Carlos Grijalva-Eternod1, Marko Kerac1, Hannah Blencowe2,, Marie McGrath3, Jeremy Shoham3, Andrew Seal1

1. UCL Centre for International Health & Development, London UK2. London School of Hygiene & Tropical Medicine, London UK3. Emergency Nutrition Network, Oxford UKFunding body: MAMI Project - UNICEF Nutrition Cluster

Malnutrition in <6 months old infants:

Disease burden in developing countries& implications of WHO Child Growth Standards

BACKGROUND

Causes of Death in under-5 children (Worldwide)Modified from: WHO estimates of the causes of death in children Lancet 2005; 365: 1147–52Jennifer Bryce, Cynthia Boschi-Pinto, Kenji Shibuya, Robert E Black, & WHO Child Health Epidemiology Reference Group*

Background (1)

10.8 million child deaths / year10.8 million child deaths / year

UNDERNUTRITION underlies 53% of deaths

Severe wasting1- 2 million

deaths

Causes of Death in under-5 children (Worldwide)Modified from: WHO estimates of the causes of death in children Lancet 2005; 365: 1147–52Jennifer Bryce, Cynthia Boschi-Pinto, Kenji Shibuya, Robert E Black, & WHO Child Health Epidemiology Reference Group*

Background (1)

10.8 million child deaths / year10.8 million child deaths / year

UNDERNUTRITION underlies 53% of deaths

Severe wasting1- 2 million

deaths

Causes of Death in under-5 children (Worldwide)Modified from: WHO estimates of the causes of death in children Lancet 2005; 365: 1147–52Jennifer Bryce, Cynthia Boschi-Pinto, Kenji Shibuya, Robert E Black, & WHO Child Health Epidemiology Reference Group*

Background (1)

10.8 million child deaths / year10.8 million child deaths / year

Therapeutic Feeding

Programme

Background (2)

Diagnosis of severe wasting (children)Diagnosis of severe wasting (children)

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

La

nce

t 2

00

6 (

Co

llin

s e

t a

l)

La

nce

t 2

00

8

(Bla

ck

et

al)

Background (3)

The 1995 WHO ‘Field Guide to Nutrition Assessment’states that:

“…children under 6 months of age, apart from being more difficult to measure, are often still breast-fed and therefore satisfactorily nourished…”

Background (3)

The 1995 WHO ‘Field Guide to Nutrition Assessment’states that:

“…children under 6 months of age, apart from being more difficult to measure, are often still breast-fed and therefore satisfactorily nourished…”

Common Held Assumption

UNDERNUTRITION underlies 53% of deaths

Background (3)

Managing wasted <6 month infants is Managing wasted <6 month infants is challenging:challenging:

• Unique needs (exclusive breast feeding)

• Resources (inpatient treatment)

• Staff time

• Staff skills

• Magnitude of the problem

(individual vs. public health focus)

Poor evidence-base Poor evidence-base

Aims:

1. Describe prevalence of wasting among <6 months infants, in nutritionally vulnerable settings.

2. Examine effect of WHO-GS on burden of disease.

3. Discuss possible risk/benefit implications

METHODS

Methods

• Study Design:• Secondary data analysis

• Reference population• 36 countries identified in 2008 Lancet Nutrition series

• Study population• 21 countries with available Demographic & Health Survey (DHS)

in last 10 years• 163,228 children 0 to 59.9 months (15,534 infants <6 months)• Mean 7771 per country, range 1710 to 45,398

Methods

Ethiopia KenyaMadagascar MalawiMozambique TanzaniaZambia CameroonEgypt Burkina FasoCote D'Ivoire GhanaMali Niger Nigeria BangladeshIndia CambodiaTurkey GuatemalaPeru

Countries:

Methods

• Definitions (based on weight-for height – WHZ)

* Wasting WHZ < -2

* Severe wasting WHZ < -3

* Moderate wasting -2 > WHZ < - 3

• Integrated Food Security Phase Classification

(IPC) - Food Security* Moderately insecure >3% to <10%

* Acute crisis 10 – 15%

* Humanitarian Emergency > 15%

* Famine > 30%

Methods

• Data handling & analysis* Calculated z-scores using ENA for SMART* Excluded patients with extreme z-scores (Epi-Info criteria)

* Calculated country prevalence of wasting using:NCHS growth references (NCHS)WHO Growth Standards (WHO-GS)

* Grouped by age groupInfants 0 – 5.9 monthsChildren 6 – 59 months

RESULTS

Results (1) - wasting

% wasting

< 6 months

6 – 59 months

Results (1) - wasting

NCHS WHO

% wasting

< 6 months

6 – 59 months

Results (2) - severe wasting

-1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20-1

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Infants (<6 months)Children (6 - 59 months)

x = y

Prevalence of severe wasting (NCHS) (%)

Pre

va

len

ce

of

se

ve

re w

as

tin

g (

WH

O)

(%) y = 3.54x + 2.3 (R2=0.78)

y = 1.68x + 0.1 (R2=0.96)

Results (2) - severe wasting

-1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20-1

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Infants (<6 months)Children (6 - 59 months)

x = y

Prevalence of severe wasting (NCHS) (%)

Pre

va

len

ce

of

se

ve

re w

as

tin

g (

WH

O)

(%)

NCHS WHO

y = 3.54x + 2.3 (R2=0.78)

y = 1.68x + 0.1 (R2=0.96)

Results (3) - moderate wasting

-1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20-1

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Infants (<6 months)Children (6 - 59 months)

x = y

Prevalence of moderate wasting (NCHS) (%)

Pre

va

len

ce

of

mo

de

rate

wa

sti

ng

(W

HO

) (%

)

y = 1.43x + 2.02 (R2=0.79)

y = 0.86x – 0.005 (R2=0.98)

Results (3) - moderate wasting

-1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20-1

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Infants (<6 months)Children (6 - 59 months)

x = y

Prevalence of moderate wasting (NCHS) (%)

Pre

va

len

ce

of

mo

de

rate

wa

sti

ng

(W

HO

) (%

)

NCHS WHO

y = 1.43x + 2.02 (R2=0.79)

y = 0.86x – 0.005 (R2=0.98)

Results (4) - disease burden

Extrapolating to 55.8 million infantsU6m in all developing countries:

NCHS

Severe wasting:

920,000 (95%CI 812,000 to 1,036,000)

Moderate wasting

2,757,000 (95%CI 2,571,000 to 2,951,000)

WHO

Severe wasting:

4,799,000 (95%CI 4,558,000 to 5,050,000)

Moderate wasting

5,446,000 (95%CI 5,189,000 to 5,710,000)

Results (5) - programme burden

Effect of WHO-GS:Effect of WHO-GS:

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

Results (5) - programme burden

Effect of WHO-GS:Effect of WHO-GS:

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

DISCUSSION

Discussion – We call for (1)

Urgent further workUrgent further work(including <6 month infants in surveys)(including <6 month infants in surveys)

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

Representative ?Representative ?

Discussion – We call for (2)

PreparednessPreparedness

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

PLANNING ? PLANNING ? RESOURCES ?

RESOURCES ?

Discussion – We call for (2)

PreparednessPreparedness

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

Sensitivity ?

Sensitivity ?

Specificity ?

Specificity ?

Discussion – We call for (3)

Risk/benefit analysisRisk/benefit analysis( children > 6 months )( children > 6 months )

RisksRisksminimalminimal BenefitsBenefits

evidence basedevidence based

programmesprogrammes

- community-based - community-based

feeding programmesfeeding programmes

can be scaled upcan be scaled up

Discussion – We call for (3)

Risk/benefit analysisRisk/benefit analysis(infants <6 months)(infants <6 months)

RisksRisks- - Exclusive

breast

feeding?

BenefitsBenefits

Possible early detection and

referral to::

?

CONCLUSIONS

Conclusions

1) Infant wasting is a public health scale problem1) Infant wasting is a public health scale problem

2) Increase in Dx wasting using WHO-GS –> planning / resources2) Increase in Dx wasting using WHO-GS –> planning / resources

3) Post-rollout surveillance3) Post-rollout surveillance

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

THANK YOU

We thank:• UNICEF led Inter Agency Standing Committee (IASC) Nutrition Cluster for funding the MAMI project

(Management of Acute Malnutrition in Infants), from which this work arose. www.humanitarianreform.org/humanitarianreform/Default.aspx?tabid=74,

www.ucl.ac.uk/cihd/research/nutrition/mami• MEASURE DHS (Macro International Inc., Calverton, USA) & all countries surveyed for DHS datasets

QUESTIONS

13 million 13 million

( NCHS )( NCHS )

19 million 19 million

( WHO )( WHO )

38 ….against the WHO Growth Standards, UK

populations appear large at birth and show apparent ‘catch-

down’ growth by around one centile band (0.67 SD) during

the first 2 to 4 months. There is a risk that such an early

growth pattern might discourage some families from

continuing breastfeeding. Thus it is suggested that WHO

Growth Standards be used only beyond that point.

39. It is therefore appropriate to consider the adoption of

WHO Growth Standards from 2 weeks of postnatal age…

.

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.04

9.0

51

.0

53

.0

55

.0

57

.0

59

.0

61

.0

63

.0

65

.0

67

.0

69

.0

71

.0

73

.0

75

.0

77

.0

79

.0

Length (cm)

We

igh

t (k

g)

-3 z-score WHO

-3 z-scores NCHS

WHO vs NCHS cut-off curves for Severe Acute Malnutrition

Figure 2. Weight cut-offs used to define wasting by either NCHS or WHO criteria. Arrows show median lengths at age 6 months and 1 year. The chart is for boys: girl’s charts follow a similar pattern.

Median lengths

(WHO-GS): 67.6cm @ 6m, 75.5cm @ 1yr

Discussion – WHO-GS are coming

Results (5) - feeding centre burden

0 4 8 12 16 20 24 28 32 36 400

4

8

12

16

20

24

28

32

36

40

x = y

% of TFP admissions aged <6 months (NCHS)

% o

f TF

P a

dm

issi

on

s ag

ed <

6 m

on

ths

(WH

O-G

S)

0 4 8 12 16 20 24 28 32 36 400

4

8

12

16

20

24

28

32

36

40

x = y

% of SFP admissions aged <6 months (NCHS)

% o

f TF

P a

dm

issi

on

s ag

ed <

6 m

on

ths

(WH

O-G

S)

a) b)