Regular Growth Monitoring (RGM) of Young Children in Guinea-Bissau

Wasting is prevalent in rural Guinea-Bissau villages and adversely affects child health and cognitive development long-term. Prior work by this team of investigators suggests that regular feedback from Community Health Agents (CHAs) to caregivers, including recommendations of locally available nutritious recipes for at-risk children, may reduce the incidence of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). However, routine growth monitoring (RGM) has been largely unfeasible at the village level due to measurement complexity and limited training resources. Modern technology and artificial intelligence may help make this more scalable.

This is a proof-of-concept, sequential pilot study conducted in two villages in Guinea-Bissau with which the team has an established relationship. Baseline anthropometric measurements will be collected on all eligible children (aged 6 months to 5 years, without SAM at enrollment) in both villages. Children identified with SAM at baseline will be referred to the local malnutrition clinic and excluded from the study.

One village will begin the RGM intervention immediately after baseline data collection. The second village will begin the intervention after final data collection in the first village. Assignment order will be by PI decision rather than randomization, as required by the collaborating UCSF team members.

During the RGM period, CHAs will screen each child monthly using all three mid-upper arm circumference (MUAC) methods: (1) WHO tape measure (reference standard), (2) arm photograph, and (3) bracelet. Data will be entered into a secure REDCap database. Children meeting SAM criteria (by tape measure) will be referred to tertiary care; children with MAM will receive weekly CHA nutrition education on local recipes. Measurements collected at baseline and end-of-study include: weight, height, MUAC by all three methods, skinfold thicknesses (biceps and triceps), and family demographics.

After study completion, brief questionnaires will be administered to parents, CHAs, and Ministry of Health staff to assess perceived effects, acceptability, feasibility, and preferences among the monitoring methods. This study has been approved by both the Dartmouth College CPHS and the Ministry of Health in Guinea-Bissau.

• Regular Growth Monitoring (RGM) by Community Health Agents (Behavioral): Monthly malnutrition screening by Community Health Agents (CHAs) using three MUAC methods: (1) WHO standard tape measure, (2) arm photograph for remote review, and (3) a solid bracelet device. The tape measure is the reference standard. Children identified with SAM are referred to a tertiary malnutrition clinic; children with MAM have their caregivers provided with weekly education on using local nutritious recipes to support recovery. Data are entered into REDCap and reviewed remotely by the US research team.

Primary outcomes

• Prevalence of severe acute malnutrition (SAM) [Baseline to study completion (~4 months)]: Proportion of enrolled children meeting SAM criteria (by WHO tape measure MUAC) at study completion, compared between early-start and delayed-start villages.

Secondary outcomes

• Prevalence of moderate acute malnutrition (MAM) [Baseline to study completion (~4 months)]: Proportion of enrolled children meeting MAM criteria (by WHO tape measure MUAC) at study completion, compared between early-start and delayed-start villages.
• Weight-for-length z-score [Baseline to study completion (~4 months)]: Change in weight-for-length z-score between baseline and final assessment, compared between early-start and delayed-start villages
• Weight-for-age z-score [Baseline to study completion (~4 months)]: Change in weight-for-age z-score between baseline and final assessment, compared between early-start and delayed-start villages.
• Length-for-age z-score [Baseline and study completion (~4 months)]: Change in length-for-age z-score between baseline and final assessment, compared between early-start and delayed-start villages

Other outcomes

• Agreement of new RGM methods vs. reference standard [Assessed at each study visit (monthly from baseline to 4 months follow-up)]: Accuracy of the arm photograph and bracelet for detecting MAM and SAM relative to the WHO tape measure MUAC.
• Acceptability and feasibility of RGM methods [N/A, data collected at study completion (4 month visit)]: Perceived acceptability and feasibility of the three MUAC monitoring methods among parents, CHAs, and Ministry of Health staff, collected via brief structured questionnaires.

Sex: All, ages: 6 Months to 5 Years, accepts healthy volunteers

Inclusion Criteria:

* Children aged 6 months to 5 years residing in one of the two selected villages in Guinea-Bissau
* Caregiver willing to enroll the child in the study (verbal consent provided)
* Caregiver can provide birth certificate or documentation of child's age
* Child does not have severe acute malnutrition (SAM) at the baseline assessment

Exclusion Criteria:

* Children diagnosed with severe acute malnutrition (SAM) at baseline (these children will be referred to the local malnutrition clinic)
* Children whose caregivers do not wish to participate

• Susan B. Roberts, Ph.D., Principal investigator, Dartmouth College