Biology The of Malnutrition Part 4
Effects of Nutritional Insult at Different Points in the Lifecycle
Key Indicator of Malnutrition
Infant Mortality Rate
Defined as number of children per 1,000 live births who die before their 1st birthday Italy Finland China India Nigeria Uganda 5 4 31 70 76 88
US infant mortality rate: 8
Maternal Malnutrition
Studies of famine situations
Dutch famine of WWII Siege of St. Petersburg Warsaw ghetto
Data showed effect of protein energy malnutrition on pregnancy
PEM early in pregnancy resulted in increased rate of fetal loss and malformations PEM late in pregnancy resulted in low birth weight babies
Maternal Malnutrition
Effect of maternal malnutrition on breastfeeding
Lower volume of milk produced with energy nutrients in the same concentration
Quality stays the same but quantity diminished
Nutrients such as calcium and iron are taken from the maternal stores
Maternal Malnutrition
Effect of anemia
Increased blood volume in pregnancy results in increased iron needs Maternal anemia associated with low birth weight and then low/no stores for the infant
Affect on infant cognition if born with low stores
Anemia in mother also results in decreased work capacity Increased maternal mortality rate
Severe anemia accounts for up to 20% of maternal deaths in developing countries
Maternal Malnutrition
Affect of maternal iodine deficiency
Cretinism in infant Stunted women have smaller babies Smaller pelvic area also results in higher incidence of difficult births
Affect of maternal size
Results in infant and maternal mortality
Effects of Malnutrition on the Infant
Intra Uterine Growth Retardation (IUGR)
Major determinants are
Inadequate maternal nutritional status before conception Short maternal stature
Principally due to undernutrition and infection during childhood
Poor maternal nutrition during pregnancy
Effects of Malnutrition on the Infant
In industrialized countries, cigarette smoking is the most important determinant of IUGR
Followed by low gestational weight gain and low pre-pregnancy body mass index
Effects of IUGR
IUGR newborns in industrialized countries
Partially catch up to controls during the first 2 years of life but usually about 5 cm shorter and 5 kg lighter in adulthood
Same was shown in Guatemala, but still shorter, lighter and weaker than controls as young adults Neurologic dysfunctions (ADD) and immune function impairment also occur
Effects of IUGR
Barkers fetal origins of disease hypothesis
Nutritional insults during critical periods of gestation and early infancy, followed by relative affluence, increase the risks of chronic diseases in adulthood Baby programmed for a life of scarcity and then confronted with a world of plenty
See increases in CVD, DM and HBP, esp. if insult is in the 3rd trimester
Effects of IUGR
Low birthweight (<2500 gm) results in
a higher mortality rate Impaired mental function
Majority of brain growth occurs during fetal period and first 18 months of life
Increased risk of adult disease
IUGR
"Intrauterine growth retardation is a pivotal indicator of progress in breaking the intergenerational cycle of undernutrition, a prospective marker of a child's future nutrition and health status as well as a retrospective measure of the nutrition and health status of the mother." 4th Report
Infant Nutritional Status
Influenced by
Inadequate feeding Frequent infections Inadequate food Health Care
Defined as "the behaviors and practices of caregivers to provide the food, health care, stimulation, and emotional support necessary for children's health growth and development" -4th Report
Infant Nutritional Status
Babies who breast feed usually have better nutritional status than those who do not
Infant does not compete with food supply for family Breast milk is a clean food supply in a clean container Breast milk has immunologic benefits so decreases disease in this way, too
Infant Nutritional Status
BREAST IS BEST
Breast feeding is considered the best method of feeding infants
Exclusive breast feeding usually extends the time between children
Length of the birth interval strongly related to infant and child survival NOT an effective method of birth control however
Infant Nutritional Status
Evidence linking breastfeeding to:
Stronger intellectual development of the child Reduced risk of cancer, obesity and several chronic diseases Women who were breastfed as infants have a reduced risk of breast cancer
Infant Feeding Recommendations
Exclusive breast feeding for 4 to 6 months Breastfeeding with complementary feedings starting at about 6 months of age Continued breastfeeding in the second year of life and beyond
Infant Feeding Recommendations
Field studies show no advantage in growth or development when complementary foods introduced between 4 and 6 months
UNICEF and many ministries of health in general recommend exclusive breastfeeding for 6 months WHO recommends exclusive breast feeding for 4-6 months, so some confusion on this issue
Infant Feeding Recommendations
Interventions to improve intake of complementary foods can result in improved infant and child growth among populations at risk of undernutrition
Effects of improved nutritional intake on growth are greatest in the first year of life with significant effects into the second and third year Adequate nutrition mitigates the negative effect of diarrhea seen in these years on linear growth
Infant Feeding Recommendations
Complementary foods are required in the second 6 months of life to provide adequate nutrition and stimulate development
Delayed introduction of food is a serious problem in countries such as Bangladesh, India and Pakistan
Infant Feeding Recommendations
Complementary foods must be adequately dense in energy and micronutrients to meet the requirements of infants and young children. Must be prepared, stored and fed in hygienic conditions to prevent diarrhea Foods also must be easy to prepare and culturally appropriate.
Breastfeeding and HIV/AIDS
Breastfeeding is a significant and preventable mode of HIV transmission Observational data have shown that 3 month old infants of HIV-positive women who were exclusively breastfed have the same risk of contracting HIV as infants who were never breastfed
Partially breastfed infants had a significantly higher risk
Breastfeeding and HIV/AIDS
New guidelines call for urgent action to educate, counsel, and support HIV-positive women in making decisions about how to feed their infants safely. In order for a mother to make a decision, she must have access to
Voluntary and confidential testing and counseling Information about feeding options and risk associated with them
Breastfeeding and HIV/AIDS
Previous recommendations stated that infants of HIV-positive mothers in developing countries should be breastfed because mortality was still lower in the breastfed infants. Shorter duration of breastfeeding is one option suggested in the new UNAIDS/WHO/UNICEF guidelines
Awaiting confirmation of protective effect of exclusive breastfeeding
Role of National and International Initiative in Support of Optimal Infant Feeding
3 particularly important national and international initiatives to promote breastfeeding
The International Code of Marketing of Breastmilk Substitutes "The Code" The Innocenti Declaration The WHO/UNICEF Baby Friendly Hospital Initiative
"The Code"
Adopted by the World Health Assembly in 1981 Provides guidelines for the marketing of breast milk substitutes, bottles and teats Aims to restrict practices that make infant feeding decisions responsive to market pressures
Especially restricts direct promotion to the public
"The Code"
Resolutions also urge
No donations of free or subsidized supplies of breastmilk substitutes to any part of the health care system
Even with a mixed record of compliance, it has had a major impact on the way formula is advertised and marketed
"The Code"
Has been particularly effective in the virtual elimination of the direct marketing to women who receive services through the public sector and in the restriction of marketing to health providers.
The Innocenti Declaration
Focuses on the need to protect, promote, and support breastfeeding Was signed by more than 30 countries in 1989 One operational target of this is the universal implementation of the Ten Steps to Successful Breastfeeding
Forms the basis for the WHO/UNICEF Baby Friendly Hospital Initiative
The WHO/UNICEF Baby Friendly Hospital Initiative
Endorsed by the 45th World Health Assembly in 1992 Has influenced the routines and norms of hospitals around the world through the Baby Friendly certification process
The WHO/UNICEF Baby Friendly Hospital Initiative
A hospital is designated as Baby Friendly it when has agreed not to accept free or low-cost breastmilk substitutes, feeding bottle and teats and to implement the Ten Steps 14,500 hospitals in over 142 countries have been certified
The Maternal Milk
Protects the baby from
Diarrhea The flu Infection allergies
Mobile Restaurant
Tax free All free Perfectly balanced No infections Natural nourishment Attractive Open 24 hours Service with love
Maternal Lactation: come in , the most nutritious, exquisite, free food
MMM, it's time to eat But what are they going to give me? Ahh! My mother chose the best Mother's milk
Child
Brain cells increase in number (hyperplasia) until about age 18 months
Malnutrition results in fewer cells and decreased mental capacity Prenatal malnutrition combined with postnatal malnutrition leads to a larger deficit
Child
Chronic malnutrition also has an indirect effect on mental development because it makes children less active and therefore their brains are less stimulated
Less exploratory behavior
Iodine deficiency has been shown to lower IQ by 13.5 points
If average is 100, -13.5 = 86.5, a level that is only higher than about 20% of the population
Child
Measures of malnutrition
Stunting Wasting Underweight
Child
Underweight
Low weight-for-age at < 2SD of the median value of the NCHS/WHO reference Weight for age is influenced by the height and weight of a child
Therefore is a composite of stunting and wasting Makes interpretation of this indicator difficult since both weight for age and height for age reflect the long-term nutrition and heath experience of the individual or population
Child
Wasting
< 2SD of median weight for height
Severe < 3SD
Usually due to acute food shortage and/or severe disease Chronic dietary deficit or disease can also lead to wasting This indicator is used extensively in emergency settings
Child
Chronic low intake leads to STUNTING
Growth charts key indicators Linear growth
<2 SD from median value of international growth reference for height = stunting <3 SD = severe stunting Know that nutrition, not heredity, is the cause because of studies of better fed children in the same culture and growth velocity when breastfed
Poor diet and disease leads to shortness
Child
Incidence of stunting is estimated at 32.5% of children under age 5 in developing countries Potential for catch-up growth is limited amongst stunted children after the age of 2
Especially kids in poor environments
Some catch-up possible between 2 and 8 /12 if NOT born with LBW or severely stunted in infancy
Child
Stunting at age 2 is associated significantly with later deficits in cognitive ability Alleviating hunger improves learning
School feeding, both breakfast and lunch programs, has been shown t improve school performance in both developing and industrialized countries
Child
Alleviating hunger helps children perform better
Hungry children have more difficulty concentrating and performing complex tasks, even if they are otherwise well nourished Studies in Jamaica have shown that children who were wasted, stunted, or previously malnourished benefited the most from feeding programs
Child
Poor nutrition also increases nutrition-related illnesses, causing children to miss more days of school
Text cites case of 4 Latin American countries where illness causes children to miss more than 50 days of school a year This has a definite affect on learning as well
Child Catch Up
Child
A higher proportion of boys than girls are stunted in all countries
Probably due to the increased time boys spend outside the home Girls have better physical access to available food
Child
Ways to improve nutrition and health status of children
Antihelminthics
Given in conjunction with vitamin A or iron supplementation shows better outcomes
Delivery of micronutrients Treatment of injuries and routine health problems
Adolescents
Adolescent hormonal changes accelerate growth
Growth is faster than at any other postnatal time except the first year
Adolescent Girls
Better nourished girls
Have higher premenarcheal growth velocity Reach menarche earlier Grow longer before a later menarche
Undernourished girls
Growth of better nourished and undernourished girls during this period balances out
Growth difference due to pre-existing childhood stunting even when total growth during growth spurt ends up being the same
Adolescent Girls
Undernourished girls grow for a longer period of time, so may not be finished growing before the 1st pregnancy
Leads to smaller infants due to competition for nutrients and poorer placental function Calcium a special concern since bones of adolescents have not reached maximum density
Higher maternal and infant mortality and preterm delivery with adolescent pregnancies
Adolescent Boys
Growth occurs for a longer time before growth spurt Velocity of growth spurt higher and longer than for girls Requires significant calories, protein, iron and other nutrients to support
Adolescents
Some catch-up growth may be possible in adolescence but there is little evidence to support it "Stunted children are more likely than non-stunted children to become stunted adults as long as they continue to reside in the same environment that gave rise to the...