Solutions to malnutrition in children are not straightforward. Even a logical approach, like supplying adequate supplementary sources of nutrients, is fraught with confounding barriers.
In northern Nigeria, the problem of malnutrition is compounded by a high rate of sickle cell anemia. Michael R. DeBaun, M.D., M.P.H., director of the Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease at Vanderbilt University Medical Center, and his team have unveiled the landscape of sickle disease and malnutrition to create a comprehensive understanding of health risks.
DeBaun’s mentee, Lauren Klein, M.D., led one such study that measured the impact of maternal depression on a child’s growth. Individuals studied were malnourished children, aged 5 to 12, with sickle cell anemia.
“We wanted to learn more about the biology of treating malnutrition by adding more calories, more protein,” said Klein, an instructor of pediatric gastroenterology, hepatology and nutrition at Vanderbilt. “But we were also thinking about the nutrition ecosystem and how malnutrition develops and responds to treatment. One of the considerations is maternal depression.”
Claire Ritter, a medical student at Meharry Medical College, analyzed the data for this project under Klein’s supervision and wrote the paper for the 12-week study.
“We were also thinking about the nutrition ecosystem and how malnutrition develops, and one of the things that is a consideration is maternal depression.”
“We found there was a modest but significant negative association between maternal depression score and BMI,” Ritter said. “So, it’s a factor – among multiple others – that we should consider in vulnerable populations like this one.”
High-Risk, Vulnerable Children
Children with sickle cell anemia are at higher risk of malnutrition and death than those without the disease.
“We consider this a very high-risk, vulnerable population,” Klein said. “When I was a fellow, the first thing that we looked at was the impact of malnutrition in children with sickle cell disease. We found that these children were much more likely to die young.”
This is heightened in low-income settings, which see higher rates of death among children with sickle cell disease than high-income settings.
Depression Link
To explore variables that influence BMI growth, the Vanderbilt researchers, along with Shehu Abdullahi, co-primary investigator in Kano, Nigeria, supplied 108 pairs of mothers and children with Plumpy’nut, a packaged food consisting of peanut paste, sugar, oil, milk powder, vitamins, and minerals.
Over 12 weeks, almost all the Plumpy’nut packages were returned, as requested, and all were empty.
The team used the PHQ-9 instrument that has been validated in this population to screen for maternal depression beginning at baseline and throughout the 12-week study period, while the children were being treated for malnutrition. At baseline, 25.7 percent of mothers (26 of 101) screened positive for at least mild depression.
“What we found was that the negative associations with the children’s BMIs that rose on a steady gradation with higher depression scores.”
“What we found was a negative association with the children’s BMIs that mirrored higher depression scores along a steady gradation,” Ritter said.
Reasons Obscured
Among the premises of the study was that sufficient supplies of calories and protein and micronutrients will allow children to grow to their genetic potential. However, given the higher energy needs of someone with sickle cell anemia, even adequate food supplies gave no guarantee that the child was properly nourished.
“There are multiple possibilities,” Klein said. “Is the higher depression a reflection of a mother’s degree of hardship? If she’s given extra food, even though it is meant only for that child, does she give some to another hungry child in her family? Is she as nurturing as a mother without depression? Does she notice when the child is hungry?”
Through focus groups, Klein and her team looked at some potential drivers of maternal depression, including marital status, number of children, and education.
“Ultimately, I think all those things play a role,” Klein said. “But there are so many factors you have to consider – biological, societal, and socioeconomic.”
Moving Toward Treatment
While Klein plans to investigate these further, she says not knowing all the “whys” doesn’t have to delay interventions to treat depression.
“Even if these women and family members have just have a little bit more hardship or a slightly elevated depression score, we should think about interventions to help them,” she said. “We have a working relationship with a psychiatrist in Nigeria, and if the mothers are open to a referral, they can be seen.”
She is now launching an educational initiative through the Katherine Dodd Faculty Scholars Program to help prevent malnutrition in children with sickle cell anemia who are between six to 18 months old, around the time of transition from exclusive breastfeeding to the addition of table food.
A Useful Microcosm
Klein points out that the problems faced by the study population – including malnutrition and sickle cell disease, maternal depression, and limited access to foods – are also present here in the United States.
“The rates of malnutrition and sickle cell disease are higher in northern Nigeria, so it’s a little easier to get a large study population together in that setting, but all those issues exist here,” she said. “We can and should create interventions that are wide-reaching.”
