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