Infant Cereal Program in Nunavut:

What Can We do Better?Vesselina Petkova, RD

Territorial Coordinator,Canada Prenatal Nutrition Program (CPNP)

Introduction

• No disclosures or conflicts of interest• Will discuss process, barriers, and some

outcomes related to infant cereal program implementation

• Project in progress– Not an example of a perfect program– Sometimes more questions than answers– Share with you and get feedback

What is Iron Deficiency Anemia• When low iron in the system = iron deficiency anemia (IDA)

– Ferritin is the measure of body’s iron storage– Low iron store if ferritin < 12 ng/mL

• Lack of iron interferes with ability to create haemoglobin (Hg)– Anemia when Hg less than 2 s.d.– Usually when Hg < 110 g / L

• Hg responsible for distributing oxygen to tissue, including heart and brain

ᐊᐅᐸᖅᑐᑦᐊᐅᑦ

ᐊᐅᐸᖅᑐᑦ ᐊᐅᑦ ᐊᒡᔭᕐᓯᔨᐅᕗᑦ

ᐊᓂᕐᓂᖃᕐᓇᖅᑐᒥᒃ

Why does IDA matter

• Negatively affects billions worldwide• Affects cognition, psychomotor development,

work productivity and community capacity• High economic burden– Highest costing disease (other than TB)

• Generally preventable• Damage caused by IDA can be permanent if not

reversed early

Infant Risk factors for IDA include:• Pregnancy outcomes (mothers’ anemic, low birth

weight, premature infants)• Rapid growth – infancy (6-24 m.o.)• Nutrition behaviours / poor intake of iron:– Early discontinuation of breastfeeding – Poor nutritional status (food insecurity, low SES)– Low iron formula – Excessive / early cow’s milk intake– Delayed / improper introduction of solids

Is it a problem in Nunavut?

• At least 250 cases of anemia in children (0-5) managed and treated annually.– ~ 50 cases per 1000 children/year (~ 5 %)

• True burden of the disease?– Vast majority of patients are asymptomatic.– Tip of the iceberg phenomenon

Many more unknown cases?• Population screening provides proper prevalence.– No screening protocol implemented across the Territory.

• Prevalence in Igloolik: – 48% had anemia – 28% had IDA - up to 8 x national averages!– 53% depleted iron stores

Christofides 2005

Infant Screening in Iqaluit

% of infants who are anemic (Hg below 110 g/L)

37,5

62,5

anemic

non anemic

• 6 m.o. - 5 y.o. • 2006 – May 2010• N = 677, but 1291 readings

70% of anemia is mild

Anemia by age group

Age in Months

Summary Iqaluit Anemia Screening

• Prevalence rates are very high– Highest at 8 – 11 months. – If analysis is limited to infants < 24 months, then

42.7% of infants were anemic.– Majority is mild. – But 17% of the children had at least one reading

below 100 g/L (moderate anemia)

Venous Draws

• Only 53 / 118 (~45%) patients went for venous blood work to confirm diagnosis

• 30% of those who went for blood work did not have a ferritin done to establish iron storage

Infant Cereal Supplementation

1. Context and Background2. Plan 3. Process4. Outcomes and Feedback

Objective: Reduce the Prevalence of IDA in Infants and Children• Step 1: identify IDA as a public

health priority– “By 2013, the rate of anemia in infants and toddlers will be halved”

• Step 2: commit to a focused strategy in order to address it– IDA program

Nunavut Iron Deficiency Anemia Project Evaluation Strategy 2008

Food-Based Intervention OptionsConsidered ease of implementation, safety profile of a product, cost, and availability.

1. Fresh meats, including country food2. Jarred meats distribution

3. Infant cereal distribution4. Vitamin supplementation

Project Goals1. Provide iron-fortified infant cereal to Nunavut

infants from 6-12 months of age, in quantity sufficient to meet the Recommended Dietary Allowance of 11 mg/day for iron.

2. Deliver cereal to infants via collaboration between community-based CPNP projects and Health Centers

3. Determine if iron-fortified infant cereal is acceptable to mothers and infants.

Implementation1st phase: 2009-2010 • Provision of cereal– Through CPNP community based programs, with

support of local Health Centers– 15 communities around Nunavut

• Order and distribution of cereal– Partnership with Northwest Company

Cost and Funding

• Need: average of 3 boxes per month per child x 6 months

• Cost of cereal: ~ $5/box (incl. shipping)• ~ $ 90 per child• Total cost: $60,000 provided by CPNP– CPNP workers’ time and wages not included

Educational information

Evaluation of 1st Phase

• Feedback from CPNP workers and mothers who received cereal.

• Process:– # of boxes of cereal distributed– # of users & who used cereal– perspective of CPNP workers

• Acceptability of cereal

Outcomes• All 15 communities received cereal.• Very few provided detailed information on

distribution – Systematic tracking wasn’t implemented– Some workers simply stated – ‘most’ distributed

• Also not clear on the number of users• Unexpected issues related to program success

such as Heinz recall of unrelated product

CPNP Workers’ Perspective

• Most centers found the program easy to administer

• A request for ‘not so much paper work’– Asked to track how many users and how many boxes

distributed at a time

• “I got it but never opened it… I didn’t know what to do with it”

CPNP Workers’ Perspective• There was a major stress with where to keep

the cereal stock• General request for fewer boxes– Knowing there is an expiry date – Feeling responsible for complete distribution

Acceptable to Children?

• 50% like, 30% neutral, 20% dislike taste – Some mothers say children won’t eat it– “My child doesn’t like the flavor, can we get

flavored?”• 50% of mothers admit to sharing cereal

with other members of household– Typically sibling outside age group

Acceptable to Mothers?• 100% mothers support CPNP program to

continue• 75% would purchase cereal if availableFeedback from CPNP workers: – “some mothers feel uncomfortable taking the

cereal… almost implying they were poor and couldn’t afford the cereal”

– Felt that some mothers used it but not as the predominant infant food source

Summary• Iron fortified infant cereal is one part of

decreasing iron deficiency anemia amongst infants

• Program helps with broader goals of food security

• Accepted by most mothers and infants• General support for program and its continuation

Next Steps• Fully implement cereal program – In all communities– Integrated in regular CPNP programming– Address barriers (storage, summer break...)

• Continue to develop education and communication strategy

• Evaluate health outcomes– implementation of screening program

Next Steps

• How to better integrate program with health centre?

• How to integrate with local store?

• Are there locally sustainable options using country food?

• What to do with anemia that is NOT iron deficiency?

Thanks to:CPNP community workersMothers who provided feedback

V. Avinashi S. Zlotkin

Public Health Nutritionists R. JettyG. Osborne

CPNP