Early childhood malnutrition is a global public health problem with serious short- and long-term consequences. The aim of this thesis is to evaluate the effects of psychosocial stimulation (PS) with or without food supplementation (FS) on growth and development of severely malnourished children, quality of home environment, mother’s child-rearing practices and depressive symptoms. The study setting was Dhaka, Bangladesh, and the participants were severely malnourished children, aged 6-24 months, admitted at Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). A hospital-based study was conducted in Nutrition Rehabilitation Unit of ICDDR,B hospital, where a control group (n=43) was studied initially, followed by an intervention group (n=54). All received standard nutrition rehabilitation care. The intervention group received daily group meetings and play sessions in the hospital, and was thereafter visited at home for 6 months. A community-based randomised trial was conducted including children (n=507) admitted at hospital for initial treatment of an acute infection, and thereafter assigned to PS, FS, PS+FS, clinic control or hospital control groups. PS was delivered at follow-up visits, fortnightly for 6 months at community clinics. FS included distribution of cereal-based food packets (150–300 kcal/day depending on age) for 3 months. All groups received standard medical care and micronutrient supplementation. In the hospital-based study, the intervention group had significantly higher scores in mental (p<0.001, effect size 0.52 SD) and motor development (p=0.047, effect size 0.37 SD), and weight (p=0.03, effect size 0.39 SD), after 6- months intervention. In the community-based trial, there was a significant effect of stimulation after six months of intervention on children’s mental development (group*session interaction p=0.037, effect size=0.37 SD) and weight (group*session interaction p=0.02, effect size=0.26 SD) but no effect on motor development or linear growth. The PS+FS and PS groups differed in total HOME score, two HOME subscales (maternal involvement and play materials), and in mother’s child- rearing practices scores but not in depressive symptoms. PS with or without FS had small improvement on children’s growth and development, quality of home environment and mother’s rearing-practices of severely malnourished children. More intensive interventions with longer duration are therefore recommended.

Background. Swaziland adopted the World Health Organization’s (WHO) guidelines for the inpatient treatment of severely malnourished children in 2007 to reduce case -fatality rates for childhood malnutrition. However, no follow-up studies have been conducted to determine the reduction in the case -fatality rate post-implementation of the guidelines. Objectives. To determine the case -fatality rate for childhood malnutrition post-implementation of the WHO treatment guidelines and determine the level of adherence to the guidelines at Mbabane Government Hospital. Methods. A retrospective observational study was undertaken. All children under 5 years admitted for inpatient treatment of malnutrition between January 2010 and December 2011 had their demographic-, anthropometric- and clinical characteristics recorded and analysed, as well as the outcome of admission. Results. Of the 227 children admitted during the study period, 179 (64.6%) were severely malnourished and 98 (35.4%) had moderate malnutrition. One-hundred-and-eleven children died during admission, an overall case -fatality rate of 40.1%. Mortality was significantly higher among severely malnourished children compared to those with moderate malnutrition, (46.9% vs 27.6%, OR 3.0 (95% CI 1.7 to 5.3)). Comorbid pneumonia and gastroenteritis were significant predictors of mortality – , OR 2.0 (95% CI 1.2 to 3.4) and 1.9 (95% CI 1.1 to 3.2) respectively. Conclusion. Case -fatality rates for childhood malnutrition remain high, despite adoption of the WHO treatment guidelines. A need exists for improved adherence to the WHO guidelines and periodic clinical audits to reduce deaths from childhood malnutrition to meet the WHO mortality target of less than 5% and improve child survival. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Clinical Epidemiology / unrestricted