xml: <clinical_study>
    <!-- This xml conforms to an XML Schema at:
      https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
    <required_header>
      <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
      <link_text>Link to the current ClinicalTrials.gov record.</link_text>
      <url>https://clinicaltrials.gov/ct2/show/NCT06025786</url>
    </required_header>
    <id_info>
      <org_study_id>BNP Quasi Experimental Study</org_study_id>
      <nct_id>NCT06025786</nct_id>
    </id_info>
    <brief_title>Impact Evaluation of Benazir Nashonuma Program (BNP) on Stunting Among Under-five Children</brief_title>
    <official_title>Impact Assessment of Benazir Nashonuma Program (BNP) on Stunting Prevention Among Children 0-59 Months of Age in Pakistan</official_title>
    <sponsors>
      <lead_sponsor>
        <agency>Aga Khan University</agency>
        <agency_class>Other</agency_class>
      </lead_sponsor>
      <collaborator>
        <agency>International Food Policy Research Institute</agency>
        <agency_class>Other</agency_class>
      </collaborator>
      <collaborator>
        <agency>Bill and Melinda Gates Foundation</agency>
        <agency_class>Other</agency_class>
      </collaborator>
    </sponsors>
    <source>Aga Khan University</source>
    <oversight_info>
      <is_fda_regulated_drug>No</is_fda_regulated_drug>
      <is_fda_regulated_device>No</is_fda_regulated_device>
    </oversight_info>
    <brief_summary>
      <textblock>
        The aim of the study is to evaluate the impact of Benazir Nashonuma Program (BNP) on&#xD;
        prevalence of stunting among under-five children in low income setting of Pakistan. The&#xD;
        research question that the study aims to answer is:&#xD;
  &#xD;
        Is there any change in the prevalence of stunting among under-five children in districts&#xD;
        where Benazir Nashonuma Program (BNP) is established compared to districts where BNP is not&#xD;
        established?&#xD;
  &#xD;
        Districts where BNP is functional, and women and children are receiving the intervention will&#xD;
        be compared at baseline and end line with control districts where conventional reproductive&#xD;
        care services are given. Prevalence of stunting among under-five children will be compared&#xD;
        along with other nutritional and growth status indicators over a period of 4 years.&#xD;
      </textblock>
    </brief_summary>
    <detailed_description>
      <textblock>
        Maternal and child malnutrition is a significant public health challenge, with 40% of under&#xD;
        five children being stunted in Pakistan. Stunting is associated with morbidity and mortality&#xD;
        with detrimental effects on the physical, social and cognitive development of children. The&#xD;
        two key determinants include maternal undernutrition during in-utero and poor infant and&#xD;
        child feeding practices in the first two years of life. The opportunity to improve maternal,&#xD;
        infant, and child outcomes is provided by the interventions aimed at improving maternal and&#xD;
        child nutrition throughout the first 1000 days, known as &quot;window of opportunity&quot;. In this&#xD;
        study, the investigators aim to assess the effectiveness of the Benazir Nashonuma Programme&#xD;
        (BNP) on stunting reduction and related maternal and child health outcomes and to determine&#xD;
        the uptake of BNP related services in the intervention districts in all provinces and regions&#xD;
        of Pakistan.&#xD;
  &#xD;
        The study will achieve the following objectives:&#xD;
  &#xD;
        Primary Objective&#xD;
  &#xD;
        • To determine the baseline to end-line change in the prevalence of stunting among children&#xD;
        0-59 months of age among low income settings&#xD;
  &#xD;
        Secondary Objectives&#xD;
  &#xD;
        For under-five children:&#xD;
  &#xD;
        To determine the baseline to end-line change in the&#xD;
  &#xD;
          -  Prevalence of wasting among children 0-59 months of age&#xD;
  &#xD;
          -  Prevalence of underweight children 0-59 months of age&#xD;
  &#xD;
          -  Prevalence of Moderate Acute Malnutrition (MAM) among children 0-59 months of age&#xD;
  &#xD;
          -  Prevalence of Severe Acute Malnutrition (SAM) among children 0-59 months of age&#xD;
  &#xD;
          -  Prevalence of 0-23 months old children meeting Infant and Young Child Feeding (IYCF)&#xD;
             indicators including exclusive breastfeeding, complementary feeding, dietary diversity,&#xD;
             minimum acceptable diet and minimum meal frequency.&#xD;
  &#xD;
          -  Proportion of children 0-59 months of age who received all recommended vaccinations&#xD;
             according to the national immunization schedule.&#xD;
  &#xD;
        For Women of Reproductive Age (15- 49 years):&#xD;
  &#xD;
        To determine the baseline to end-line change in the&#xD;
  &#xD;
          -  BMI (body mass index) and prevalence of underweight women of reproductive age (WRA)&#xD;
  &#xD;
          -  Reproductive services uptake by WRA&#xD;
  &#xD;
          -  Minimum dietary diversity among WRA&#xD;
  &#xD;
          -  Percentage of households that experienced food insecurity.&#xD;
  &#xD;
        A quasi-experimental study with baseline and end-line cross-sectional surveys will be&#xD;
        conducted in 18 districts of the four provinces and two administrative areas of Pakistan. The&#xD;
        intervention districts includes Shaheed Benazir Abad and Dadu from Sindh, Rajanpur from&#xD;
        Punjab, Lasbela and Harnai from Balochistan, Upper Dir and Tank from Khyber Pakhtunkhwa,&#xD;
        Diamer from Gilgit Baltistan and Bagh from Azad Jammu and Kashmir. Their control districts&#xD;
        are Sangarh, Naushero Feroze, Bahawalnagar, Sibbi, Sherani, Shangla, D. I. Khan, Shigar and&#xD;
        Muzaffarbad respectively.&#xD;
  &#xD;
        The study will employ a two-stage cluster sampling to enroll children 0-59 months of age and&#xD;
        their mothers/caregivers from the 13,200 households (734 per district). The primary (PSUs)&#xD;
        and secondary sampling units (SSUs) will include villages and households respectively.&#xD;
      </textblock>
    </detailed_description>
    <overall_status>Recruiting</overall_status>
    <start_date type="Actual">December 1, 2021</start_date>
    <completion_date type="Anticipated">June 30, 2026</completion_date>
    <primary_completion_date type="Anticipated">December 20, 2025</primary_completion_date>
    <phase>N/A</phase>
    <study_type>Interventional</study_type>
    <has_expanded_access>No</has_expanded_access>
    <study_design_info>
      <allocation>Non-Randomized</allocation>
      <intervention_model>Parallel Assignment</intervention_model>
      <primary_purpose>Prevention</primary_purpose>
      <masking>None (Open Label)</masking>
    </study_design_info>
    <primary_outcome>
      <measure>Baseline to end-line change in the prevalence of stunting among children 0-59 months of age</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Height-for-age ≤-2 SD of the WHO Child growth standards median</description>
    </primary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of underweight women of reproductive age (15-49 years)</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>WRA with a Body Mass Index (BMI) less than 18.5 kg/m2 will be considered underweight</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of wasting among children 0-59 months of age</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Weight-for-height ≤-2 SD of the WHO Child growth standards median</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of food insecurity status at household level</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Food Insecurity Experience Scale (FIES) by Food and Agriculture Organization (FAO) is experience-based measures of household or individual food security. It consists of eight questions regarding people's access to adequate food in last 12 months due to lack of money or other resources. Food insecurity is reported as mild, moderate and severe.</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the number of antenatal care (ANC) visits during pregnancy</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Number of antenatal care (ANC) visits done during the preceding pregnancy, leading to a live birth within the last two years.</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of institutional deliveries</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Number of women who gave birth at a healthcare facility during the preceding pregnancy, leading to a live birth within the last two years.</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of skilled birth attendance</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Number of women whose birth was attended by a skilled health personnel during the preceding pregnancy, leading to a live birth within the last two years.</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in prevalence of utilization of iron folic acid (IFA) during pregnancy</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Consumption of iron folic acid tablets during pregnancy</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of Minimum dietary diversity for women (MDDW)</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Consumption of at least five out of the ten food groups during the previous day and night (24 hours)</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of infants who were ever breastfed</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Number of infants who were breastfed at least once</description>
    </secondary_outcome>
    <secondary_outcome>
      <measure>Baseline to end-line change in the prevalence of exclusive breastfeeding among infants 0-5 months of age</measure>
      <time_frame>3 years (on study completion)</time_frame>
      <description>Number of infants who were fed exclusively with breast milk during the previous day</description>
    </secondary_outcome>
    <number_of_arms>2</number_of_arms>
    <enrollment type="Anticipated">13200</enrollment>
    <condition>Stunting</condition>
    <condition>Wasting</condition>
    <condition>Anemia</condition>
    <condition>Nutrient Deficiency</condition>
    <arm_group>
      <arm_group_label>Districts with established and operational BNP implementation</arm_group_label>
      <arm_group_type>Experimental</arm_group_type>
      <description>The intervention arm consists of nine districts from four provinces and two regions of Pakistan where the Benazir Nashonuma Program (BNP) is operational, providing reproductive and healthcare services to pregnant women and their children under the age of two.</description>
    </arm_group>
    <arm_group>
      <arm_group_label>Districts without BNP implementation and functionality</arm_group_label>
      <arm_group_type>No Intervention</arm_group_type>
      <description>The control arm comprises of nine districts where Benazir Nashonuma Program (BNP) has not been implemented. These districts are comparable to their respective intervention districts in terms of average maternal BMI and prevalence of stunting.</description>
    </arm_group>
    <intervention>
      <intervention_type>Combination Product</intervention_type>
      <intervention_name>Benazir Nashonuma Program (BNP)</intervention_name>
      <description>Benazir Nashonuma Program (BNP)&#xD;
  Dietary supplement for pregnant women and lactating mothers during the first six months of lactation:&#xD;
  Maamta is a 75-gram sachet made from peanut butter with 400 kcal of energy&#xD;
  Dietary supplement for children aged 6-23 months:&#xD;
  Wawamum is a lipid-based nutrient supplement consisting of skimmed milk powder, micronutrients, vegetable oil, roasted chickpeas and antioxidants. Wawamum covers the recommended daily dose of most micronutrients and 255 kcal of energy.&#xD;
  Conditional Cash Transfer (CCT):&#xD;
  This includes stipends of PKR 2000 during pregnancy contingent on three antenatal care visits, consuming SNF, attending awareness sessions on health and nutrition, getting two doses of tetanus toxoid and institutional delivery. After delivery PKR 2000/- for boys and 2500/- for girls are paid as incentives conditioned on getting child's birth registered, routine immunization and consumption of SNF by the child from 6-23 months</description>
      <arm_group_label>Districts with established and operational BNP implementation</arm_group_label>
    </intervention>
    <eligibility>
      <criteria>
        <textblock>
          All those households are eligible to be included in the study who have:&#xD;
  &#xD;
            -  An under-five child with a mother registered with Benazir Income Support Program&#xD;
               (BISP)&#xD;
  &#xD;
            -  Both available at the time of interview&#xD;
  &#xD;
          Exclusion criteria includes:&#xD;
  &#xD;
          • Mother of the child who is not a woman of reproductive age, i.e., less than 15 years or&#xD;
          greater than 49 years&#xD;
        </textblock>
      </criteria>
      <gender>All</gender>
      <minimum_age>1 Day</minimum_age>
      <maximum_age>59 Months</maximum_age>
      <healthy_volunteers>Accepts Healthy Volunteers</healthy_volunteers>
    </eligibility>
    <overall_official>
      <last_name>Zulfiqar A Bhutta, PhD, FRC</last_name>
      <role>Principal Investigator</role>
      <affiliation>Aga Khan University</affiliation>
    </overall_official>
    <overall_contact>
      <last_name>Sajid Bashir Soofi, MD, CPSP</last_name>
      <phone>+923002769398</phone>
      <email>sajid.soofi@aku.edu</email>
    </overall_contact>
    <overall_contact_backup>
      <last_name>Shah Muhammad, MD</last_name>
      <phone>+923325590559</phone>
      <email>shah.muhammad@aku.edu</email>
    </overall_contact_backup>
    <location>
      <facility>
        <name>Aga Khan University</name>
        <address>
          <city>Karachi</city>
          <state>Sindh</state>
          <zip>75290</zip>
          <country>Pakistan</country>
        </address>
      </facility>
      <status>Recruiting</status>
      <contact>
        <last_name>Asma Abdul Malik, MBBS, MSc</last_name>
        <phone>+923311388051</phone>
        <email>asma.qureshi@aku.edu</email>
      </contact>
      <contact_backup>
        <last_name>Shah Mohammad</last_name>
        <email>shah.muhammad@aku.edu</email>
      </contact_backup>
    </location>
    <location_countries>
      <country>Pakistan</country>
    </location_countries>
    <verification_date>July 2023</verification_date>
    <study_first_submitted>August 16, 2023</study_first_submitted>
    <study_first_submitted_qc>August 30, 2023</study_first_submitted_qc>
    <study_first_posted type="Actual">September 6, 2023</study_first_posted>
    <last_update_submitted>September 8, 2023</last_update_submitted>
    <last_update_submitted_qc>September 8, 2023</last_update_submitted_qc>
    <last_update_posted type="Actual">September 11, 2023</last_update_posted>
    <responsible_party>
      <responsible_party_type>Principal Investigator</responsible_party_type>
      <investigator_affiliation>Aga Khan University</investigator_affiliation>
      <investigator_full_name>Dr Zulfiqar Ahmed Bhutta</investigator_full_name>
      <investigator_title>Distinguished University Professor and Founding Director of the Institute for Global Health and Development and the Centre of Excellence in Women and Child Health</investigator_title>
    </responsible_party>
    <keyword>Quasi experimental study</keyword>
    <keyword>Maternal and child nutrition</keyword>
    <keyword>Stunting</keyword>
    <keyword>Wasting</keyword>
    <keyword>Under-five malnutrition</keyword>
    <keyword>Specialized Nutritious Food (SNF)</keyword>
    <condition_browse>
      <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
      <mesh_term>Wasting Syndrome</mesh_term>
      <mesh_term>Cachexia</mesh_term>
      <mesh_term>Growth Disorders</mesh_term>
    </condition_browse>
    <!-- Results have not yet been posted for this study                                          -->
  </clinical_study>
  
  
text: download date: ClinicalTrials.gov processed this data on September 20, 2023
  link text: Link to the current ClinicalTrials.gov record.
  url: https://clinicaltrials.gov/ct2/show/NCT06025786
  org study id: BNP Quasi Experimental Study
  nct id: NCT06025786
  lead sponsor: 
  collaborator: 
  collaborator: 
  is fda regulated drug: No
  is fda regulated device: No
  The aim of the study is to evaluate the impact of Benazir Nashonuma Program (BNP) on
        prevalence of stunting among under-five children in low income setting of Pakistan. The
        research question that the study aims to answer is:
  
        Is there any change in the prevalence of stunting among under-five children in districts
        where Benazir Nashonuma Program (BNP) is established compared to districts where BNP is not
        established?
  
        Districts where BNP is functional, and women and children are receiving the intervention will
        be compared at baseline and end line with control districts where conventional reproductive
        care services are given. Prevalence of stunting among under-five children will be compared
        along with other nutritional and growth status indicators over a period of 4 years.
  Maternal and child malnutrition is a significant public health challenge, with 40% of under
        five children being stunted in Pakistan. Stunting is associated with morbidity and mortality
        with detrimental effects on the physical, social and cognitive development of children. The
        two key determinants include maternal undernutrition during in-utero and poor infant and
        child feeding practices in the first two years of life. The opportunity to improve maternal,
        infant, and child outcomes is provided by the interventions aimed at improving maternal and
        child nutrition throughout the first 1000 days, known as "window of opportunity". In this
        study, the investigators aim to assess the effectiveness of the Benazir Nashonuma Programme
        (BNP) on stunting reduction and related maternal and child health outcomes and to determine
        the uptake of BNP related services in the intervention districts in all provinces and regions
        of Pakistan.
  
        The study will achieve the following objectives:
  
        Primary Objective
  
        • To determine the baseline to end-line change in the prevalence of stunting among children
        0-59 months of age among low income settings
  
        Secondary Objectives
  
        For under-five children:
  
        To determine the baseline to end-line change in the
  
          -  Prevalence of wasting among children 0-59 months of age
  
          -  Prevalence of underweight children 0-59 months of age
  
          -  Prevalence of Moderate Acute Malnutrition (MAM) among children 0-59 months of age
  
          -  Prevalence of Severe Acute Malnutrition (SAM) among children 0-59 months of age
  
          -  Prevalence of 0-23 months old children meeting Infant and Young Child Feeding (IYCF)
             indicators including exclusive breastfeeding, complementary feeding, dietary diversity,
             minimum acceptable diet and minimum meal frequency.
  
          -  Proportion of children 0-59 months of age who received all recommended vaccinations
             according to the national immunization schedule.
  
        For Women of Reproductive Age (15- 49 years):
  
        To determine the baseline to end-line change in the
  
          -  BMI (body mass index) and prevalence of underweight women of reproductive age (WRA)
  
          -  Reproductive services uptake by WRA
  
          -  Minimum dietary diversity among WRA
  
          -  Percentage of households that experienced food insecurity.
  
        A quasi-experimental study with baseline and end-line cross-sectional surveys will be
        conducted in 18 districts of the four provinces and two administrative areas of Pakistan. The
        intervention districts includes Shaheed Benazir Abad and Dadu from Sindh, Rajanpur from
        Punjab, Lasbela and Harnai from Balochistan, Upper Dir and Tank from Khyber Pakhtunkhwa,
        Diamer from Gilgit Baltistan and Bagh from Azad Jammu and Kashmir. Their control districts
        are Sangarh, Naushero Feroze, Bahawalnagar, Sibbi, Sherani, Shangla, D. I. Khan, Shigar and
        Muzaffarbad respectively.
  
        The study will employ a two-stage cluster sampling to enroll children 0-59 months of age and
        their mothers/caregivers from the 13,200 households (734 per district). The primary (PSUs)
        and secondary sampling units (SSUs) will include villages and households respectively.
  allocation: Non-Randomized
  intervention model: Parallel Assignment
  primary purpose: Prevention
  masking: None (Open Label)
  measure: Baseline to end-line change in the prevalence of stunting among children 0-59 months of age
  time frame: 3 years (on study completion)
  description: Height-for-age ≤-2 SD of the WHO Child growth standards median
  measure: Baseline to end-line change in the prevalence of underweight women of reproductive age (15-49 years)
  time frame: 3 years (on study completion)
  description: WRA with a Body Mass Index (BMI) less than 18.5 kg/m2 will be considered underweight
  measure: Baseline to end-line change in the prevalence of wasting among children 0-59 months of age
  time frame: 3 years (on study completion)
  description: Weight-for-height ≤-2 SD of the WHO Child growth standards median
  measure: Baseline to end-line change in the prevalence of food insecurity status at household level
  time frame: 3 years (on study completion)
  description: Food Insecurity Experience Scale (FIES) by Food and Agriculture Organization (FAO) is experience-based measures of household or individual food security. It consists of eight questions regarding people's access to adequate food in last 12 months due to lack of money or other resources. Food insecurity is reported as mild, moderate and severe.
  measure: Baseline to end-line change in the number of antenatal care (ANC) visits during pregnancy
  time frame: 3 years (on study completion)
  description: Number of antenatal care (ANC) visits done during the preceding pregnancy, leading to a live birth within the last two years.
  measure: Baseline to end-line change in the prevalence of institutional deliveries
  time frame: 3 years (on study completion)
  description: Number of women who gave birth at a healthcare facility during the preceding pregnancy, leading to a live birth within the last two years.
  measure: Baseline to end-line change in the prevalence of skilled birth attendance
  time frame: 3 years (on study completion)
  description: Number of women whose birth was attended by a skilled health personnel during the preceding pregnancy, leading to a live birth within the last two years.
  measure: Baseline to end-line change in prevalence of utilization of iron folic acid (IFA) during pregnancy
  time frame: 3 years (on study completion)
  description: Consumption of iron folic acid tablets during pregnancy
  measure: Baseline to end-line change in the prevalence of Minimum dietary diversity for women (MDDW)
  time frame: 3 years (on study completion)
  description: Consumption of at least five out of the ten food groups during the previous day and night (24 hours)
  measure: Baseline to end-line change in the prevalence of infants who were ever breastfed
  time frame: 3 years (on study completion)
  description: Number of infants who were breastfed at least once
  measure: Baseline to end-line change in the prevalence of exclusive breastfeeding among infants 0-5 months of age
  time frame: 3 years (on study completion)
  description: Number of infants who were fed exclusively with breast milk during the previous day
  arm group label: Districts with established and operational BNP implementation
  arm group type: Experimental
  description: The intervention arm consists of nine districts from four provinces and two regions of Pakistan where the Benazir Nashonuma Program (BNP) is operational, providing reproductive and healthcare services to pregnant women and their children under the age of two.
  arm group label: Districts without BNP implementation and functionality
  arm group type: No Intervention
  description: The control arm comprises of nine districts where Benazir Nashonuma Program (BNP) has not been implemented. These districts are comparable to their respective intervention districts in terms of average maternal BMI and prevalence of stunting.
  intervention type: Combination Product
  intervention name: Benazir Nashonuma Program (BNP)
  description: Benazir Nashonuma Program (BNP)
  Dietary supplement for pregnant women and lactating mothers during the first six months of lactation:
  Maamta is a 75-gram sachet made from peanut butter with 400 kcal of energy
  Dietary supplement for children aged 6-23 months:
  Wawamum is a lipid-based nutrient supplement consisting of skimmed milk powder, micronutrients, vegetable oil, roasted chickpeas and antioxidants. Wawamum covers the recommended daily dose of most micronutrients and 255 kcal of energy.
  Conditional Cash Transfer (CCT):
  This includes stipends of PKR 2000 during pregnancy contingent on three antenatal care visits, consuming SNF, attending awareness sessions on health and nutrition, getting two doses of tetanus toxoid and institutional delivery. After delivery PKR 2000/- for boys and 2500/- for girls are paid as incentives conditioned on getting child's birth registered, routine immunization and consumption of SNF by the child from 6-23 months
  arm group label: Districts with established and operational BNP implementation
  criteria: 
  gender: All
  minimum age: 1 Day
  maximum age: 59 Months
  healthy volunteers: Accepts Healthy Volunteers
  last name: Zulfiqar A Bhutta, PhD, FRC
  role: Principal Investigator
  affiliation: Aga Khan University
  last name: Sajid Bashir Soofi, MD, CPSP
  phone: +923002769398
  email: sajid.soofi@aku.edu
  last name: Shah Muhammad, MD
  phone: +923325590559
  email: shah.muhammad@aku.edu
  facility: 
  status: Recruiting
  contact: 
  contact backup: 
  country: Pakistan
  responsible party type: Principal Investigator
  investigator affiliation: Aga Khan University
  investigator full name: Dr Zulfiqar Ahmed Bhutta
  investigator title: Distinguished University Professor and Founding Director of the Institute for Global Health and Development and the Centre of Excellence in Women and Child Health
  mesh term: Wasting Syndrome
  mesh term: Cachexia
  mesh term: Growth Disorders