Child Health Research Project Research Results and Policy Formulation on Nutrition and Micronutrients

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Child Health Research ProjectResearch Results
and Policy Formulationon Nutrition and
Micronutrients
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Selective Presentation of CHR Researchand Policy
Activities in Nutrition and Micronutrients

• Breastfeeding/Complementary Feeding
• Underweight (PEM)
• Vitamin A
• Zinc
• Iron/Multiple micronutrients

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Breastfeeding - Importance

• Not breastfeeding increases risk of death lt 6 mo
  6-23 mo - 2x Diarrhea
  6.1xPneumonia 2.4x
• Not exclusively breastfeeding for 4 mo (compared
  with partial breastfeeding) increases risk of
  death Diarrhea 3.9xPneumonia 2.4x

• From WHO Collaborative Study Team, Lancet 2000
  and Arifeen et al., Pediatrics 2001

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Research Results with IMCI Nutritional Counseling

• 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 lt 70
• From Santos et al, J Nutr 2001 (Brazil), others
  unpublished)

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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)

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Underweight (Low Weight for Age) Causes and
Prevalence in Children lt 5y Old

• Caused by IUGR, inadequate breastfeeding/complemen
  tary 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

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Increased Risk of Morbidity and Mortality for
Underweight Children
Infectious disease morbidity (lt -2z) Infectious disease morbidity (lt -2z) Infectious disease morbidity (lt -2z)
Diarrhea - RR 1.25
Pneumonia - RR 1.86
Mortality (- 1z to -2z -2z to -3z lt -3z) Mortality (- 1z to -2z -2z to -3z lt -3z) Mortality (- 1z to -2z -2z to -3z lt -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
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Major causes of death among children under five,
global, 2000
Deaths associated with undernutrition 60
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.
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Contribution of undernutrition to under-five
mortality by cause, for 2000
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.
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Vitamin A Deficiency Prevalence and Disease Risk
in Children lt 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

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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

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Zinc Deficiency Prevalence in Children lt 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

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Risk of Child Morbidity and Mortality with Zinc
Deficiency

• Infectious disease morbidity (incidence)Diarrhea
  - RR 1.28Pneumonia - RR 1.69Malaria - 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)

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Process of Priority Setting, Research
Implementation and Policy Formulation Regarding
Zinc Deficiency

• 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

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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

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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

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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

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Zinc Supplements in Prevention of Morbidity
(Incidence)

• 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

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Alternatives for Increasing Zinc Intake

• 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

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Iron Deficiency Prevalence and Disease Risk

• 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

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Meta-analyses of Effects of Oral Iron
Supplements in Infectious Disease Morbidity

• 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)

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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

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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 lt -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.)

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Continuing Challenges/Research Questions

• 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?

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Continuing Challenges/Research Questions

• 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?