malnutrition and child survival prof dr. patrick kolsteren nutrition and child health unit institute...
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Malnutrition and child survival
Prof Dr. Patrick Kolsteren
Nutrition and Child Health Unit
Institute of Tropical Medicine Antwerp
Malnutrition and mortality
• Malnutrition is the underlying cause of 3.5 million deaths
• 35 % of the disease burden in children under five due to malnutrition
• 11 % of the total mortality and disability
Diarrhoea12%
Other29%
Perinatal22% HIV/AIDS
4%
Measles5%
Malaria8%
Pneumonia20%
Major Causes of Death among Children around the World
Deaths associated with undernutrition
60%
Sources:EIP/WHO, Caulfield LE, Black RE. Year 2000
Expression of malnutrition
• Thinness or acute severe/ moderate malnutrition
• Sub-optimal growth: stunting or short stature
• Micronutrient deficiencies– Vitamin A– Zinc– Iron – Iodine
Stunting
Lancet series maternal and child nutrition 19 January 2008
Vitamin A deficiency
Lancet series maternal and child nutrition 19 January 2008
Zinc deficiency
Lancet series maternal and child nutrition 19 January 2008
Health effects
• Decreased immunity “nutritional immune deficiency syndrome”
• Frequent infections • Psycho-motor development
delays• School performance• Lower IQ• Blindness • Neurological malformations• Short adults pregnancy
complications
Immediate causes of malnutrition
• Low birth weight / maternal nutrition • No breastfeeding or non exclusive breastfeeding• Complementary feeding:
– Low quantity– Low energy density– Low quality: diversity, fruit and vegetables
• Low quality diet : family dish• Micronutrient deficiencies• Infection pressure
DANGERS WITH COMPLEMENTARY FOODS
1. Diarrhea 2. Food allergies and atopic (in particular
before 4 months of age)3. Not enough:
- Composition (Fat = 40 %)- Poor density (150 CC /meal )
- Time and frequency
4. Too salty
DANGERS WITH COMPLEMENTARY FOODS
5. Low quality
- Poor in micronutrients
- Low-bioavailability
- Low fat :ADEK
- Little variation
- Qualilty of proteins ( 2/3 cereals and 1/3 tubers) cereals are rich in lysine, poor in methionine and cysteine)
- No fruits and vegetables
- No animal protein
Table 2: Estimation of the minimum energy density of complementary foods (kcal/ 100g)
Requirement(kcal/ d)
Minimum energydensity dependingon the number ofmeals per day
Classof age
Average1
+2SD
Energy intakefrombreastmilk(kcal/ d)
Energy that achild must beable toconsume fromCF (kcal/ d)
Gastriccapa-city3
(ml)2m/ d
3m/ d
4 m/ d
Low2: 217 635 128 85 646-8month
682 852Average: 413 439
24988 59 44
Low2: 157 880 155 103 779-11month
830 1037Average: 379 658
285116 77 58
Low2: 90 1275 185 123 9212-23month
1092 1365Average: 346 1019
345148 98 74
1From Butte (11) and Torun et al (12)2Mean-2SD of energy intakes observed in developing countries3Taking into account an average gastric capacity of 30 ml per kg of body weigh
Table 3: Nutrient content of some infant flours from local production units in Africa
Country Flour name Protein (g/ 100gDM)
Lipids(g/ 100g DM)
Calcium(mg/ 100gDM)
Iron(mg/ 100gDM)
Benin Ouando 2nd age 22.5 6.4 102 9.4Misola 16.2 11.4 96 5.2Burkina FasoVitaline 12.7 9.5 128 6.7
Burundi Musalac 15.0 8.6 79 12.9Chad Vitafort 11 to 15 4.6 to 7.8 20 to 28 2.3 à 7.0Congo Harina forte 12.1 6.8 325 8.6Côte d'Ivoire Farinor 15.8 6.8 324 24.0Gabon Nourivit 9.8 5.7 492 4.9Guinea Yéolac 14.8 8.1 96 10.8Niger Bitamin 15.7 9.4 43 6.6RD Congo Cérévap 15.4 6.5 369 7.3Rwanda Sosoma 17.8 3.8 500 18.1
Ruy Xalel 8.0 5.2 39 5.1SenegalProvital 9.6 7.4 41 1.9
Togo Viten 2nd age 15.5 7.6 100 10.9Minimal recommended value 12,0 8.5 500 16.0Determination on randomly collected flours in market Source: Trèche (18)
DANGERS WITH COMPLEMENTARY FOODS
6. Contamination
Mycotoxine: aflatoxine and fumonisinsLittle research : In tanzania 20 % of infant in the Kilimanjaro region have intakes above the recommended safety levels. Large seasonal variation. CF is largely cereal based.
Infection pressure
• Drop in maternal immunological protection at 6 months
• Environmental sanitation : – Diarrhoea– Worm infections – Parasites : vector borne diseases (malaria)
• Cause of malnutrition and a result of malnutrition
What works?
• Promotion of exclusive breastfeeding
• Improve complementary feeding and nutrition support
• Hand-washing and hygiene interventions
How to improve complementary feeding?
• Food based approach: food diversity, accept new food sources in CF
• Increase fat content • Role of ω3 and ω6 fatty
acids is not clear. • Invest in toxine analyses
What works ?
• Treatment of malnutrition, severe and moderate
• Focus on identification of malnourished children
• Vitamin A fortification • Iodisation of salt• Zinc supplementation• Improve maternal nutritional
status pregnancy
How to get there in operational terms?
• Coverage means access to infrastructures
• Infrastructures exist : health care system
• Most interventions can be delivered through health system if they focus on child health
• Health systems needs to be supported with a particular emphasis on child health and health promotion
Way forward
• Accept that we know what to do • Focus on what works and increase coverage• Use existing structures • Find ways to deliver the interventions in a local
context. Support local initiatives in research and development. Who drives the agenda???
• 99 % grants for “new solutions” that can reduce mortality by 22%
• 1 % for solutions that increase coverage that can reduce mortality by 66 %
Thank you