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Linear growth following complicated severe malnutrition: 1-year follow-up cohort of Kenyan children
  1. Moses M Ngari1,2,
  2. Per Ole Iversen3,4,5,
  3. Johnstone Thitiri1,2,
  4. Laura Mwalekwa1,
  5. Molline Timbwa1,2,
  6. Greg W Fegan1,6,
  7. James Alexander Berkley1,2,7
  1. 1 KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
  2. 2 Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
  3. 3 Department of Nutrition, IBM, University of Oslo, Oslo, Norway
  4. 4 Department of Hematology, Oslo University Hospital, Oslo, Norway
  5. 5 Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
  6. 6 Swansea Trials Unit, Swansea University Medical School, Swansea, UK
  7. 7 Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
  1. Correspondence to Moses M Ngari, KEMRI/Wellcome Trust Research Programme, Kilifi 230-80108, Kenya; mngari{at}


Background Stunting is the most common manifestation of childhood undernutrition worldwide. Children presenting with severe acute malnutrition (SAM) are often also severely stunted. We evaluated linear growth and its determinants after medically complicated SAM.

Methods We performed secondary analysis of clinical trial data (NCT00934492) from HIV-uninfected Kenyan children aged 2–59 months hospitalised with SAM. Outcome was change in height/length-for-age z-score (HAZ) between enrolment and 12 months later. Exposures were demographic, clinical, anthropometric characteristics and illness episodes during follow-up.

Results Among 1169 children with HAZ values at month 12 (66% of those in original trial), median (IQR) age 11 (7–17) months and mean (SD) HAZ −2.87 (1.6) at enrolment, there was no change in mean HAZ between enrolment and month 12: −0.006Z (95% CI −0.07 to 0.05Z). While 262 (23%) children experienced minimal HAZ change (within ±0.25 HAZ), 472 (40%) lost >0.25 and 435 (37%) gained >0.25 HAZ. After adjusting for regression to the mean, inpatient or outpatient episodes of diarrhoea and inpatient severe pneumonia during follow-up were associated with HAZ loss. Premature birth and not being cared by the biological parent were associated with HAZ gain. Increases in mid-upper arm circumference and weight-for-age were associated with HAZ gain and protected against HAZ loss. Increase in weight-for-height was not associated with HAZ gain but protected against HAZ loss. No threshold of weight gain preceding linear catch-up growth was observed.

Conclusions Interventions to improve dietary quality and prevent illness over a longer period may provide opportunities to improve linear growth.

  • malnutrition
  • undernutrition
  • stunting
  • growth
  • height

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  • Contributors MMN designed the study, performed statistical analysis and wrote the first manuscript draft. POI and GWF provided supervision and advice on design, analysis and interpretation of the results. JT, LM and MT were responsible for clinical care and data collection. JAB was the principal investigator of the original trial, and offered overall supervision in design, analysis and interpretation of study results. All authors reviewed and agreed on the final manuscript.

  • Funding The trial was funded by the Wellcome Trust (grant number WT083579MA) awarded to JAB. JAB and MMN are currently supported by the Bill & Melinda Gates Foundation, including for this analysis, within the Childhood Acute Illness and Nutrition (CHAIN) Network (grant number OPP1131320).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Kenya National Ethical Review Committee (SSC 1562) and the Oxford Tropical Research Ethics Committee (OXTREC reference 18-09)

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Managed access to the original trial clinical and anthropometric data may be sought by writing to

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