Childhood malnutrition encompasses a plethora of nutritional disorders that include stunting, underweight, wasting, severe acute malnutrition (SAM), and micronutrient deficiency disorders. Overweight and obesity, at the other end of the nutritional spectrum, are also manifestations of childhood malnutrition. Nearly 24 million children (younger than 5 years) worldwide experience SAM. The vast majority is located in Africa and Asia (8 million are in India alone). A child with SAM is 10 times more likely to die than a well-nourished child. SAM is one of the top 3 nutrition-related causes of death in children younger than 5 years. Estimates of deaths directly attributable to SAM varied from 0.5 to 2 million annually. Moderate and severe child malnutrition account for 40% to 50% of all deaths in children younger than 5 years. If the United Nations Millennium Development Goals (http://www.un.org/millenniumgoals) of reducing children malnutrition and mortality by 50% by 2015 are to be met, SAM needs to be prevented and controlled effectively.
UN SYSTEM (UNICEF-WHO-WFP) ACTIVITIES IN PREVENTION AND TREATMENT OF SAM
1. Support countries with high levels of SAM to scale up coverage for treatment through community-based management of acute malnutrition (CMAM)
2. Preventing acute malnutrition in children and women through increasing coverage of high-effect interventions (eg, micronutrients)
3. Inpatient treatment is reserved for the smaller group that requires close medical monitoring and therapies that are exclusive to medical facilities: parenteral hydration, treatment of hypotension, shock, metabolic alterations (hypoglycemia, hypothermia), or severe infections
4. Integrated management of PEM considers both inpatient and outpatient treatment of SAM; whenever possible outpatient treatment should be used based on the following advantages:
a. Minimizes effect on family and requires limited health services support
b. Simpler treatment: no food preparation is required, can be eaten directly
c. Broad coverage: eliminates primary barriers to “scaling up” (need for doctors and health facilities)
d. Active case finding relies on community outreachThe support for using community-based treatment is also based on equal or lower mortality rates and reduced cost (US$∼450–∼$130/child).
5. Policy formulation at country level is progressing rapidly; 95% countries have national guidelines/protocols for acute malnutrition as evidenced by:
a. Visible policy documents and joint statements
b. Increasing coverage and scaling-up of programs: 55 countries implementing CMAM; an additional 7 countries are in the planning stages.
c. Integration of CMAM with other primary health progress in at least 50% to integrate activities: integrated management of childhood illness, infant and young child feeding, human immunodeficiency virus/acquired immune deficiency syndrome
d. Increasing adherence to a comprehensive integrated approach into health systemGlobal guidelines and training resources are available including incorporation of infant feeding orientation into trainings.
6. Challenges encountered in the implementation of the CMAM include
a. Weakness in existing intersectoral linkages; stronger links with food security and other sectors are required in support of long-term solutions and prevent short-term emergencies
b. Unpredictable funding; most resources still derived from humanitarian response for acute emergencies averting multiyear planning
c. Difficulties in setting up long-term supply plans to ensure that ready to use therapeutic food (RUTF) needs are met and buffer stocks are in place.
d. Geographical distance of manufacturers from the final beneficiaries is a problem; however, proliferation of unreliable local suppliers with poor quality control systems is not the answer.
UN SYSTEM ACTIVITIES IN PREVENTION AND TREATMENT OF SAM
The WHO Electronic Library of Evidence for Nutrition Actions (eLENA) has been released (www.who.int/elena). This updated version of the site includes new nutrition intervention topics such as food supplementation for children with moderate acute malnutrition, vitamin D supplementation in infants, multiple micronutrient supplementation in pregnant women, and community-based feeding for the promotion of child growth. Updates of the eLENA site have been launched and include translations into the 5 official WHO languages. The Spanish site was launched during the World Health Assembly in May 2012 (www.who.int/elena/es). Updated guidelines on the integrated management of SAM in children are expected to be released in the upcoming edition of eLENA.
The Global Database on the Implementation of Nutrition Action is a complementary Web-based tool in which governments and organizations can upload and share information on their nutrition activities. The Global Database on the Implementation of Nutrition Action will have a user-friendly interface with interactive maps, lists, and fact sheets that show what is being done where, when, with whom, why, and how to scale up and improve nutrition. Users are invited to continue to upload nutrition action information via the online form at www.who.int/nutrition/gina.
CHALLENGES FOR HEALTH PROFESSIONALS CONCERNED WITH GASTROINTESTINAL DISEASES AND NUTRITION IN ADDRESSING SAM
Clearly, there is a need for all concerned parties to join forces; pediatricians and especially those with interest in gastrointestinal (GI) diseases and nutrition have an important role to play. Key challenges ahead and potential approaches in addressing them are summarized in the next section.
1. Lack of political commitment: Nutrition is often a low priority on the political agenda resulting in limited funding or in some cases no secure budget allocation being made. SAM in many cases is not even recognized as a health problem (not included in surveillance systems). Health professionals should also be strong in advocacy efforts and lead the battle against SAM calling the attention of all concerned parties, not only on moral grounds but also as a key investment for national development.
2. The implementation of known solutions requires a strong delivery system, such as infant and young child feeding. Thus, a well-supported health care service with broad coverage is fundamental, particularly in hard-to-reach areas and for population groups living in poverty or emergency conditions.
3. Resistance of some governments to use imported ingredients, that is, RUTF or other costly supplies, limits implementation of CMAM programs in some areas of the world. The concerns are commonly based on sustainability and having to depend on imported commodities. These can be circumvented by using local ingredients and/or local blending of ingredients depending on circumstances.
4. The appropriate design and effective implementation of CMAM requires local capacity to design, implement, and evaluate programs. Limited local capabilities impede progress in controlling and preventing malnutrition in many countries.
5. The effectiveness of CMAM program requires local institutional capacity to ensure the delivery of a comprehensive package of services in emergencies (CMAM and micronutrients); in addition, information needs to be collected and reported to assess cost-effectiveness of the interventions.
6. Successful sustained control of SAM requires intersectoral linkages beyond health; at the very least, they should include agriculture (food and nutrition security), water and sanitation, women's and children rights, community participation and empowerment. Creating sustainable livelihoods allows communities to meet their basic needs. Only then can governments be held accountable and responsible in addressing the social and economic determinants of SAM.
7. Sustained funding for activities, programs, development of institutional and human capacity is fundamental to avert acute emergencies. Predictable medium- and long-term funding and multiyear planning are essential to prevent malnutrition in all its forms and avert the consequences on human and social development.
8. Long-term supply to ensure that raw materials to produce RUTF are met and buffer stocks are in place and available to cover local needs. This requires appropriate quality control and distribution systems.
9. Systematic collection of local, regional, and national data collection and information systems should be in place to guide CMAM activities, map SAM, and focus efforts on most-affected areas.
10. Information flow from field to national level should be established; consistent use of WHO reference growth standards should be used within and between countries, defining common performance indicators for regional- and country-level reports.
This report is a short account of present efforts in addressing SAM; what we do or fail to accomplish in the next few years will have major significance if we are to achieve the millennium development goals 1 and 4. Halving hunger by 2015 most likely will not be achieved on a global basis; however, with appropriate support, this may be achieved by many countries in Africa and southeast Asia. Similarly, reducing by two-thirds the mortality of children younger than 5 years unless we make this a global priority for action and do not leave this to action by local governments that may or may not see this as a top priority. It is time that we consider child health and well-being a global priority subject to commitments by global governance; sooner or later we must face that “children's needs cannot be postponed.” We must act now to secure their basic needs—the future of humanity is at stake.
All JPGN readers are concerned with malnutrition in children because most diseases of the GI tract have a negative effect on nutrition. Because they are common all over the world, essentially as a consequence of infection, they represent a major cause of malnutrition.
Malnutrition, A Risk to All Children and Humanity
Nutrition is essential for all life to be perpetuated through reproduction. Childhood is the period in which growth and psychosocial development are supported by use of food through metabolic processes genetically determined. Malnutrition is a generic term that covers the results of any deviation that impairs growth and development. It may be so severe that it may remove the life of the child. Most often the child recovers after proper treatment, but in too many children, it will last for years. Many girls reach reproductive age in poor nutritional condition. The millions of children born to malnourished women are more likely to face cognitive impairments, short stature, lower resistance to infections, and a higher risk of diseases throughout their lives, thus perpetuating the cycle of malnutrition.
Select Realistic Target
At the global scale, the most prevalent situation is deficit rather than abundance in food availability or food use or both, for example, as a consequence of GI disorder, infectious disease, or low birth weight (LBW). According to UNICEF, 1 in 4 children in the developing world are underweight. Because pediatricians are facing such a disaster, it is difficult to imagine what can be done to solve it; however, by targeting specific population, it may be possible to envisage proper treatment. First, it is important to define the different states of malnutrition. Malnutrition may be the results of general or selective food deprivation, essentially iron, iodine, zinc, and vitamin A. The most common clinical conditions are underweight, stunting, and wasting. All of these conditions occur in different context that need to be analyzed.
Second, it is important to identify the regions of the world that need context-specific approaches. More than 10 million children die each year, most from preventable causes and almost all in poor countries. Six countries account for 50% of worldwide deaths in children younger than 5 years, and 42 countries for 90%. The causes of death differ substantially from one country to another. A better understanding of child health epidemiology could contribute to more effective approaches to saving children's lives (1).
Severe Acute Malnutrition
SAM is defined by an extremely low weight for height, by visible severe wasting, or by the presence of nutritional edema. Until the end of the 20th century, the median under-5 case-fatality rate for SAM typically ranges from 30% to 50%. It was reduced substantially (typically <5%) when physiological and metabolic changes were taken into account and a standardized protocol was initiated (2). The use of F100 as a milk powder reconstituted with water to obtain 100 kcal/100 mL was effective but its use was limited to medical structures. The RUTF was a major step in overcoming the limitation of F100 (3–5). In 1997, André Briend, who was the initiator of such treatment, conducted the first clinical trial in Tchad as a proof of concept. In 2005, in Niger, Médecins Sans Frontières treated at home 60,000 children with a success rate of 90%. Such a therapeutic approach is expected to save millions of children.
One approach to prevent malnutrition and maintain healthy nutritional status is to use locally available food. However, many limits need to be taken into account, including food availability, composition, and cost, which must cover the nutrient recommendations for that population. Historically, such an approach was based, at best, on experimental trial and error. The science of nutrition has been enriched with a mathematical tool called linear programming (6). The principle is simple: The more a child eats a food, for example, rice, the more he or she absorbs energy, and such a relation is linear. The same applies for energy, macro- and micronutrients, and cost of the meal. This is precisely what linear programming can solve (7). Initially, an Excel program was used, then more user-friendly programs were designed, for example, Nutrisurvey. In 2012, a program called Optifood was being developed (http://www.unicef.org) and should be released soon, allowing more pediatricians and nutritionists to provide proper recommendations that are expressed as food rather than individual nutrients. Such an approach could be used in many different settings in both developed and developing regions.
Childhood Malnutrition in Asia
Stunting, defined as height-for-age >2 standard deviations (SD) below the reference median, is the most common type of childhood malnutrition and reflects chronic malnutrition. It is associated with impaired cognitive functions and reduced physical productivity. Of the 178 million (32% of all of the under-5 children) stunted children in the developing world, Asia accounts for 112 million (8). The number of stunted children in south Asia alone (74 million) is greater than in the entire African continent (57 million). Wasting indicates acute malnutrition and is defined as a weight-for-height z score <−2SD. Wasted children are susceptible to infections and have a 3 to 4 greater odds of death from diarrhea or pneumonia. More than 19 million (3.5%) children experience globally the extreme form of wasting, SAM, which is characterized by any one of the following: weight-for-height z score <−3 SD, mid-upper-arm circumference <11.5 cm, or bilateral pedal edema. India is home to >8 million children with SAM (9), whereas Africa has 5.6 million children with SAM, which carries a >9-fold risk of death compared with well-nourished peers. Underweight is a combination of stunting and wasting. The mean length-for-age z score of Asian infants at birth is lowest compared with infants of other regions, and the gap between children in different regions remains unchanged after 24 months, when compared with a healthy reference group (10). It is obvious that Asia, particularly south Asia, has the greatest burden of childhood malnutrition.
Worldwide, 17% of neonates are born each year with LBW, which is a body weight <2500 g at birth. In Asia, the prevalence of LBW ranges from 15% in Bhutan to 36% in Bangladesh (11). This is important because LBW is a major risk factor for malnutrition. Moreover, children who survive LBW have an increased risk of chronic diseases in adulthood including type 2 diabetes mellitus, hypertension, and coronary artery disease.
Micronutrient malnutrition, much of which is not “visible” and is also known as “hidden hunger,” affects millions of children in Asia. In children under 5 years, 115 million in southeast Asian compared with 83 million in all of Africa suffer from anemia, which is mostly nutritional in origin. Between 1995 and 2005, 50% of pre-school age children in Asia had subclinical vitamin A deficiency characterized by a serum retinol level <0.7 μmol/L. Iodine deficiency has negative effects on growth and development due to inadequate thyroid hormone production. In 2011, 39.3% school-age children in Africa had insufficient iodine intake compared with 30% in southeast Asia (absolute number being much greater in southeast Asia). Countries at high risk for zinc deficiency are those with a stunting prevalence of >20% and estimated prevalence of inadequate zinc intake of >25%. Zinc deficiency is high in south Asia (8).
Overweight and obesity are the epidemics of the 21st century. Overweight in childhood is defined as a body mass index ≥25 kg/m2, whereas obesity can be defined as having a body mass index ≥30 kg/m2(12). Although it has become a primary childhood health problem in developed nations, Asian countries are also beginning to see childhood obesity emerging as a problem. By 2010, >40% of children in the North American and eastern Mediterranean WHO regions were predicted to be overweight or obese, followed by 38% in Europe, 27% in the western Pacific, and 22% in southeast Asia (13). A study done on Indian children showed a significant increase in prevalence of obesity from 9.8% in 2006 to 11.7% in 2009 (14).
The huge burden of malnutrition and the looming threat from obesity in children of Asia call for concerted efforts. Nutrition must be treated as a development agenda and brought to the forefront in national policy formulation and budgetary considerations. Food insecurity is a major hurdle in many countries and needs careful attention for producing more cereal as well as noncereal crops, fisheries, and livestock. This has become even more relevant for countries such as Bangladesh, which face imminent agricultural disaster caused by climate change. Direct, nutrition-specific interventions should be scaled up to reach entire populations. These interventions include breast-feeding, appropriate complementary feeding, micronutrient supplementation, deworming, treatment of moderate acute malnutrition and SAM (15). These interventions alone will not be enough. Indirect, nutrition-sensitive interventions like fruits and vegetables growing, fish culture in small water bodies, female literacy and empowerment, poverty alleviation, and so on need to be implemented at scale. It is also imperative to have multisectoral programs such as social protection schemes, hygiene and sanitation, and income-generation interventions. The overweight/obesity problem seen in countries should be dealt with programs for changing diet and lifestyle with emphasis on physical activity of children.
Fluids and Diets in the Early Treatment of SAM
The treatment of SAM must focus on prevention of childhood malnutrition, with a multipronged approach including micronutrient supplements during pregnancy, exclusive breast-feeding of human immunodeficiency virus–exposed infants for 6 months with effective antiretroviral therapy, use of ready-to-use therapeutic foods in the community, water and hygiene (hand washing with soap) interventions, and, most importantly, addressing the social determinants of health through greater equity within societies. This section, however, focuses on the importance of careful fluid and dietary management of SAM during the early phase of treatment, which has such a high mortality.
Although ready-to-use therapeutic food (RUTF) has greatly improved our capacity for rapid catch-up growth in both hospital and community, we need to focus more on the initial diets of unwell children with severe malnutrition, often accompanied by acute or persistent diarrhea. Fasting is clearly deleterious for such children, as the practice of resuscitation on children's wards with IV fluids, minerals, vitamins, and antibiotics (without milk or equivalent) has shown. Small frequent feeding is crucial, but volumes may need to be individualized, which makes it very difficult on pediatric wards with the scarcity of nursing resources, especially during evening and night shifts. WHO guidelines recommend the use of F75 formula, following research done >30 years ago (15,20). But we now have a clearer concept of the gut in malnutrition, so should be able to design better diets. Osmolality in particular may be important (21). F75 has an osmolarity of 333 mOsmol/L, while there are commercial lactose-free formulas with 160 mOsmol/L. We need high-quality randomized trials comparing F75 with commercial formulas to see whether they improve outcomes, as they are being increasingly used without clear evidence of a benefit.
Finally, new genetic techniques are transforming our understanding of childhood diseases, and we are learning the importance and complexity of genetics as a contributor to childhood obesity (22). In settings of poverty and deprivation, it is often unclear why some children become malnourished and many do not. Because survival from severe malaria and diarrheal disease has greatly affected our genetic makeup, it would be surprising if childhood growth and nutrition had not also. Although this is not likely to lead to better treatment immediately, it may improve our understanding of the biological determinants of malnutrition and it may even be possible to identify children at risk and intervene earlier to prevent malnutrition. It is important for children in developing countries to benefit from scientific advances equitably.
Nutritional Transitions: From Undernutrition Related to Poverty to Energy Excess and Chronic Diseases in Affluent Societies
The history of nutrition of Australian children is a history of social and economic transitions, with a marked effect on access to food and adequate nutrition. The sparse information available regarding the health of pre-European Australian aborigines identifies a culture well adapted to a harsh environment. Individuals without earlier European contact were hunter-gatherers, described as slimly built, sinewy “featherweights,” whose diet consisted of mammals, reptiles, birds, fish and invertebrates, nuts, fruit, roots, and seeds (23). European colonization resulted in the loss of traditional ways of living and autonomy, progressive social disadvantage, and widespread poverty by the aborigines. Children in particular paid a heavy cost from the increase in the burden of infectious disease and malnutrition.
The effect of child undernutrition associated with infection, especially enteric infection, is well documented since the 1960s. In 1969, Aboriginal children comprised 4% of the population but accounted for 46% of hospitalizations for deficiency anemias and 27% of admissions for other nutritional deficiencies (24). Recurrent infections, with hospitalization rates up to 8-fold the rest of the population, together with poor nutrition interact to produce a chronic enteropathy, characterized by poor mucosal barrier function, malabsorption, especially of carbohydrates and electrolyte disturbance, perpetuating a cycle of diarrhea and malnutrition (25).
Nutritional disadvantage related to poverty manifests first with lower birth weight, up to 1 kg less than Australian norms in some settings, and with double the risk of LBW, which on average was 220 g less than the rest of the Australian community in 2005 (23). This is followed by early growth faltering despite breast-feeding in the first 6 months of life. In the mid-20th century, 30% and 28% of infants were below the 10th centile for weight and height, respectively, increasing to 87% and 74% by 24 months of age (26).
At the beginning of the 21st century, infant mortality among the poor remains 1.75 times that of higher socioeconomic groups at 7.30 versus 4.13 per thousand live births, and there is a life-expectancy deficit of 12 years for aboriginal Australians (27). Despite these statistics and persisting disadvantage, late 20th century socioeconomic change produced health improvements, with fewer hospitalizations for infections, and less severe early nutritional disadvantage and a decreasing life-expectancy gap (23); however, transition from third-world conditions to a situation that has improved, but remains suboptimal, has generated another set of nutritional issues related to overweight and obesity. Approximately 40% of 15- to 24-year-olds are overweight or obese, increasing to almost 60% during the remaining adult years (23). This problem begins in childhood with recent surveys demonstrating 4-year-olds more likely to be overweight or obese than higher social class peers (28% vs 18%) (28). Increasing obesity is associated with increasing type 2 diabetes mellitus and metabolic syndrome, which occur in up to 14% of low social class adolescents (29). High proportions of remote area rural poor are obese, and experience higher blood pressure, cholesterol, triglycerides, glucose, and insulin (30). The leading causes of death among those of low social class living in poverty are ischemic heart disease and diabetes mellitus, with standardized mortality rates for heart disease 2.5 to 2.9 times, and for endocrine and metabolic disease 7.5 to 10.5 times greater than higher socioeconomic class groups (23,24). Noncommunicable disease now accounts for 70% of the life-expectancy gap between higher and lower social class Australians (27).
The rapid transition from diseases of nutritional deficiency to diseases of excess is related to the overall nutritional experience of children, with early nutritional experience translating into long-term health risks. Problems of poverty and food insecurity and food quality persist. Families frequently have inadequate financial resources to guarantee food security, and poor access to a healthy, nutritious diet is common, increasing reliance upon low-cost high-energy alternatives. More important though is in utero nutrition and LBW, influenced by both maternal underweight and overweight, which with early childhood malnutrition is associated with later obesity and its long-term risks (23). These early nutritional deficits provide lifelong programming of behavioral and metabolic responses critical to the way in which individuals deal with food. These represent major potential points of intervention essential for improving health and well-being at the population level.
There are no well-validated solutions to the difficulties faced by children. The solutions are not primarily nutritional, although breast-feeding and healthy eating are important, nor are they unique to Australian low socioeconomic groups, but common to many other low-income and socially disadvantaged groups globally. Recognition of the languages, cultures, and connection to their land of indigenous people is important, as is establishing autonomy and self-determination, enhancing the role of women, building social capital and resilience, and cultural reconciliation. These aspirations may seem removed from pediatric nutritional research and practice, but advocacy remains a core part of pediatric practice.
Food Insecurity and Obesity in Affluent Societies: The 2 Faces of Malnutrition
The public health implications of childhood obesity are serious and command significant attention globally. In resource-rich countries, food insecurity does not have the same public visibility and yet it too is a global pediatric issue that occurs in resource-poor and -rich countries, with significant implications for long-term health and development.
In North America, >15 million (21%) US children live in poverty and >16 million (22%) live in food-insecure households; (31,32) more than one third of US children and adolescents are overweight or obese (33) Although food insecurity and obesity are traditionally viewed as separate public health issues, there is increasing awareness there is significant overlap between these conditions.
Although children are often protected from reductions in food intake in food-insecure households, children who face food insecurity are more likely to report hunger (32). Children who struggle with hunger are more likely to be hospitalized, experience headaches, abdominal pain, and fatigue (34). They have a higher prevalence of iron-deficiency anemia and inadequate intake of key nutrients and are more likely to have behavioral, emotional, and academic troubles (34,35). The immediate and long-term consequences of overweight and obesity are well described and include psychosocial issues, diabetes mellitus, sleep apnea, hypertension, and joint disease and their long-term consequences.
Unlike obesity, food insecurity and hunger are often hidden problems in North America, even in families in which other indicators of poverty are evident. US families underuse food assistance programs: Fewer than half of the children eligible for a free or reduced-price school lunch receive a school breakfast and <15% of eligible children participate in a summer meal program (36). Risk factors for food insecurity include households with: incomes near or below the poverty line, children headed by single (particularly female) parents, racial/ethnic minorities, and those located in large cities or rural areas. Food insecurity disproportionately affects communities at high risk for obesity (32), just as obesity is more prevalent among those who are poor and minorities (33).
What accounts for this overlap of these 2 seemingly opposite conditions? Although there is no definitive answer, some observations are informative. Families in rural, minority, and low-income neighborhoods have limited access to stores selling healthy affordable foods, which leads to lower-quality diets with increased consumption of low cost but energy-dense food. These high-energy foods are also easier to overconsume (37). Families living in low-income communities also often lack access to safe sidewalks, parks, and recreation centers with fewer opportunities for outdoor activity and more inactive time watching television or playing video games (38). Thus, the connections among poverty, food insecurity, and obesity are apparent.
What is less clear is whether there are causal relations between food insecurity (independent of poverty) and obesity. Although studies in children have been inconsistent, several cross-sectional studies have found associations, particularly in certain subpopulations. Behavioral adaptations of families to poverty and low income may be a common thread linking obesity and food insecurity. In such households, periods of limited access to food may result in distorted patterns of food consumption (overcompensating for periods of food scarcity), resulting in overall excessive food intake. Additionally, food insecurity increases parental stress and may affect parenting practices such as adherence to infant feeding recommendations and ability to provide healthy meals.
Thus, the association between food insecurity and obesity has both an empirical and plausible relation; both remain important public health issues for children in North America. As public health policy evolves to deal with the pressing epidemic of childhood obesity, it must concurrently consider measures to deal with the environmental and social conditions that result in food insecurity. Although the face of malnutrition in North America, like in other resource rich countries, differs from that seen in resource-limited countries, food insecurity and obesity have serious nutritional and long-term health implications. Control of both of these issues is vital to the long-term health and development of children.