Download Child Health Research Project Research Results and Policy

Child Health Research Project
Research Results and Policy Formulation
on Nutrition and Micronutrients
Selective Presentation of CHR Research
and Policy Activities in Nutrition and
Micronutrients
Breastfeeding/Complementary Feeding
Underweight (“PEM”)
Vitamin A
Zinc
Iron/Multiple micronutrients
Breastfeeding - Importance


Not breastfeeding increases risk of death
< 6 mo
6-23 mo - ≈ 2x
Diarrhea – 6.1x
Pneumonia – 2.4x
Not exclusively breastfeeding for 4 mo
(compared with partial breastfeeding)
increases risk of death
Diarrhea – 3.9x
Pneumonia – 2.4x
From WHO Collaborative Study Team, Lancet 2000 and Arifeen et al., Pediatrics 2001
Research Results with
IMCI Nutritional Counseling

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Clinic-based intervention in Brazil improved
diet and weight gain
Clinic and community intervention in India
increased breastfeeding in 0-3 mo. olds from
14% to 73%
Clinical and community intervention in Peru
reduced stunting by < 70%
From Santos et al, J Nutr 2001 (Brazil), others unpublished)
Cohort length for age
Control
Intervention
0
-0.2
Z-score
-0.4
-0.6
-0.8
-1
-1.2
-1.4
Control
Intervention
0
3
6
-0.48 -0.0041 -0.47
-0.51 -0.0027 -0.24
9
12
15
18
-0.69
-0.43
-0.94
-0.58
-1.13
-0.68
-1.2
-0.81
Age (months)
% of children
Cumulative percent of children with stunting
18
16
14
12
10
8
6
4
2
0
0
2
4
6
8
Age in months
15
18
Intervention
Control
Nutrition Policy Formulation


WHO recommends exclusive breastfeeding
for first 6 mo. of life
WHO meeting in December 2001 develops
Global Strategy for Infant and Young Child
Feeding (to protect, promote and support
optimal infant and young child feeding)
Underweight (Low Weight for Age) Causes
and Prevalence in Children < 5y Old


Caused by IUGR, inadequate
breastfeeding/complementary feeding
and zinc intake and by infectious disease
morbidity
Prevalence varies from 5% in middle income
countries in Latin America to 46% in low
income countries of South Asia
Increased Risk of Morbidity and
Mortality for Underweight Children
Infectious disease morbidity (< -2z)
Diarrhea
- RR 1.25
Pneumonia - RR 1.86
 Mortality (- 1z to -2z; -2z to -3z; < -3z)
Diarrhea
- RR 2.3 → 12.5
Pneumonia - RR 2.0 → 8.0
Malaria
- RR 2.1 → 9.5
Measles
- RR 1.7 → 5.2

Major causes of death
among children under five, global, 2000
Pneumonia
20%
Other
29%
Deaths
associated with
undernutrition
Diarrhoea
12%
60%
Malaria
8%
Perinatal
22%
Measles
HIV/AIDS 5%
4%
Sources:
For cause-specific mortality: EIP/WHO using 1999 data.
For deaths associated with malnutrition: Caulfield LE, Black RE. Malnutrition and the global
burden of disease: underweight and cause-specific mortality. Paper in preparation;
NOT FOR CITATION.
Contribution of undernutrition
to under-five mortality by cause, for
2000
100%
80%
60%
40%
20%
0%
Diarrhoea
Malaria
Pneumonia
Measles
Proportion of deaths associated with undernutrition
All-cause
All Deaths
Sources:
For cause-specific mortality: EIP/WHO using 1999 data.
For deaths associated with malnutrition: Caulfield LE, Black RE. Malnutrition and the global
burden of disease: underweight and cause-specific mortality. Paper in preparation;
NOT FOR CITATION.
Vitamin A Deficiency Prevalence and
Disease Risk in Children < 5y Old



Prevalence varies from 16% in middle
income countries in Latin America to 48%
in low income countries of Asia
Infectious disease morbidity (incidence)
Malaria
- RR 1.43
Mortality
Diarrhea - RR 1.47
Measles - RR 1.35
Safety of Delivery of Vitamin A with EPI




RCT in 9424 mother-infant pairs in Ghana,
India and Peru
Mothers 200,000 IU vitamin A post-partum,
infants 25,000 IU at 6, 10, 14 weeks with
immunizations
No adverse effects
Small reduction in vitamin A deficiency
at 6 mo of age
From WHO/CHD Immunization-Linked Vitamin A Supplementation Group,
Lancet 1998
Zinc Deficiency Prevalence in
Children < 5y Old


Estimated using FAO food balance sheets
to determine prevalence of inadequate
availability of zinc per capita to meet
zinc requirements
Prevalence up to 72% in South Asia
(31% global)
From International Zinc Consultative Group
Risk of Child Morbidity and Mortality
with Zinc Deficiency



Infectious disease morbidity (incidence)
Diarrhea
- RR 1.28
Pneumonia - RR 1.69
Malaria
- RR 1.56
Mortality – likely greater risk than for
incidence since also effect on severity
Published 2/3 ↓ in mortality in 1-9 mo old
SGA infants (Sazawal, Pediatrics 2001)
Process of Priority Setting, Research
Implementation and Policy Formulation
Regarding Zinc Deficiency

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
CHR meeting Nov. 1996 reviewed evidence
and published research priorities
Pooled analyses of existing studies
conducted – 1997-8
Research undertaken – 1997-present
Recommendations made – 1998-present
Zinc in Therapy of Persistent Diarrhea


5 published trials: 29% ↓ in duration, 40% ↓
in treatment failure or death
WHO recommends zinc be used in
treatment of persistent diarrhea
From Zinc Investigators’ Collaborative Group, Am J Clin Nutr 2000
Zinc in Therapy of Acute Diarrhea



7 published trials: 22% ↓ in duration, plus
reduction in stool output
4 of 6 additional trials show similar benefit
Controlled trial (12,000 child-years) shows
19% ↓ diarrhea hospitalization, 51% ↓ in
mortality and 62% ↓ in antibiotic use
Zinc in Therapy of Acute Diarrhea:
Policy and Needed Research



WHO meeting in May 2001 concludes
that zinc supplementation is efficacious
in reducing severity and duration
Effectiveness studies needed to assess
strategies for delivering zinc
supplementation to children with diarrhea
Initiating 5-site study of acceptability and
2-site study of effectiveness and impact
Zinc Supplements in Prevention of
Morbidity (Incidence)



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9 trials with diarrhea outcome: 22% ↓
4 trials with pneumonia outcome: 41% ↓
2 trials with malaria (clinic visits)
outcome: 36% ↓
3 mortality impact trails underway in India,
Nepal, Zanzibar
From Zinc Investigators’ Collaborative Group, J Pediatrics 1999
Alternatives for Increasing Zinc Intake

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Supplements – dispersible tablet with zinc
or zinc/iron highly acceptable and costs
1 U.S. cent or less
“Sprinkle” with multiple micronutrients
Fully fortified (i.e. RDA) sachet of food
Fortified staple foods, e.g. maize flour
in Mexico
Iron Deficiency Prevalence and
Disease Risk


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Prevalence of anemia in children up to
63% in South Asia and 50% thought to be
IDA; estimates of risk per gram decrease
in hemoglobin
AF of maternal mortality – 20%
AF of early neonatal mortality – 22%
AF of mental retardation – 18%
Meta-analyses of Effects of
Oral Iron Supplements in
Infectious Disease Morbidity


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50% ↑ clinical malaria and other infectious
diseases in malarious areas (Oppenheimer,
J Nutrition 2001)
17%↑ P. falciparum infection; non sig.
9% ↑ clinical malaria (Shankar, submitted)
11% ↑ diarrhea, no difference in other
morbidity (Gera, submitted)
Effects of Multiple Micronutrients vs.
Zinc Supplementation in Peru


RCT compared daily zinc (10 mg) or
multiple micronutrients with placebo
in 6-24 mo old infants
Supplement for 6 mo, home visits by
workers 5 d/wk to give supplement
and record morbidity
Effects of Multiple Micronutrients (MN) vs.
Zinc, Iron or Zinc/Iron Supplementation on
Diarrhea of Moderate Severity in Bangladesh



RCT compared weekly zinc (20 mg), iron,
zinc/iron, or MN with placebo in 6-11 mo
old infants
Infants < -1z W/A: diarrhea reduced 19% by
zinc and 17% by zinc/iron (borderline sig.)
and increased 10% by MN (not sig.)
All infants: diarrhea same in zinc, iron or
zinc/iron, but increased by 18% in MN (sig.)
Continuing Challenges/Research Questions
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

Can we successfully implement programs
to improve BF/CF and thus enhance
nutritional status?
Can we devise sustainable means to improve
nutrition/micronutrient status where dietary
approaches are not sufficient?
What are the positive and negative
interactions of micronutrients provided in
supplements?
Continuing Challenges/Research Questions
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How should programs be implemented to
use zinc for treatment of diarrhea?
How can zinc and iron deficiencies be
prevented?
What are the nutritional/micronutrient
effects in malaria, TB, HIV/AIDS?