Correlates of whole-blood polyunsaturated fatty acids among young children with moderate acute malnutrition

RESEARCH Open Access Co ela es o whole-blood polyunsa u a ed a y acids among young child en wi h mode a e acu e malnu i ion C. W. Yaméogo 1,2,3* , B. Cichon 2 , C. Fabiansen 2 , M. J. H. Ry e 2 , D. Fau hol -Jepsen 2,4 , K. D. S a k 5 , A. B iend 2,6 , S. Shephe d 7 , A. S. T ao é 1 , V. B. Ch is ensen 2,8 , K. F. Michaelsen 2 , H. F iis 2 and L. Lau i zen 2 Abs ac Backg ound: Se e e acu e malnu i ion (SAM) has been associa ed wi h low polyunsa u a ed a y acid (PUFA) s a us. Howe e , in es iga ions ega ding PUFA s a us and co ela es in child en wi h mode a e acu e malnu i ion (MAM) om low-income coun ies a e sca ce. The aim o his s udy was o desc ibe whole-blood PUFA le els in child en wi h mode a e acu e malnu i ion (MAM) and o iden i y co ela es o PUFAs. Me hods: We conduc ed a c oss-sec ional s udy using baseline da a om a p ospec i e nu i ional in e en ion ial among 1609 child en wi h MAM aged 6–23 mon hs in Bu kina Faso,Wes A ica. Whole-blood PUFAs we e measu ed by gas ch oma og aphy and exp essed as pe cen o o al whole-blood a y acids (FA%). Po en ial co ela es o PUFAs including in ec ion, in lamma ion, hemoglobin, an h opome y (di e ence be ween child en diagnosed as ha ing MAM based on low mid-uppe -a m-ci cum e ence (MUAC) only, low MUAC and weigh - o -heigh z-sco e (WHZ), o low WHZ only) and die we e assessed by linea eg ession adjus ed o age and sex. Resul s: Child en wi h MAM had low concen a ions o whole-blood PUFAs, pa icula ly n-3 PUFAs. Mo eo e , child en diagnosed wi h MAM based only on low MUAC had 0.32 (95% con idence in e al (CI), 0.14; 0.50) and 0.40 (95% CI, 0.16; 0.63) FA% lowe a achidonic acid (AA) han hose ec ui ed based on bo h low WHZ as well as low MUAC and hose ec ui ed wi h low WHZ only, espec i ely. In ec ion and in lamma ion we e associa ed wi h low le els o all long-chain (LC)-PUFAs, while hemoglobin was posi i ely associa ed wi h whole-blood LC-PUFAs. Conclusion: While PUFA de iciency was no a gene al p oblem, o e all whole-blood PUFA concen a ions, especially o n-3 PUFAs, we e low. In ec ion, in lamma ion, hemoglobin, an h opome y and die we e co ela es o PUFAs concen a ions in child en wi h MAM. T ial egis a ion: The ial is egis e ed a h p://www.is c n.com (ISRCTN42569496). Keywo ds: Essen ial a y acids, Unde nou ished child en, Die , Mo bidi y In oduc ion App oxima ely, 33 million child en wo ldwide su e om mode a e was ing [1]. The cu en case de ini ion o mod- e a e acu e malnu i ion (MAM) includes child en wi h mode a e was ing, de ined as a weigh - o -heigh z-sco e (WHZ) be ween -2 and -3, based on he 2006 WHO g ow h s anda d [2], and/o child en wi h a mid-uppe - a m ci cum e ence (MUAC) be ween 115 and 125 mm [3]. Child en wi h MAM a e a immedia e isk o mo bidi y and mo ali y om in ec ious diseases [4, 5], and may p esen wi h lipid me abolism dis u bances likely o impai blood le els o polyunsa u a ed a y acids (PUFAs) [6]. Tissue concen a ions o PUFAs a e e lec ed in he a y acid composi ion o plasma and e y h ocy es and he amoun o a ious PUFAs in hese pools has been shown o be low in child en wi h se e e malnu i ion [7, 8]. Lim- i ed da a exis on ea ly li e in ake and blood le els o * Co espondence: [email p o ec ed] 1 Cen e de Reche che en Sciences Biologiques, Alimen ai es e Nu i ionnelles, Uni e si é Ouaga I P o Joseph KI-ZERBO, Ouagadougou, Bu kina Faso 2 Depa men o Nu i ion, Exe cise and Spo s, Uni e si y o Copenhagen, F ede iksbe g C, Denma k Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2017 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. Yaméogo e al. Nu i ion Jou nal (2017) 16:44 DOI 10.1186/s12937-017-0264-3 PUFAs in low-income coun ies among malnou ished child en [9]. The a y acid composi ion in plasma o ed blood cells om child en wi h mode a e malnu i ion has only been in es iga ed in wo s udies wi h small samples sizes [7, 10]. Howe e , in hese s udies included child en wi h mode a e s un ing and/o unde weigh a he han was ing and used di e en g ow h e e ences a he han he cu en WHO g ow h s anda ds om 2006 [2]. No s udy was ound ha in es iga ed a y acids in child en wi h MAM based on he abo e de ini ion and compa ed he a y acid composi ion in whole-blood be ween chil- d en diagnosed wi h MAM based on low MUAC only, low MUAC and WHZ, o low WHZ only. PUFAs play an impo an ole in ea ly li e because hey a e needed o ensu e op imal g ow h and de elopmen o all o gan sys ems [11]. Mo e speci ically, linoleic acid (LA), α-linolenic acid (ALA), docosahexaenoic acid (DHA) and a achidonic acid (AA) a e in ol ed in nume - ous me abolic p ocesses in addi ion o ac ing as a sou ce o ene gy [12]. LA, inco po a ed in skin ce amides, is o g ea impo ance o skin ba ie in eg i y [13]. DHA is abundan in he cells o he cen al ne ous sys em and is impo an o b ain de elopmen [14]. Fu he mo e, DHA and AA a e inco po a ed in o cell memb ane phospho- lipids and a e p ecu so s o lipid media o signalling mole- cules [15, 16], which play impo an oles, among o he s, in he immune sys em [17]. Conside ing hese impo an unc ions, mo e a en ion should be paid o PUFA s a us in child en wi h MAM and i should be in es iga ed how blood PUFA composi ion co ela es wi h ac o s such as die , in ec ions (e.g. dia hea, mala ia), in lamma ion and anemia and whe he he e is an associa ion be ween PUFAs and an h opome y. P e ious s udies in es iga ing blood PUFA composi ion in Bu kina Faso, Wes A ica, ha e been unde aken in popula ions no su e ing om MAM and in he cen al egion [18–20], an a ea o he coun y whe e g oundnu s a e widely a ailable and die s a e high in a [21]. Ou s udy was ocused on whole-blood PUFA composi ion among 6–23 mon hs-old child en wi h MAM om he no he n egion in Bu kina Faso, whe e ood insecu i y is common. The aim o he s udy was 1) o desc ibe whole- blood PUFA composi ion in child en wi h MAM and 2) o iden i y co ela es (e.g. hemoglobin, acu e phase p o- eins, clinical in ec ion, an h opome y and die ) o PUFA composi ion. Subjec s and me hods S udy se ing and pa icipan s This is a c oss-sec ional s udy using baseline da a om a p ospec i e nu i ional in e en ion ial among 1609 child en wi h MAM aged 6–23 mon hs. The s udy ook place in he P o ince du Passo é, Bu kina Faso, a i e local go e nmen al heal h cen e s (Gomponsom, La oden, Baga é, Bokin and Samba). The ec ui men a ea co e ed a o al o 143 illages and a popula ion o app oxima ely 258,000. Rec ui men ook place om Sep embe 2013 o Augus 2014. Child en, aged 6–23 mon hs, esiding in he ec ui - men a ea we e in i ed o pa icipa e i hey we e diag- nosed wi h MAM; based on a WHZ be ween -3 and -2 based on he 2006 WHO g ow h s anda d [2] and/o MUAC be ween 115 mm and 125 mm [3]. Child en we e excluded i hey we e ea ed o SAM, i hey we e al eady in a nu i ional p og am o i hey had been hospi alized wi hin he pas 2 mon hs, had med- ical complica ions equi ing hospi aliza ion, o a se- e e disabili y. Socio-demog aphic, clinical and die da a collec ion A local nu se ca ied ou a clinical examina ion and col- lec ed da a on sociodemog aphic cha ac e is ics as well as 2 week e ospec i e mo bidi y. Fe e was de ined as an axilla y empe a u e ≥37.5 °C [22]. The nu se also collec ed da a on b eas eeding and he child ens’die using s uc u ed ques ionnai es adminis e ed o he ca e ake s by ained in e iewe s. Wi h ega d o b eas eeding, ca e ake s we e asked whe he he child was e e b eas ed, cu en ly b eas ed and i so how many imes he child was b eas ed in he p e ious 24 h. Die a y da a was collec ed using a quali a i e 24-h ecall in e iew. Mo e speci ically, ca e ake s we e asked wha he child en consumed in he p e ious 24-h, bu no quan i ies we e eco ded. I a pa icula dish was men- ioned, ca e ake ’s we e asked o lis he ing edien s. In- o ma ion eco ded du ing he quali a i e 24-h ecall in e iew was hen used o comple e he ood g oup lis sec ion o he ques ionnai e by answe ing “yes”o “no” o each ood g oup. The lis o 25 ood g oups was based on in e na ionally a ailable ques ionnai es om WHO [23], FAO [24] as well as esea ch abou die s in Ouagadougou ca ied ou by he Ins i u de Reche che e Dé eloppemen [25] and adap ed o he local con ex using die a y in o ma ion collec ed du ing he T ea ood pilo s udy. Fo easons o simplici y, he 25 ood g oups was hen agg ega ed in o eigh ood g oups, namely i) ce eals, oo s, and ube s; ii) legumes and nu s; iii) liquid oils and a s; i ) dai y; ) lesh oods; i) eggs; ii) i amin A- ich ui s and ege ables o iii) o he ui s and eg- e ables as sugges ed by WHO [23]. Blood sampling and analyses Du ing he medical examina ion up o 2.5 mL o none as ing enous blood we e collec ed by phlebo omy using needle and sy inge. One d op o blood was used o ca y ou apid an igen es o Plasmodium alcip- a um mala ia (SD Bioline, Mala ia an igen P. .), and a second d op o de e mina ion o hemoglobin le el by Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 2 o 11 Hemocue (HB 301, Ängelholm, Sweden). A hi d d op was used o sa u a e 1 cm 2 o a ch oma og aphy pape s ip ea ed wi h 50 μg 2,6-di- e -bu yl-4-me hylphenol (bu yla ed hyd oxy oluene) and 1000 μg de e oxamine mesyla e sal (bo h om Sigma-Ald ich, S . Louis, MI, USA) as desc ibed p e iously [26]. The blood spo s we e allowed o ai d y and hen he pape s ip we e kep in cold boxes in he ield and s o ed in zip lock plas ic bags a 4 °C un il shipmen o Canada. The emaining blood sample was pu in o a ube wi h clo ac i a o (BD ube e e ence #368492; Bec on, Dickinson and Company, F anklin Lakes, USA) and anspo ed in a coldbox a 2– 8 °C o he ial lab, whe e se um was isola ed ollowing cen i uga ion a 3000 RPM o 5 min (EBA 20 S He - ich, Tu lingen, Ge many). Se um was s o ed a -20 °C un il shipmen o a labo a- o y in Ge many (Vi amin lab, Wills ae , Ge many) o analysis. Se um C- eac i e p o ein (CRP) and α 1 -acid glycop o ein (AGP) we e de e mined using a simple sandwich enzyme-linked immunoso ban assay [27]. The h esholds used o de ining abno mal alues o CRP and AGP we e as ollows: CRP >10 mg/L [28] and AGP >1 g/L [29]. The a y acid composi ion o whole-blood was ana- lysed as p e iously desc ibed [30, 31]. In b ie , a y acid me hyl es e s we e p epa ed om d ied blood spo s by di ec ans-es e i ica ion in 14% bo on i- luo ide in me hanol (Pie ce Chemicals, Rock o d, IL, USA) wi h hexane using a con ec ional block hea e se a 95 °C o 60 min. The o ganic laye con aining he a y acid me hyl es e s was collec ed o analysis on a Va ian 3900 gas ch oma og aph wi h a CP-8400 au osample (Va ian Inc., Mississauga, ON, Canada) and equipped wi h a DB-FFAP 15 m × 0.10 mm i.d. × 0.10 μm ilm hickness, ni o e eph halic acid modi ied, polye hylene glycol, capilla y column (J&W Scien i ic om Agilen Technologies, Mississauga, ON, Canada). Fas gas ch oma og aphy se ings wi h hyd ogen as he ca ie gas we e used as p e iously desc ibed [30, 31]. Peaks we e iden i ied by e en ion imes h ough compa i- son o an ex e nal mixed s anda d sample (GLC-462, Nu Chek P ep Inc., Elysian, MN, USA). Whole-blood a y acid concen a ion is gi en as (μg a y acid/100 μL whole-blood) and a y acid composi ion da a a e gi en as weigh pe cen o indi idual a y acids ela- i e o he o al a y acid concen a ion in each sam- ple (FA%). Due o lack o cu -o poin s o whole-blood Mead acid and n-6 docosapen aenoic acid (DPA), he a ios Mead acid:AA, n-6 DPA:DHA o n-6/n-3 PUFAs we e used o de ine PUFA de iciency. Based on da a in heal hy well-nou ished Danish in an s (Lau i zen e al. unpub- lished da a), we conside ed a Mead acid:AA a io > 0.02 as an indica o o PUFA de iciency and a a io o n-6 DPA:DHA > 0.2 and a n-6/n-3 PUFA a io > 10.5 was aken o indica e low n-3 PUFA s a us. An h opome ic measu es An h opome ic measu emen s we e done by ained s a , a e s anda disa ion sessions. Weigh was measu ed in duplica e o he nea es 100 g wi h an elec onic scale (Seca model 881 1021659, Seca GmbH & Co. KG, Hambu g, Ge many) wi h double weighing unc ion. Leng h was measu ed in duplica e o he nea es 1 mm wi h a wooden leng h boa d. MUAC was measu ed o he nea es 1 mm a he midpoin be ween he olec anon and he ac omion p ocess using a s anda d measu ing ape. Da a analysis The da a we e doubled en e ed in o Epida a 3.1 so wa e (Epida a Associa ion, Odense, Denma k). The s a is ical analysis and es s we e pe o med in S a a 12 (S a aCo p, College S a ion, TX, USA). A WHO WHZ able was used du ing ec ui men a si es, bu o da a analysis WHZ sco es we e ecalcula ed using he STATA package “zsco e06”. Va iables we e es ed o no mali y using Shapi o-Wilk es s and his og ams. Resul s a e shown as mean ± s anda d de ia ion (±SD) o median (in e qua ile ange (IQR)). The di e ence be ween g oups was analyzed by one-way analysis o a iance (ANOVA) and p- alues om pos -hoc pai wise compa isons ( h ee compa isons o each ANOVA es ) we e Bon e oni adjus ed. Mul i a i- able linea eg ession analysis was pe o med o assess co - ela es o indi idual PUFAs in child en wi h MAM adjus ed o age and sex. S a is ical signi icance was se a p<0.05. Resul s Among he 1609 ec ui ed child en, a o al o 1572 (97.7%) child en had whole-blood a y acids de e - mined and 37 (2.3%) did no ei he due o ailu e o d aw blood o p oblems du ing blood analysis a he lab. Upon ec ui men , 457 (29%), 786 (50%), and 329 (21%) we e diagnosed wi h MAM based on “MUAC only”,“MUAC and WHZ”,and“WHZ only”, espec - i ely, as p e iously epo ed [32]. The median (IQR) age was 11.3 (8.2; 16) mon hs, hal (54.8%) we e gi ls (Table 1) and 95% we e s ill b eas ed. As epo ed elsewhe e [33], co-mo bidi y was common. Among he 1572 child en wi h a y acid da a, 593 (38.1%) child en had been ill in he 2 weeks be o e admission based on ma e nal ecall –he eo 318 (20.2%) wi h e e and 277 (17.6%) wi h dia hea. A ec ui men , 629 (40.2%) had a posi i e mala ia es , 275 (17.5%) had e e and 83 (5.3%) had dia hea. The mean hemoglobin was 10.0 (±1.6) g/dL, while he median CRP and AGP we e 2.3 (0.8; 9.5) mg/L and 1.2 (0.9; 1.6) g/L, espec i ely, and 364 (23.6%) had ele a ed CRP and AGP. Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 3 o 11 The majo i y (85.2%) o he child en had consumed ce eals, oo s and ube s in he p e ious 24 h, while 285 (18.1%), 237 (15.1%), and 454 (28.9%) had consumed li- quid oils and a s, legumes and nu s o i amin A- ich ui s and ege ables, espec i ely (Table 4). Mo e han hal (54.5%) o he child en had also consumed o he s ui s and ege ables. Almos all child en we e b eas ed (95%) and only 6 (0.4%), 60 (3.8) and 107 (6.8%) had ea en eggs, dai y and lesh oods, espec i ely, on he day be o e he examina ion. Concen a ions and co ela es o polyunsa u a ed a y acids The mean weigh pe cen o whole-blood LA and ALA we e 16.22 (±2.26) and 0.21 (±0.09) FA%, espec i ely, while ha o hei espec i e LC-PUFAs, AA and DHA, we e 7.08 (±1.53) and 1.64 (±0.53) FA%, espec i ely (Table 2). The mean Mead acid:AA a io o 0.01 (±0.00) and he gene ally low mean weigh pe cen o Mead acid (0.07 (±0.03) FA%) indica es ha essen ial a y acid de i- ciency was no equen in he pa icipan s. Based on ou de ini ion, only 1.21% o he child en wi h MAM had signs o PUFA de iciency. Howe e , he mean a io o 0.25 (±0.10) be ween n-6 DPA and DHA and he mean n-6/n-3 PUFA a io o 11.23 (±2.85) indica es low n-3 PUFA s a us. The pe cen s o child en who we e abo e he mean a io o 0.25 (±0.10) be ween n-6 DPA and DHA o 11.23 (±2.85) be ween n-6 and n-3 PUFA we e 51.2 and 45.8% espec i ely. Compa isons using ANOVA showed ha child en e- c ui ed based on MUAC only had lowe AA han hose ec ui ed based on bo h MUAC and WHZ (6.88 s. 7.15 FA%, p= 0.007) and WHZ only (6.88 s. 7.19 FA%, p= 0.013), bu highe ALA han hose ec ui ed based on WHZ (0.22 s. 0.20 FA%, p= 0.042) (Table 3). Fu he - mo e, child en ec ui ed based on low MUAC only had lowe EPA han hose ec ui ed wi h WHZ only (0.12 s. 0.14 FA%, p= 0.040). Fu he mo e, mul iple eg ession Table 1 Backg ound da a, an h opome ic, clinical and biochemical cha ac e is ics among 1572 child en wi h mode a e acu e malnu i ion Age (mon hs), median (IQR) 11.3 (8.2; 16.0) 6-11, n (%) 854 (54.3) 12-17, n (%) 447 (28.5) 18-23, n (%) 271 (17.2) Sex Boys, n (%) 682 (45.2) Gi ls, n (%) 710 (54.8) B eas eeding s a us S ill b eas ed, n (%) 1488 (94.8) No b eas ed, n (%) 82 (5.2) An h opome ics indica o s, mean (±SD) WHZ −2.2 (±0.5) HAZ −1.7 (±1.1) MUAC (mm) 122.6 (±4) Biochemical Hemoglobin (g/dL), mean (±SD) 10.0 (±1.6) AGP (g/L), median (IQR) 1.2 (0.9; 1.6) CRP (mg/L), median (IQR) 2.3 (0.8; 9.5) Mo bidi y Ill he las wo weeks No, n (%) 967 (61.9) Yes, n (%) 596 (38.1) Dia hea a ec ui men No, n (%) 1489 (94.7) Yes, n (%) 83 (5.3) Fe e a ec ui men No, n (%) 1295 (82.5) Yes, n (%) 275 (17.5) Mala ia a ec ui men No, n (%) 936 (59.8) Yes, n (%) 629 (40.2) Da a a e o al numbe s (%), mean (±SD) o median (in e qua ile ange (IQR): 25 h ;75 h pe cen ile) as indica ed. Numbe s in ca ego ies may no sum up 1572 due o missing da a, e.g. da a on b eas eeding we e a ailable om 1570, on AGP o CRP om 1541, on ill he las wo weeks om 1563, on e e om 1570 and on mala ia om 1565 Table 2 Whole blood a y acids composi ion in 1572 child en wi h mode a e acu e malnu i ion Mean (±SD) Sa u a ed a y acid 45.29 (±2.99) Monounsa u a ed a y acid 22.57 (±3.39) Polyunsa u a ed a y acid (PUFA) 28.52 (±2.78) n-6 PUFA 25.99 (±2.65) Linoleic acid (LA) 18:2n-6 16.22 (±2.26) Dihomo-y-linolenic acid 20:3n-6 0.85 (±0.21) A achidonic acid (AA) 20:4n-6 7.08 (±1.53) Ad enic Acid 22:4n-6 0.95 (±0.26) n-6 Docosapen aenoic acid (DPA) 22:5n-6 0.38 (±0.12) n-3 PUFA 2.48 (±0.65) α-Linolenic acid (ALA) 18:3n-3 0.21 (±0.09) Eicosapen aenoic acid (EPA) a 20:5n-3 0.13 (0.10; 0.18) n-3 Docosapen aenoic acid 22:5n-3 0.43 (±0.12) Docosahexaenoic acid (DHA) 22:6n-3 1.64 (±0.53) Mead acid 20:3n-9 0.07 (±0.03) Mead acid:AA 20:3n-9/20:4n-6 0.01 (±0.00) n-6 DPA:DHA 22:5n-6/22:6n-3 0.25 (±0.10) n-6 PUFA:n-3 PUFA 11.13 (±2.85) Da a a e gi en as mean (± s anda d de ia ion, SD) in weigh pe cen ela i e o o al a y (FA%), i no o he wise indica ed. Mean o al a y acid concen a ion was 417 (±183) μg/100 μL whole blood in s udy child en. a Median (in e qua ile ange: 25 h ;75 h pe cen ile) Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 4 o 11 analyses, adjus ed o age and sex, e ealed ha he chil- d en who we e ec ui ed based on MUAC only had 0.32 (95% con idence in e al (CI), 0.14; 0.50) FA% lowe AA han hose ec ui ed based on bo h MUAC and WHZ and 0.40 (95% CI, 0.16; 0.63) FA% lowe AA han hose ec ui ed based on WHZ only. Rec ui men based on MUAC only was also associa ed wi h 0.09 (95% CI, 0.01; 0.17) FA% lowe DHA han hose ec ui ed based on WHZ only, whe eas ec ui men based on bo h MUAC and WHZ was associa ed wi h a highe a io o n-6 DPA ela i e o DHA (0.01 [95% CI, 0.00; 0.02]) and highe Mead acid (0.004 [95% CI, 0.000; 0.007] FA%) compa ed o hose ec ui ed wi h WHZ only. Being ec ui ed based on MUAC only compa ed o WHZ only was posi i ely associa ed wi h Mead acid:AA a io (β= 0.001, 95% CI, 0.000; 0.002). Al hough median age di e ed be ween child en ec ui ed based on MUAC only, bo h MUAC and WHZ, o WHZ only, he di e ence in AA, DHA and Mead acid:AA ac oss ec ui men c i e ia was no con ounded by age, sex and b eas eeding. Die was ound o be a co ela e o whole-blood PUFA s a us adjus ed o age and sex (Table 4). Rela i e o chil- d en who we e no b eas ed, b eas ed child en had 1.17 (95% CI, 0.64; 1.70), 0.75 (95% CI, 0.39; 1.11), and 0.13 (95% CI, 0.01; 0.25) FA% highe LA, AA, and DHA, espec i ely. Child en who had consumed oods om he legumes and nu s g oup o he oils and a s g oup in he p e ious 24 h had 0.38 (95% CI, 0.16; 0.59) and 0.32 (95% CI, 0.12; 0.52) FA% lowe AA, espec i ely, com- pa ed o hose who did no consume hese oods. This was also he case o child en wi h a die a y in ake om he i amin A- ich ui s and ege ables g oup. Child en wi h a die a y in ake om he oils and a s g oup o he lesh ood g oup had 0.08 (95% CI, 0.09; 0.15) and 0.23 (95% CI, 0.12; 0.33) FA% highe DHA, espec i ely com- pa ed o hose who had no ea en hese oods. Die a y in ake om he lesh oods g oup was ound o be asso- cia ed wi h a highe p opo ion o DHA ela i e o ha o AA and ha was also he case o die a y in ake o oils, which we e mainly ege able oils. Die a y in ake om bo h o hese ood g oups was also ound o p o- ide a la ge di e ence in he p opo ion o n-3 PUFAs han in n-6 PUFAs. Mo bidi y and biochemical ma ke s o in ec ion we e also co ela es o whole-blood PUFA con en a e ad- jus men o age and sex (Table 5). Child en who had Table 3 Whole blood a y acids composi ion by ec ui men c i e ia in 1572 child en wi h mode a e acu e malnu i ion MUAC (n= 457) MUAC and WHZ (n= 786) WHZ (n= 329) Median age (IQR) 9.6 (7.3; 13.6) Median age (IQR) 11.6 (8.4; 16.4) Median age (IQR) 13.3 (9.9; 17.8) Mean FA (±SD) Mean FA (±SD) Mean FA (±SD) Sa u a ed a y acid 45.35 (±3.38) 45.29 (±2.82) 45.24 (±2.82) Monounsa u a ed a y acid 22.77 (±3.53) 22.57 (±3.34) 22.29 (±3.31) Polyunsa u a ed a y acid (PUFA) 28.40 (±2.69) 28.54 (±2.78) 28.68 (±2.92) n-6 PUFA 25.91 (±2.53) 25.99 (±2.67) 26.11 (±2.77) Linoleic acid (LA) 18:2n-6 16.37 (±2.16) 16.15 (±2.31) 16.22 (±2.29) Dihomo-y-linolenic acid 20:3n-6 0.87 (±0.21) 0.85 (±0.21) 0.85 (±0.21) A achidonic acid (AA) 20:4n-6 6.88 (±1.53) 1,2 7.15 (±1.53) 7.19 (±1.54) Ad enic Acid 22:4n-6 0.92 (±0.26) 2 0.96 (±0.27) 0.97 (±0.27) n-6 Docosapen aenoic acid (DPA) 22:5n-6 0.37 (±0.13) 0.39 (±0.13) 0.38 (±0.13) n-3 PUFA 2.42 (±0.64) 2.50 (±0.68) 2.51 (±0.62) α-Linolenic acid (ALA) 18:3n-3 0.22 (±0.09) 2 0.22 (±0.09) 0.20 (±0.09) Eicosapen aenoic acid (EPA) a 20:5n-3 0.12 (0.09; 0.18) 2 0.13 (0.10; 0.18) 0.14 (0.10; 0.20) n-3 Docosapen aenoic acid 22:5n-3 0.43 (±0.12) 0..45 (±0.13) 0.44 (±0.12) Docosahexaenoic acid (DHA) 22:6n-3 1.60 (±0.52) 1.65 (±0.54) 1.67 (±0.53) Mead acid 20:3n-9 0.07 (±0.03) 0.07 (±0.03) 0.07 (±0.02) Mead acid:AA 20:3n-9/20:4n-6 0.01 (±0.01) 0.01 (±0.00) 0.01 (±0.01) n-6 DPA:DHA 22:5n-6/22:6n-3 0.25 (±0.10) 0.25 (±0.10) 0.24 (±0.09) n-6 PUFA:n-3 PUFA 11.40 (2.91) 11.10 (2.86) 11.00 (2.77) Da a a e gi en as mean (±s anda d de ia ion, SD) weigh pe cen o o al whole blood a y acids, i no o he wise indica ed. p- alue o di e ence be ween admission g oups a e based on ANOVA es wi h Bon e oni adjus men . Abb e ia ions:WHZ weigh- o -heigh z-sco e, MUAC mid-uppe a m ci cum e ence 1 p<0.05 be ween MUAC and, MUAC and WHZ, and 2 p<0.05 be ween MUAC and WHZ a Median (in e qua ile ange: 25 h ;75 h pe cen ile) and ANOVA es on log alue Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 5 o 11 Table 4 Co ela ions be ween indi idual whole blood polyunsa u a ed a y acid and die a y in ake o a ious ood componen es based on a 24-hou ecall in 1572 child en wi h mode a e acu e malnu i ion n (%) n-6 polyunsa u a ed a y acids n-3 polyunsa u a ed a y acids Ra ios LA 18:2n-6 AA 20:4n-6 n-6 DPA 22:5n-6 ALA 18:3n-3 DHA 22:6n-3 Mead acid 20:3n-9 Mead acid/AA 20:3n-9/20:4n-6 n-6 DPA/DHA 22:5n-6/22:6n-3 G ains, oo s, and ube s g oup No 231 (14.8) Re Re Re Re Re Re Re Re Yes 1335 (85.2) −0.05 (-0.38 ; 0.27) 0.01 (-0.21 ; 0.22) 0.006 (-0.01 ; 0.02) −0.01 (-0.02; 0.01) 0.03 (-0.04 ; 0.10) 0.001 (-0.003; 0.004) 0.000 (-0.001; 0.001) −0.00 (-0.01; 0.01) Legumes and nu s g oup No 1335 (84.9) Re Re Re Re Re Re Re Re Yes 237 (15.1) 0.07 (-0.24 ; 0.38) −0.38 (-0.59 ; -0.16) * −0.03 (-0.04 ; -0.01) ** 0.02 (0.00; 0.03)* −0.05 (-0.13 ; 0.01) −0.000 (-0.004; 0.003) 0.001 (0.000; 0.001)* −0.01 (-0.02; 0.01) Oils and a s g oup No 1286 (81.9) Re Re Re Re Re Re Re Re Yes 285 (18.1) −0.01 (-0.31 ; -0.28) −0.32 (-0.52 ; -0.12)** −0.04 (-0.05 ; -0.02)** −0.02 (-0.01; 0.01) 0.08 (0.09 ; 0.15)* 0.001 (-0.002; 0.004) 0.001 (0.000; 0.002)** −0.03 (-0.04; -0.01)** Dai y g oup No 1512 (96.2) Re Re Re Re Re Re Re Re Yes 60 (3.8) −0.41 (-0.99 ; 0.17) 0.002 (-0.39 ; 0.39) 0.02 (-0.01 ; 0.05) 0.01 (-0.02; 0.03) 0.01 (-0.12 ; 0.15) 0.008 (0.002; 0.010)* 0.001 (-0.000; 0.020) 0.01 (-0.01; 0.04) Flesh oods g oup No 1464 (93.2) Re Re Re Re Re Re Re Re Yes 107 (6.8) −0.24 (-0.69 ; 0.20) −0.18 (-0.49 ; 0.11) −0.03 (-0.06 ; -0.01)* −0.01 (-0.03; 0.00) 0.23 (0.12 ; 0.33)** −0.003 (-0.008; 0.002) −0.000 (-0.001; 0.006) −0.04 (-0.05; -0.02)* Eggs g oup No 1561 (99.6) Re Re Re Re Re Re Re Re Yes 6 (0.4) −1.11 (-2.93; 0.70) −0.96 (-2.19; 0.26) −0.02 (-0.12; 0.08) 0.04 (-0.03; 0.12) −0.04 (-0.47; 0.37) −0.004 (-0.020; 0.010) 0.001 (-0.003; 0.005) −0.01 (-0.08; 0.07) Vi amin A- ich ui s and ege ables g oup No 1116 (71.1) Re Re Re Re Re Re Re Re Yes 454 (28.9) 0.15 (-0.1; 0.40) −0.24 (-0.41; -0.07)* −0.02 (-0.03; -0.00)** 0.01 (-0.00; 0.02) 0.01 (-0.05; 0.07) −0.000 (-0.003; 0.002) 0.000 (-0.000; 0.001) −0.01 (-0.02; 0.00) O he s ui s and ege ables g oup No 715 (45.5) Re Re Re Re Re Re Re Re Yes 857 (54.5) −0.06 (-0.29; 0.17) 0.10 (-0.05; 0.26) 0.12 (-0.00; 0.02) −0.01 (-0.02; -0.00)* 0.03 (-0.02; 0.09) 0.001 (-0.001; 0.004) 0.000 (-0.000; 0.001) −0.00 (-0.01; 0.01) B eas eeding No 82 (5.2) Re Re Re Re Re Re Re Yes 1488 (94.8) 1.17 (0.64; 1.70)** 0.75 (0.39; 1.11)** 0.00 (-0.02; 0.03) −0.01 (-0.03; 0.01) 0.13 (0.01; 0.25)* −0.020 (-0.030;-0.020)** −0.005 (-0.006;-0.004)** −0.04 (-0.06; -0.01)** Da a a e gi en as eg ession coe icien s (95% con idence in e al) in weigh pe cen o o al whole blood a y acid concen a ion a e adjus men o age and sex. Abb e ia ions:LA Linoleic acid, AA A achidonic acid, n-6DPA n-6 Docosapen aenoic acid, ALA α-Linolenic acid, DHA Docosahexaenoic acid, e e e ence g oup. Numbe s in ca ego ies may no sum up o 1572 due o missing da a. Da a on in ake o g ains, oo s, and ube s g oup we e a ailable o 1566 child en, on in ake o lesh oods om 1571, eggs om 1567, on i amin A- ich ui s and ege ables and b eas eeding om 1570. *p<0.05; **p<0.01 Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 6 o 11 Table 5 Biochemical and mo bidi y co ela es o indi idual polyunsa u a ed a y acid in 1572 child en wi h mode a e acu e malnu i ion n (%) n-6 polyunsa u a ed a y acids n-3 polyunsa u a ed a y acids Ra ios LA 18:2n-6 AA 20:4n-6 n-6 DPA 22:5n-6 ALA 18:3n-3 DHA 22:6n-3 Mead acid 20:3n-9 Mead acid/AA 20:3n-9/20:4n-6 n-6 DPA/DHA 22:5n-6/22:6n-3 Hemoglobin g/dl 1572 (100) −0.22 (-0.29; -0.15)** 0.39 (0.35; 0.44)** 0.02 (0.01 ; 0.02)** −0.02 (-0.02; -0.01)** 0.11 (0.10; 0.13)** 0.000 (-0.001; 0.001) −0.001 (-0.001; -0.001)** −0.004 (-0.008;- 0.001)** ≥11 472 (30.0) Re Re Re Re Re Re Re Re <11 1100 (70.0) 0.73 (0.49; 0.98)** −0.77 (-0.93; -0.61)** −0.03 (-0.05; -0.02)** 0.03 (0.02; 0.04)** −0.27 (-0.33; -0.21)** −0.001 (-0.004; 0.002) 0.001 (0.007; 0.002)** 0.02 (0.01; 0.03)** CRP <10mg/L 1166 (75.7) Re Re Re Re Re Re Re Re ≥10mg/L 375 (24.3) −0.04 (-0.30 ; 0.23) −0.91 (-1.10; -0.74)** −0.05 (-0.06 ; -0.03)** 0.04 (0.02; 0.05)** −0.23 (-0.30; -0.17)** −0.005 (-0.008; -0.002)** 0.001 (0.000; 0.001)** 0.01 (-0.00; 0.16) AGP <1g/L 516 (33.5) Re Re Re Re Re Re Re Re ≥1g/L 1025 (66.5) 0.01 (-0.22; 0.25) −0.60 (-0.76; -0.43)** −0.02 (-0.04 ; -0.12)** 0.02 (0.01; 0.03)** −0.10 (-0.15; -0.04)* 0.001 (-0.001; 0.004) 0.001 (0.001; 0.002)** 0.00 (-0.01; 0.10) Dia hea No 1489 (94.7) Re Re Re Re Re Re Re Re Yes 83 (5.3) −0.64 (-1.14; -0.14)* 0.20 (-0.13; 0.55) 0.02 (-0.01; 0.05) −0.02 (-0.04; 0.00) 0.16 (0.05; 0.28)** −0.004 (-0.010; 0.001) −0.001 (-0.002; 0.000) −0.02 (-0.04; 0.00) Fe e No 1295 (82.5) Re Re Re Re Re Re Re Re Yes 275 (17.5) −0.52 (-0.82; -0.23)** −0.29 (-0.49; -0.09)** −0.01 (-0.02; 0.005) 0.01 (-0.00; 0.02) −0.10 (-0.17; -0.03)** −0.005 (-0.009; -0.002)** −0.000 (-0.001; 0.000) 0.01 (-0.00; 0.02) Mala ia No 936 (59.8) Re Re Re Re Re Re Re Re Yes 629 (40.2) 0.20 (-0.02; 0.43) −1.06 (-1.20; -0.91)** −0.02 (-0.04; -0.01)** 0.05 (0.04; 0.05)* −0.30 (-0.35; -0.25)** 0.002 (-0.001; 0.004) 0.002 (0.001; 0.003)** 0.02 (0.01; 0.03)** Da a a e gi en as eg ession coe icien s (95% con idence in e al) in weigh pe cen o o al whole blood a y acids concen a ion a e adjus men o age and sex. Abb e ia ions:LA Linoleic acid, AA A achidonic acid, n-6DPA n-6 Docosapen aenoic acid, ALA α-Linolenic acid, DHA Docosahexaenoic acid, e e e ence g oup. Numbe s in ca ego ies may no sum up o 1572 due o missing da a, e.g. da a on CRP and AGP we e a ailable o 1541 child en, on e e om 1570, on mala ia om 1565. *p<0.05; **p<0.01 Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 7 o 11 e e a ec ui men had lowe LA, AA and DHA by 0.52 (95% CI, 0.23; 0.82), 0.29 (95% CI, 0.09; 0.49) and 0.10 (95% CI, 0.03; 0.17) FA%, espec i ely. Simila ly, e e in he 2 weeks p io o ec ui men was associa ed wi h low AA and DHA, bu no LA. Dia hea a ec ui - men was nega i ely associa ed wi h LA, bu posi i ely associa ed wi h DHA, which was also seen wi h dia hea based on ma e nal ecall (p< 0.05, da a no shown). Child en wi h ele a ed CRP had 0.91 (95% CI, 0.74; 1.10) and 0.23 (95% CI, 0.17; 0.30) FA% lowe AA and DHA, espec i ely, bu 0.04 (95% CI, 0.02; 0.05) FA% highe ALA. Ele a ed AGP was also associa ed wi h lowe AA and DHA (0.60 [95% CI, 0.43; 0.76] and 0.10 [95% CI, 0.04; 0.15] FA%, espec i ely) bu highe ALA (0.02 [95% CI, 0.01; 0.03] FA%). A posi i e mala ia es was associa ed wi h lowe AA and DHA (1.06 [95% CI, 0.91; 1.20] and 0.30 [95% CI, 0.25; 0.35] FA%, espec i ely) and highe ALA (0.05 [95% CI, 0.04; 0.05] FA%). O e all, ele a ed se um CRP and AGP, and a posi i e mala ia es we e associa ed wi h a highe Mead acid:AA a io. A posi- i e mala ia es was also associa ed wi h a highe n-6 DPA/DHA a io. Fo each 1 g/dl inc ease in hemoglobin, LA and ALA dec eased by -0.22 (95% CI, -0.29; -0.15) and -0.02 (95% CI, -0.02; -0.01) FA%, espec i ely. Howe e , o each 1 g/dl inc ease in hemoglobin, AA and DHA in- c eased by 0.39 (95% CI, 0.35; 0.44) and 0.11 (95% CI, 0.10; 0.13) FA%, espec i ely. Discussion While we ound ha PUFA de iciency was no a gene al p oblem in child en wi h MAM, o e all PUFA concen- a ions, especially o n-3 PUFAs, we e low. The e could be a numbe o explana ions o his. Fi s ly, he low le els o whole-blood n-3 PUFAs ound in child en wi h MAM could be linked o hei die [34]. The child en we e om a popula ion wi h a mainly plan -based die ich in LA, including peanu oils and peanu based- p oduc s, co ons seed oils and ce eals. In an s and young child en in such a popula ion will ha e an n-3 PUFA in ake a below he ecommended in ake [35]. P e ious s udies om he cen al egion in Bu kina Faso ha e demons a ed a high p opo ion o n-6 PUFAs ela- i e o n-3 PUFAs in b eas milk o heal hy mo he s nu sing 5-mon hs-old in an s and his was nega i ely as- socia ed wi h g ow h [18]. The low ela i e le els o n-3 PUFAs in child en wi h MAM was compensa ed o by a high p opo ion in SFA, which is in line wi h da a om mode a ely was ed Pakis ani child en [6]. This high p o- po ion o SFA in ou s udy could be due o mo e b eas eeding in Bu kina Faso as shown in p e ious s ud- ies [18, 36]. Secondly, he low whole-blood n-3 PUFAs could be due o me abolic dis u bances occu ing wi h malnu i ion [6]. Mic onu ien de iciencies such as zinc and i on combined wi h p o ein de iciency may impai del a-6 desa u ase ac i i y [5, 37] and dec ease he con- e sion o ALA o DHA. As expec ed, b eas eeding, lesh oods, ege able oils and a s we e ound o be co ela es o PUFAs in chil- d en wi h MAM. B eas milk is ecognised as a good sou ce o LC-PUFAs [38], al hough his is in luenced by ma e nal die [39]. Child en who we e b eas ed on he day be o e blood sampling had highe LA, AA, and DHA compa ed o hose who we e no b eas ed. Chil- d en who consumed lesh oods (mea and ish) in he p e ious 24 h also had highe whole-blood n-3 PUFAs and DHA han hose who did no consume hese ypes o oods. This is in line wi h mea and speci ically ish being he dominan sou ces o n-3 LC-PUFAs [34]. A high in ake o n-3 LC-PUFAs has been shown o in- c ease EPA and DHA in plasma and issue phospho- lipids [40], which is o en compensa ed by a educ ion in LA, AA and n-6 DPA. Wi h ega d o an h opome y, child en ec ui ed by MUAC only seem o ha e lowe whole-blood n-6 PUFAs and n-3 PUFAs compa ed o hose ec ui ed by WHZ only. Speci ically, ec ui men by MUAC only was asso- cia ed wi h low AA and DHA and his could be ela ed o a low muscle mass. Low MUAC only has been shown o be ela ed o low a m muscle mass [41], which is gen- e ally associa ed wi h hype co isolemia occu ing wi h malnu i ion [42]. Hype co isolemia inc eases es ing ene gy expendi u e ueled by inc eased oxida ion o a [43], and his may dec ease whole-blood LC-PUFA s a- us in child en wi h low MUAC. Ano he explana ion could be ha in ake o LC-PUFAs and p o ein quali y could be ela ed, as seen in a Canadian popula ion [44], and hus a ec muscle and whole-blood LC-PUFAs in pa allel. The issue mos a ec ed by malnu i ion in he i s mon hs o li e is muscle mass [45]. I could also be specula ed ha low MUAC is mo e ela ed o long- e m in lamma ion, which may be he cause o low PUFA s a us. Ma ke s o in ec ion and in lamma ion we e nega- i ely associa ed wi h whole-blood PUFAs. This ind- ing could be explained by an in ec ion-induced sup ession o appe i e and could be a di ec e ec o die a y in ake, bu may also be ela ed o impai ed abso p ion, poo nu ien u iliza ion and/o inc eased nu ien ca abolism caused by he in lamma o y s a e [46, 47]. We specula e ha he nega i e associa ion o LA bu posi i e associa ion o DHA wi h dia hea could be due o low abso p ion o a du ing dia hea esul ing in low plasma iacylglyce ols and hus, ela- i ely highe le els o DHA om he blood cells. Fe e du ing in ec ion leads o an inc ease in ene gy equi emen [48] and possibly an inc eased use o PUFAs as uel. In ec ion-induced in lamma ion has been sugges ed o inc ease LC-PUFA ca abolism, Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 8 o 11 mainly o AA and DHA o he p oduc ion o p o- and an i-in lamma o y media o s [49] and is likely con ibu ing o he educed AA and DHA seen in he MAM child en, speci ically hose wi h low MUAC. Fi- nally, hemoglobin was ound o posi i ely co ela e wi h whole-blood LC-PUFAs, mos ly AA and DHA, which could possibly be due o hei inco po a ion in phospholipids o e y h ocy e memb anes [14]. The nega i e associa ion be ween hemoglobin and whole- blood LA could be caused by a p e e en ial ino po a- ion o LC-PUFAs in e y h ocy e memb anes a he expense o LA. The associa ion wi h anemia and hemoglobin may he e o e in pa e lec changes in blood composi ion (e y h ocy e numbe ) and may he e o e no be an ideal indica o o whole blood PUFA s a us. The cu en s udy is he i s o in es iga e whole- blood PUFA composi ion and co ela es among a la ge sample o child en wi h MAM. Also, his is he i s s udy o show a ela ionship be ween low MUAC and PUFAs. The di e si y o co ela es such as in ec ion, in- lamma ion, die , and an h opome y highligh he com- plexi y o ac o s which may a ec whole-blood PUFA composi ion in child en wi h MAM, and hese ac o s should be aken in o accoun in s udies in es iga ing PUFAs among malnou ished child en. Howe e , he s udy had some limi a ions, in pa icula he lack o a con ol g oup om he same s udy se ing, which makes i di icul o di e en ia e be ween po en ial e ec s o die and he o e all low nu i ional s a us. Di e ences in die could con ound di e ences in nu i ional s a us e en i we had been able o collec da a om a well- nou ished g oup o child en in Bu kina Faso. The die in o ma ion was based on a single quali a i e 24-h ecall which may ha e educed accu acy and hus, educed he associa ion be ween die and PUFAs. The obse ed asso- cia ions we e howe e meaning ul. Fu he mo e, PUFA s a us was only based on a single non- as ing whole- blood sample and may no p o ide a measu e o long- e ms a usasis hecase o exampleinadipose issue samples [50], bu whole-blood EPA and DHA co ela es wi h and p edic s e y h ocy e EPA and DHA [51]. I may howe e , ma ch he sho - e m col- lec ion o die a y in o ma ion and also mo bidi y, which was based only on ecall da a om he p e i- ous 2 weeks and da a om clinical examina ions on he day o ec ui men . In conclusion, al hough PUFA de iciency based on he de ini ion used he e was no common, child en wi h MAM in Bu kina Faso ha e low whole-blood n-3 PUFA concen a ions. Low n-3 PUFA le els a e likely o be, o some ex en , explained by a low in ake o animal based oods, ege able oils and a sou ces o n-3 PUFA, o by o he co ela ing ac o s such anemia, in ec ion and in lamma ion. Child en wi h low MUAC seem o ha e lowe whole-blood PUFAs compa ed o child en wi h MAM based on WHZ. This obse a ion needs o be con- i med in u u e in es iga ions among child en wi h MAM. Abb e ia ions AA: A achidonic acid; AGP: α 1 -acid glycop o ein; ALA: α-linolenic acid; ANOVA: Analysis o a iance; CI: Con idence in e al; CRP: C- eac i e p o ein; DHA: Docosahexaenoic acid; DPA: Docosapen aenoic acid; EPA: Eicosapen aenoic acid; FA%: Fa y acid pe cen ; IQR: In e qua ile ange; LA: Linoleic acid; LC-PUFA: Long-chain polyunsa u a ed a y acid; MAM: Mode a e acu e malnu i ion; MUAC: Mid-uppe -a m-ci cum e ence; MUFA: Monounsa u a ed a y acid; PUFA: Polyunsa u a ed a y acid; SAM: Se e e acu e malnu i ion; SD:S anda dde ia ion;SFA:Sa u a ed a yacid;WHO:Wo ldheal h o ganiza ion; WHZ: Weigh - o -heigh z-sco e Acknowledgemen s We a e g a e ul o he s udy pa icipan s and hei amilies, and he s a o he Alliance o In e na ional Medical Ac ion (ALIMA) o hei aluable con ibu ion o his s udy. We hank he Minis y o Heal h in Bu kina Faso, he heal h and illage au ho i ies in P o ince du Passo é, and he s a a he heal h cen e s and o hei suppo o his s udy. Funding The s udy was unded by he Danish In e na ional De elopmen Assis ance (DANIDA, 09-097 LIFE), Médecins Sans F on iè es (MSF Denma k & MSF No way), Wo ld Food P og am (WFP), which was pa o a dona ion o WFP om a gene ous suppo o he Ame ican people h ough he suppo o he U.S. Agency o In e na ional De elopmen 's O ice o Food o Peace (USAID). Alliance o In e na ional Medical Ac ion (ALIMA) and he Eu opean Union’s humani a ian aid unds, in pa ne ship wi h Ac ion Con e la Faim (ACF), A id Nilsson ounda ion. The unding agencies had no ole in he design o s udy, da a collec ion and analysis, o p esen a ion o he esul s. A ailabili y o da a and ma e ials All da a gene a ed o analysed du ing his s udy a e included in his published a icle. Au ho s’con ibu ions The au ho s’con ibu ions o he manusc ip we e as ollows: MJHR, AB, SS, VBC, KFM, and HF concei ed and designed he s udy; CWY, BC, CF, MJHR and KDS conduc ed he esea ch; CWY, DFJ, HF and LL analyzed he da a and CWY w o e he i s d a o he manusc ip and had p ima y esponsibili y o he inal con en . CWY, BC, CF, MJHR, DFJ, KDS, AB, SS, AST, VBC, KFM, HF and LL made e isions o he manusc ip and ead and app o ed he inal submi ed e sion o he manusc ip . E hics app o al and consen o pa icipa e The s udy p o ocol was app o ed by he E hics Commi ee o Heal h Resea ch in Bu kina Faso (2012-8-059) and consul a i e app o al was ob ained om he Danish Na ional Commi ee on Biomedical Resea ch E hics (1208204). Consen was ob ained e bally and in w i ing (signa u e o inge p in s) om ca e ake s o he child en be o e inclusion. The in o ma ion and consen o m was ansla ed in o he local language and back ansla ed o ensu e accu acy. The s udy was ca ied ou in acco dance wi h he decla a ion o Helsinki and in e na ional e hical guidelines o biomedical esea ch in ol ing human subjec s, published by he Council o In e na ional O ganiza ions o Medical Sciences. Medical ea men was p o ided acco ding o an adap ed e sion o he In eg a ed Managemen o Childhood Illness guidelines and na ional p o ocol. This s udy was a pa o T ea ood ial which was egis e ed a h p://www.is c n.com (ISRCTN42569496). Consen o publica ion “No applicable”. Compe ing in e es s The au ho s decla e ha hey ha e no compe ing in e es s. Yaméogo e al. Nu i ion Jou nal (2017) 16:44 Page 9 o 11