofacial clefts are common birth defects requiring prompt feeding support and timely surgery. Little information exists about the impact of inadequate care provision in poor-resource settings. We aimed to estimate the burden of malnutrition in children from 101 low- and middle-income countries (LMICs) using cleft surgery records collected by one cleft NGO.MethodsWe conducted a cross-sectional study using anonymised records of children ≤5 years who underwent cleft surgery between 2008 and 2018. The data included birth date, gender, weight at surgery, ethnicity, country of origin, and date of primary surgery and was analysed using descriptive statistics. The prevalence of malnutrition was derived from the generation of weight-for-age z scores and described in relation to cleft type, gender, and ethnicity/geography. For purpose of comparison, the most recent prevalence estimates for underweight in children under-5 were extracted from publicly available national surveys.FindingsThe analysis included 602,568 children. The overall prevalence of underweight at the time of primary cleft surgery was 28·6%–a figure well above the global underweight prevalence in under-5 children without cleft estimated at about 13·5%. The prevalence of underweight varied with the age at primary surgery and the type of cleft, as well as with gender, ethnicity, and region of origin, and was positively correlated with country-specific estimates of underweight prevalence in children without cleft.InterpretationOur findings support the need for advancing universal health coverage with special efforts to increase timely nutrition care and access to surgery for the most disadvantaged children.FundingNone.Research in contextEvidence before this studyRegardless of the setting, infants born with an orofacial cleft have a heightened risk of failure to thrive (FTT), especially when their ability to suck and swallow is compromised.(1-3) Timely identification of feeding problems and appropriate nutrition support are essential to ensure healthy child development.(4-6) Limited access to (specialist) care in LMICs increases the risk of FTT in babies with unrepaired cleft, yet limited research has described the extent of the problem in these settings.We searched Medline and Google Scholar up to April 2020 for studies that estimated the scale of malnutrition in children with cleft born in limited-resource settings. A 2019 systematic review of the literature identified seven cross-sectional or case-control studies conducted in LMICs (three in Africa(7-9), three in Latin America(10-12), one in Iran(13)).(14) We excluded one study in Brazil(10) which did not estimate undernutrition and found one additional cross-sectional study from South Africa.(15) Overall, seven hospital-based studies published between 1999 and 2017 included a total of 2,300 children <5 years old. They all provided evidence of malnutrition in this population, yet none was designed to give a global prevalence estimate.Added value of this studyThis study is the first that attempted to provide a global prevalence estimate of malnutrition in children with unrepaired cleft in LMICs. Using pre-surgery clinical records from over 600,000 of patients operated by Smile Train’s global partners, we identified underweight in 28·6% of children ≤5 years. Country-specific figures ranging from 6·9% in Kazakhstan to 48·2% in Chad were above national statistics on the prevalence of underweight in children in the general populations. Cleft epidemiology contributes to variations in malnutrition rates across LMIC settings but do not explain health disparities between children with cleft and those without cleft within countries.Implications of all the available evidenceThere is an urgent need to identify and/or address the barriers that prevent children with cleft from receiving immediate feeding and nutritional support and timely reparative surgery. Current health services and nutrition programmes in LMICs should consider opportunities to help meet the health care needs of these children. Poor early-life nutrition has well-documented detrimental consequences on child physical, functional, and cognitive development. Accordingly, a higher prevalence of malnutrition in children born with a cleft means that this population likely experiences higher rates of morbidity and mortality – even if they are eventually operated.