Micronutrient Supplementation and Child Survival in India

Transcription

1 Symposium on Child Survival in India: Part II Micronutrient Supplementation and Child Survival in India Prakash V. Kotecha 1, 2 and Chandrakant Lahariya 3 1 A2Z, the USAID Micronutrient Project, New Delhi, 2 Department of Preventive and Social Medicine, Government Medical College, Vadodara and 3 Department of Community Medicine, G.R. Medical College, Gwalior, India ABSTRACT India contributes to a large number and proportion of child deaths, both due to higher under five mortality rate and large child population cohort in the country. The micronutrient malnutrition is an ignored area as it is not a direct cause of child mortality but a contributory factor in many deaths. The repeated surveys and studies have noted that iron deficiency anemia, vitamin A deficiency, iodine deficiency are highly prevalent amongst the children in the country and the preventive interventions are reaching only small proportion of 10-50% of the targeted populations. The contribution of these micronutrients (Iron, Vitamin A, Iodine and Zinc) towards child survival depends upon number of factors that are responsible for child mortality, and these situations vary from region to region, time to time and depend upon number of other socio demographic characteristics of the population. This paper discusses that although there may be debate on the role of some micronutrients in reducing childhood mortality, there is no doubt that these micronutrients are needed in small amount for overall child development. These micronutrients, both directly and indirectly, contribute to the child survival and should reach to each and every child in the country and the strategy is proven cost effective. [Indian J Pediatr 2010; 77 (4) : ] pvkotecha@gmail.com; c.lahariya@gmail.com Key words: Child survival; Micronutrient supplementation; Vitamin A; Iron; India India has made a remarkable progress on many health indicators in last 5 decades, the life expectancy has doubled, and infant mortality rate halved. 1 These indicators, however, mask many other problems, still affecting population and, child malnutrition in India is one such problem. The micronutrient deficiency is one of the aspects of child malnutrition and India has 1/3 rd of global 2 billion people suffering from vitamin and micronutrient deficit. 2 It has been estimated that prevalence of clinical and sub clinical vitamin A deficiency in India is among the highest in the world. 3 The data has reported the prevalence of Bitot s Spots in preschool children to be 0.7 per cent. 4 India has the largest number of Vitamin A deficient children in the world with 330,000 children dying directly or indirectly every year, due to this deficiency. 22,000 women of reproductive age die every year from severe anemia. These deficiencies are contributory to unacceptably high morbidity and mortality rates in the country. 3,5 Recently, folic acid deficiency has also been recognized as a serious problem Correspondence and Reprint requests : Dr P.V. Kotecha, 2 C-2 Parkwood Apt, Rao Tula Ram Marg, New Delhi , India. [DOI /s ] [Received January 27, 2010; Accepted January 27, 2010] in India with more severe consequences and associated deformities. It is reported that 200,000 babies are born every year with neural tube defects which is 16 times the global average. 6 The diarrhea and pneumonia account for approximately half of the child deaths in India, and malnutrition contributes to over 61% of the diarrheal deaths and 53% of pneumonia deaths. 7-8 The micronutrient deficiency received less attention as major focus has always been on tackling the rampant undernutrition first. Nevertheless, reports suggest that micronutrient deficiencies are contributory to approximately 10% of all under 5 deaths, globally. 6 This article analyzes the magnitude of the problem in India, the delivery of preventive and treatment interventions, analyzes the data in the background of policy and programmatic interventions in the recent times, and outlines the actions required to address the problem in India. Micronutrients supplementation The micronutrients are the nutrients required in minute quantities (micrograms) for various body functions that are vital to maintenance of healthy life. The micronutrients of significant public health importance are iron, vitamin A, zinc and iodine, and a large number of these are essential. 9 The Government of India (GoI) has Indian Journal of Pediatrics, Volume 77 April,

2 Prakash V. Kotecha and Chandrakant Lahariya started programs for supplementation of vitamin A, iron and iodine for nearly 4 decades. 10,11 The objectives of these prophylaxis programs were comprehensive and approach included much desired long term solution of diet improvement and education, and a short term approach of supplementation. However, as described in the other article of this series, 7 micronutrient malnutrition has been a persistent problem in India and as the recent data suggest some of micronutrient malnutrition has increased in the last 2 decades. 4,12 There has always been programmatic focus on correcting these deficiencies and policy intentions like there will be sustained efforts to reduce/eliminate micronutrient deficiencies, with stated goals: Eliminate Vitamin A deficiency as a public health problem. 2. Reduce the prevalence of anemia by 25 per cent and moderate and severe anemia by 50 per cent in children, adolescents, pregnant and lactating women. 3. Achieve universal access to iodized salt, and to reduce the prevalence of Iodine deficiency Disorders in the country to less than 10 by Though, the strategy to achieve these goals has been comprehensive, there have been gaps in the implementation and operationalization. These were initially implemented as vertical programs, prior to 1990s, with later integration with Reproductive and Child Health (RCH) program, and now with the National Rural 13, 14 Health Mission (NRHM). Micronutrient nutrition Status of Indian Children The level of anemia was high at 74% among young children under three years in , 12 which increased to 79% in The NFHS has reported that prevalence of anemia in children 6-59 month is in the range of 60-85% and the pattern is almost similar across the country, with highest prevalence in the age group of 6-23 month, the age at which the consequences are the most severe and damage caused is irreversible. 10 In the same survey, it is reported that coverage with these micronutrients is low with not only Iron but also with other micronutrients (Table 1). 4 Another survey (Table 2) in eight major states of India also indicated very poor IFA coverage. The median intake of iron by young children between the age of month was as low as 12.3 mg/day against recommended daily allowance of 28 mg, indicating less TABLE month-old Children, who Received Micronutrient Supplementation as per NFHS-3. 4 Sl. Children Percentage No. of children 1. given vitamin A supplements in last 6 months given iron supplements in last 7 days given deworming medication in last 6 months living in households using adequately iodized salt 47.5 TABLE 2. The Distribution of Children According to Receipt of IFA Tablets Under Program 1-<5 yr Children 17 States N Received IFA Tablets (%) Kerala Tamil Nadu Karnataka Andhra Pradesh Maharashtra Madhya Pradesh Orissa West Bengal Pooled from all States than 40% of RDA consumption and this is a consistent finding with earlier studies of NNMB. 15,17 The proportion of children aged 6-35 month, who received Vitamin A supplementation in last six months was as low as 25% in 2006, 4 which increased to 55% in a separate survey in A study 19 reported the prevalence of bitot spot was 0.9% in preschool boys and 0.6% in preschool girls indicating public health importance of the problem as per World Health Organization Criteria. 20 This was over 1% among scheduled castes and scheduled tribe. The dietary intake was less than 50% of RDA in more than 86% of children. The study revealed that more than 60% of children had serum retinol level of less than 20 microgram/dl, another indicator of vitamin A deficiency as a public health problem. The median percentage intake of vitamin A consumption in the same age group was found to be less than 15% for children month of age. 15 The dietary intake improvement for iron and vitamin A is the most desirable and promising solution, a part of the program in place for over 30 years but unfortunately, has consistently failed to show what is desired and strived for all these years. Recent nationwide survey in children under the age of five yr (4) has shown that neither intake of iron and vitamin A are adequate in diet, nor are they reaching these young children through the existing program as supplements. On the front of iodine deficiency disorders, according to surveys conducted in 325 districts of the union territories, 263 districts have endemic iodine deficiency with an estimated prevalence of over 71 million people with insufficient iodine intake. Every year over 13 million infants are born unprotected from Iodine Deficiency Disorder (IDD) million children are born mentally impaired every year in India due to iodine deficiency; intellectual capacity is reduced by 15 per cent across India due to iodine deficiency. 22 Fortunately, there is no controversy on the use of iodine supplementation and efforts of iodization of salt on the right path. However, ensuring the continuous use of iodine require sustained efforts and is a big challenge ahead. The intake of iodized salt is the simplest way to control iodine deficiency in the 420 Indian Journal of Pediatrics, Volume 77 April, 2010

3 Micronutrient Supplementation and Child Survival in India community. However, the data suggest that more than 50% of the households in India are not using adequately iodized salt. 4 The sale of Iodized salt is compulsory and non iodized salt is banned in all but a few States in India. However, the survey conducted in when the ban was lifted for a short period, only 47% of the total household used iodized salt, which was further reduced to 43% in Scheduled caste and 37% to scheduled tribe population who are more vulnerable to iodine deficiency. 4 It is however expected that after re-imposing ban on selling non-iodized salt in 2007, the situation would have improved. There are no data on the zinc deficiency from India, however; the estimates for south east Asia show that zinc deficiency is a common problem in the region. 23 There is no rational believing otherwise for India, and based upon the dietary pattern, it is believed that mild to moderate deficiency exists in the country. Zinc as a micronutrient has got much global attention in recent years and, has been recommended and promoted as part of the national strategy and also as part of Integrated management of neonatal and childhood illnesses (IMNCI), specifically with Oral Rehydration Salt (ORS) therapy during diarrhea for young children. The supplementation with zinc is different as it is not recommended for regular intake like iron, vitamin A or iodine. Government of India has included supply of water dispersible zinc tablets in the RCH Kit A and that needs to be given to every child having diarrhea along with ORS. The use of zinc is also thought to be low and an area of concern in a scenario where ORS use itself is around 26% among cases of Diarrhea. 4 In summary, the children aged 1-3 yr in India are consuming 1/3 rd of RDA for iron and 1/6 th of RDA for vitamin A and, the scenario has not changed much, for last 25 years as indicated by series of studies. 15,17 The program for supplementation are in place since early 1970s but coverage has remained negligible for iron supplementation and a recent survey 17 has pointed out that only 3.8% of children received iron supplementation (Table 2). Role of Micronutrients in Child Survival The micronutrients are of vital importance for the maintenance of health of children, who are highly vulnerable to their deficiency. India contributes to over 20% child death globally and diarrhea and acute respiratory infection contributing to over half of these deaths, role of micronutrient becomes highly significant. With present under five mortality rate of 72/1000 live birth and total population of 1160 million, 24 India has about 1.95 million under five deaths of total 9.2 million global under five deaths. 2, 7 More than half of these deaths are claimed to be caused by malnutrition and the deficiency of micronutrients contributes to this. 25 Iron: The capacity of iron and its essential role in oxygen transport in the body makes it an important nutrient within every tissue of the body, including brain. The young children have expanding muscle mass and blood volume, both of these tissues are rich in iron. The diet at this age almost in all part of the world fails to provide adequate iron and makes them the most vulnerable age group for iron deficiency. Thus, in many poor families, the iron needs of young children are nearly impossible to meet without fortification or supplementation strategies. 26 The high iron needs and low iron diets combine to make early childhood one of the highest risk periods for iron deficiency and iron-deficiency anemia. NFHS 2 and NFHS 3 data confirm that anemia prevalence is the highest in the age group of 6-23 month of age. 4,12 The Iron deficiency adversely affects the cognitive performance, behavior, and physical growth of infants, preschool and school-aged children; the immune status and morbidity from infections of all age groups. 27 Iron deficiency may be an important defense mechanism, and the term nutritional immunity is used to show the importance of adequate iron status in preventing bacterial growth. 28 The data suggest that iron deficiency is associated with impairment of cell mediated immunity and the bactericidal activity of neutrophils, thus increasing susceptibility to infection However, the role of iron in resistance to disease has become the subject of debate recently and a recent systemic review of 28 clinical trials 31 suggested that there is no additional protection offered by iron supplementation in incidence of morbidity. Vitamin A: The importance of vitamin A in maintaining healthy vision is well accepted, and vitamin A deficiency (VAD) is considered the leading cause of preventable blindness among children worldwide. India with a vitamin A supplementation program since 1970 continues to have vitamin A deficiency level of public health importance measured as Bitot spot prevalence of more than 0.5% or as serum retinol level of less than 20 mg/dl. 19 The role of prophylactic vitamin A supplementation (VAS) in preventing childhood mortality has been debated in India for last few years. The available evidences from systematic reviews estimated a 23% to 30% average risk reduction, by VAS, in all-cause mortality between 6 month and 6 yr of age. However, the result of a large study from India, which has been made public recently, showed no benefit 35 and if this study is added to earlier studies, reduces the pooled reduction of mortality to 11%. VAD is directly not a cause of mortality in children but Diarrhea and Acute Respiratory infections including measles 36 are known cause of child mortality. Depending upon the relative contribution of these factors in overall child mortality in the community, the level of clinical and Indian Journal of Pediatrics, Volume 77 April,

4 Prakash V. Kotecha and Chandrakant Lahariya sub clinical VAD in the community and other contributory factors in favor or against diarrhea and respiratory infection, the response to VAS for reducing child mortality is likely to vary in these changing epidemiological conditions. Zinc: Zinc affects various immune mechanisms and modulates host resistance to several pathogens. 37 Zinc supplementation reduces morbidity from diarrhea and pneumonia in high risk populations. 31 A large body of evidence shows important therapeutic benefit with zinc administration during and after diarrhoea and some studies also reported reduction in diarrhea morbidity in the subsequent 2 3 month without further supplementation. 38 A study done in Pemba indicated a small reduction of 7% in mortality with zinc that was statistically not significant among children 1-48 month. 39 Zinc is likely to influence mortality by reducing the deaths due to diarrhea. 40 DISCUSSION The micronutrient has not attracted the due attention of the policy makers as they had always focused upon the other forms of undernutrition. Secondly, these micronutrients has recently faced macro controversies in their possible role and conflicting results of systematic reviews and meta-analysis in preventing morbidity and mortality and delayed the decision making. In this environment of conflicting opinion, it is better to interpret these studies in their regional and geographical context, with number of other factors prevailing in the communities. The iron prophylaxis program need strengthening and more serious implementation at the field level as program hardly ever existed and there has almost no reduction of anemia in the last 3 decades. 4,7 Now, with Iron folic acid syrup being provided in RCH Kit 13 and available at the sub-center level, it is hoped that the program takes off, is monitored adequately and will improve the iron store and reduce anemia prevalence. The policy recommendations on, survey data to be used for immediate corrective actions, need attention of the policy makers and program managers. 41 It needs to be seen that the program take off at the ground level. The capacity building of the front line workers, motivating them for appropriate and adequate counseling and prioritizing monitoring for micronutrient supplementation are the steps that would improve the situation. India needs to continue with vitamin A supplementation program for young children for prevention of vitamin A deficiency till country eliminates vitamin A deficiency as public health problem. The national program clearly spells two strategies one for the long term, the dietary approach; second; where mega dose of vitamin A to be administered to young children, every six months, as a prophylaxis as short term approach. Furthermore, issues like regular availability of the vitamin A solutions needs to be ensured during the biannual campaigns. The biannual campaigns conducted by some states may be a good option and may provide the most needed lessons for the future expansion of supplementation program in India. Fortunately, there is little controversy about use of iodized salt since providing iodine has been accepted without much controversy, iodine being water soluble, toxicity is not an issue, and iodization is most widely acceptable and universal method of reaching out to the community. However, the strict enforcement of ban on non iodized salt, continuous political advocacy, and the public strategies and awareness efforts to increase the use of iodized salt by more households in India are immediately required. Zinc supplementation at the community level in India has just taken off. 42 The preventive role of zinc in diarrhoea related morbidity and mortality is proven and will contribute towards child survival. In India, it has been noticed that expansion of an intervention takes a painfully long period. The use of Zinc in the management of diarrhea is an opportunity to show that the interventions can actually be delivered to the children in the country at good pace and this may provide a lesson for future. The elimination of micronutrient deficiencies is essential not only to improve health but also to sustain economic growth and national development. The loss due to micronutrient deficiency costs India 1 percent of its GDP, (loss of Rs. 27,720 Crores) per annum in terms of productivity, illness, increased health care costs and death. 5 The micronutrient supplementation has been found to be very cost effective and the estimated additional cost of control of micronutrient malnutrition works out to be Rs per capita per year, and Rs per high risk beneficiary. This additional cost is 0.3% of government expenditure on health. The total cost thus is 77.6 Crores and is a small amount as compared to the annual budget of Rs Crores for ICDS project in yr Finally, the number of micronutrient being provided through various programs has increased in India over last 3 decades. All are being delivered through many segregated approaches. It is the time also that the program managers sit together to think about an integrated strategy 7 to ensure that all these micronutrients are delivered to all those who need. CONCLUSION Micronutrients are important for healthy life of children 422 Indian Journal of Pediatrics, Volume 77 April, 2010

5 Micronutrient Supplementation and Child Survival in India in India, who suffer with multiple micronutrient deficiencies. It is important to realize that correcting micronutrient deficiency is a cost effective intervention, and will improve health of the child and probability of child survival. The micronutrient supplementation needs sustained programmatic focus, continuous advocacy and evidence generation in support of these interventions. However, recent conflicting findings about the role of micronutrients in reducing child mortality have raised a few questions which needs more research but there is no doubt about the role of micronutrients in overall childhood development and growth. It is pertinent that the available evidences and studies are evaluated, keeping the epidemiological factors prevailing in the community in the background. There can not be any controversy that children in India need universal coverage with micronutrient supplements to prevent specific micronutrient deficiencies, which can also contribute to child survival in the country at variable levels, and thus assisting to achieve MDG 4 in India. Acknowledgements The authors thank Dr. HPS Sachdev for sharing his ideas and published and unpublished articles, which were very helpful in the drafting of this manuscript. Contributions: The views expressed in this article are those of the authors and does not necessarily reflect the views of the organizations/institutions with which they are affiliated. Conflict of Interest : None. Role of Funding Source: None. REFERENCES 1. Government of India. Annual report of Ministry of Health and Family Welfare ( ). MoHFW, Nirman Bhawan, New Delhi UNICEF. State of the world children 2008: Child Survival: UNICEF; New York: World Bank. India s Undernourished Children: A Call For Reform and Action. World Bank, New Delhi International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), : India: Volume I. Mumbai: IIPS Kotecha PV. Micronutrient malnutrition in India. Lets say no to it now. Indian J Commun Med 2008; 33: Bhutta ZA, Ahmed T, Black RE et al, for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371: Lahariya C, Paul VK. Epidemiology of 1.95 million annual child deaths in India: analysis for informed decision making. Indian J Pediatr 2010; 77: xx-xx. 8. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: Indian Council of Medical Research. Nutrient requirement and recommended dietary allowances for Indians. ICMR New Delhi. 2004: Government of India. Tenth Five Year Plan ( ), Planning Commission, Government of India, New Delhi National Nutritional Anemia Prophylaxis program. Accessed at NutritionAnemia.htm accessed Sept 19, International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS- 2), : India: Volume I. Mumbai: IIPS Government of India. Reproductive and child health (RCH) program II. Ministry of Health and Family Welfare; Government of India, New Delhi National Rural Health Mission. Mission Document, Ministry of Health and Family Welfare; Government of India, New Delhi National Nutrition Monitoring Bureau. Diet and Nutritional Status of population and prevalence of hypertension among adults in rural areas NNMB Technical Report No. 24, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India National Nutrition Monitoring Bureau. Diet and Nutritional Status of Rural Population: NNMB Technical Report No. 21, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India National Nutrition Monitoring Bureau. Prevalence of Micronutrient Deficiencies: NNMB Technical Report No. 22, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India International Institute for population sciences. District Level Household Survey III: National Family Health Survey for India, Ministry of health and conducted by International Institute for Population Science, Mumbai United States Agency for international Development. Anaemia prevention and control: What works; Part I; The Population, Health and Nutrition / Monitoring, Evaluation and Design Support/ US Assistance for International Development, USA Sommer A. Vitamin A deficiency and its consequences a field guide to detection and control (third edition) World Health Organization, Geneva Bohac L, Gulati D. Integrating small salt producers in Rajasthan into India s universal salt iodization strategy; ICCIDD News Letter No 33; Micronutrient Initiative. Controlling Vitamins and Mineral Deficiency in India, Meeting the Goal. Micronutriment Initiative, New Delhi United Nations Children s Fund. The State of Asia Pacific s Children UNICEF Regional office for Asia, Kathmandu, Nepal Directorate of Census Operations. Census of India Accessed at Projected_Population/ Accessed 8/4/ Micronutrient Initiative. Controlling Vitamins and Mineral Deficiency in India: meeting the Goal. Micronutriment Initiative, New Delhi Slotzfus RJ, Dreyfuss ML. Guidelines for the Iron Supplements to prevent and treat iron deficiency anemia: a draft document prepared for the International Nutritional Anemia Consultative Group (INCAG), 17 th July INCAG. Nutrition Foundation, Washington, DC: USA, Mimeo WHO/UNICEF/UNU. Iron deficiency anemia: Assessment, prevention and control: A guide for program managers, World Health Organization Kochan I. The role of iron in bacterial infections with special consideration of host-tubercle bacillus interaction. Curr Top Microbiol Immunol 1973; 60: Chandra RK. Reduced bactericidal capacity of polymorphs in iron deficiency. Arch Dis Child 1973; 48: Bhaskaram P, Reddy V. Cell mediated immunity in iron and vitamin deficient children. BMJ 1975; 3: Gera T, Sachdev HPS. Effect of iron supplementation on incidence of infectious illness in children: systematic review BMJ 2002; 325: Glasizou PP, Mackerras DEM. Vitamin A supplementation in Indian Journal of Pediatrics, Volume 77 April,

6 Prakash V. Kotecha and Chandrakant Lahariya infectious diseases: A meta-analysis. BMJ 1993; 306: Fawzi WW, Chalmers TC, Herrera MG, Mosteller F. Vitamin A supplementation and child mortality. JAMA 1993; 269: Gogia S, Sachdev HPS. Review of vitamin A supplementation in pregnancy and childhood. Web appendix 10 in Bhutta ZA, Ahmed T, Black RE et al. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; Published Online January 17, 2008 DOI: /S (07) Awasthi S, Peto R, Read S, Bundy D. Six-monthly vitamin A from 1 to 6 years of age. DEVTA: cluster randomised trial in 1 million children in North India. Available from: Accessed September 12, Mishra A, Mishra S, Bhadoriya RS et al. Measles related complication and the role of vitamin A supplementation. Indian J Pediatr 2008; 75: Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infections. Am J Clin Nutr 1998; 68: 447S 63S. 38. Zinc Investigators Collaborative Group: Bhutta ZA, Bird SM, Black RE et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries; pooled analysis of randomized controlled trials. Am J Clin Nutr 2000; 72: Sazawal S, Black RE, Ramsan M et al. Eff ect of zinc supplementation on mortality in children aged 1 48 months: a community-based randomized placebo-controlled trial. Lancet 2007; 369: WHO/UNICEF Joint Statement on the Clinical Management of Acute Diarrhoea, WHO/CAH/04. World Health Organization, Geneva: Lahariya C, Khandekar J. How the findings of national family health survey- 3 can act as a trigger for improving the status of anemic mothers and undernourished children in India: a review. Indian J Med Sci 2007; 61: Government of India. No. Z 28020/06/2005-CH; Department of Health and Family Welfare; Child Health Division, Government of India, dated 2 nd November Indian Journal of Pediatrics, Volume 77 April, 2010