title: Medium- and long-term outcomes after exposure to severe childhood malnutrition
Creators: name: Kirolos, Amir
Publisher: name: University of Liverpool Repository
Year: 2024

description: Background:
Research on severe childhood malnutrition remains neglected despite its high mortality and
disease burden. Despite improved treatment which has allowed more to survive to
adulthood, it remains persistent and problematic. Most research focuses on the acute
presentation and little evidence is available on long-term outcomes, though recent studies
suggest associations with impaired cognition, behaviour, and higher cardiometabolic disease
risk.

Methods:
I conducted a systematic review of MEDLINE, EMBASE, Global Health, and PsychINFO, and
used synthesis without meta-analysis guidelines to compile studies investigating severe
childhood malnutrition in three outcome areas: neurodevelopment, cognition,
behaviour/mental health.
I followed up a cohort of severely malnourished children in Blantyre, Malawi 15 years after
treatment (median age: 17.1 years). I assessed anthropometry, body composition
(bioelectrical impedance analysis), strength (hand grip strength, standing long jump
distance), blood pressure, lipid profile, glucose tolerance, cognition (CANTAB assessment),
and behaviour &amp; mental health (PHQ-9, GAD-7, Strengths &amp; Difficulties Questionnaire, Child
Behaviour Checklist (CBCL)). I compared these outcomes to siblings and adolescents from
the community (both without a history of severe malnutrition) using linear regression
models which adjusted for age, sex, disability, HIV, and socioeconomic status.

Findings:
Of previous studies identified, 6/9 found an association with impaired neurodevelopment,
7/7 with poorer school achievement, 8/11 with impaired cognition, and 5/7 with
behavioural problems. Interpretation of results was limited by many studies not accounting
for important confounders, and few investigating specific mental health conditions.
I recruited 168 ex-malnourished adolescents, 123 siblings, and 89 community adolescents.
Ex-malnourished adolescents had lower height-for-age z scores (HAZ) compared to both
siblings (HAZ adjusted difference -0.32 [95% CI -0.58, -0.05]) and community adolescents (-
0.21 [95% CI -0.52, 0.10]). Ex-malnourished adolescents’ (difference 0.33 95% CI [0.20,
0.46]) and siblings’ (0.32 95% CI [0.09, 0.55]) mean HAZ improved between late childhood
and adolescence, while community adolescents’ HAZ did not (0.01 95% CI [-0.24, 0.23]). I
found evidence of persistent grip strength deficits compared to community adolescents
(adjusted difference -2.0kg [95% CI -4.2, 0.3]) and higher CBCL internalising symptoms
compared to siblings (adjusted difference 2.8 [95% CI 0, 5.5]). There was little difference in
body composition, blood pressure, lipid profile, glucose tolerance, cognition, behaviour, and
other mental health measures between ex-malnourished adolescents and unexposed
groups.

Interpretation:
From the systematic review, I found strong evidence that severe childhood malnutrition
impairs neurodevelopment and school achievement, and moderate evidence it impairs
cognition and behaviour. There was little evidence however of these impairments in the
adolescent cohort.
Results from the cohort imply that growth and clinical catch-up of survivors into
adolescence is possible. Ex-malnourished adolescents had weaker grip strength compared
to community adolescents, though compared to siblings (despite deficits in childhood
compared to both). There was little difference in cardiometabolic disease risk measures, but
results are limited by participants’ still relatively young age, ‘healthy survivor’ bias, and loss
to follow-up.
Interventions should consider the needs of survivors beyond early childhood to maximize
outcomes. Policy must address associated adversities which likely impact long-term
outcomes; including comorbidities (particularly HIV in this setting), chronic malnutrition,
and home &amp; school environments.