Evidence Based Interventions for Improving Maternal and Child Nutrition: What Can be Done and at What Cost? Lancet, vol 382, 452 77, 2013 Dr. S.K Roy Senior Scientist Chairperson, Bangladesh Breastfeeding Foundation
Nutrition Specific Interventions and Programs
Interventions Across the Lifecycle
Nutrition Interventions and Conflict of Interest Women of reproductive age and pregnancy Folic acid supplementation Universal Fortification Does not includes 'increased folate intake during the early post fortification period may have been associated with a transient increase in Colo Rectal Cancer risk.
Iron and iron folate supplementation Intermittent iron supplementation Includes that intermittent iron supplementation (alone or with any other vitamins and minerals) reduced the risk of anaemia by 27%. But does not include More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression and adherence to the intervention.
MMN supplementation Potential replacement of IFS by MMN Includes that MMN reduce: 11 13% LBW and SGA & Anemia & IDA Ignored : IFS reduces the same amount of anema & IDA The conclusion of the review that more evidence is needed to guide a universal policy change and to suggest replacement of routine IFS with a MMS.
Ignored by the article: Future trials should be adequately powered to evaluate the effects on mortality and other morbidity outcomes. Trials should also assess the effect of variability between different combinations and dosages of micronutrients, keeping within the safe recommended levels. In regions with deficiency of a single micronutrient, evaluation of each micronutrient against a placebo in women already receiving iron with folic acid would be especially useful in justifying i the inclusion i of that micronutrient i in routine antenatal care STILL, this intervention has find a place in the packages of nutrition interventions at 90% coverage and cost evaluations were done. The reference no. 29 (a meta analysis) has been quoted inappropriately. The original review concludes 'Our meta analysis provides consistent evidence that MMN supplementation providing approximately 1 RDA of MMN during pregnancy does not result in any reduction in stillbirths, early or late neonatal deaths compared to FE + FA alone.' AND 'and MMN may increase the risk of birth asphyxia.'
Neonates Delayed cord clamping Concluded that in preterm neonates delayed cord clamping was associated with 39% reduction in need for blood transfusion and a lower risk of complications after birth. BUT same review, also says the peak bilirubin concentration was higher for infants allocated to delayed cord clamping compared with immediate clamping, which is not reported in the text though mentioned in the table 2
Promotion of breastfeeding and supportive strategies Mainly focused on promotional strategies, other important strategies like Protection of breastfeeding are not studied and if no studies were found that this fact was not mentioned. Protection is considered an important intervention for successful breastfeeding. Is it because, some of the authors are having association iti with infant formula companies, as per declaration of conflicts of interest?
Infants and children Prevention and treatment of SAM Review reports inconclusive evidence for reduction in deaths in facility, while for community settings, it reports, We identified no significant differences in mortality.
It further says, because of the nature of the evidence, establishing effect estimates for the overall approach to community management has proved challenging. hll Available evidence shows some positive ii effects with ihthe useof RUTF compared with standard care for the treatment of SAM in community settings, yet the differences were for the most part small and several outcomes had substantial heterogeneity. An emphasis not only on the choice of commodities, but also on the quality of programme design and implementation is crucial to improvement of outcomes for children with SAM, as is research to fill information gaps, such asoptimum treatment methodsand approaches for treatment of breastfed infants younger than 6 months. BUT surprisingly, management of SAM and MAM still finds number one p gy g position among the top ten interventions to reduce child mortality.
While Modeling the effect of scaling up coverage of nutrition interventions in countries with the highest burden. The article has identified ten most effective interventions and concludes that if these ten nutrition interventions were scaled up to 90% coverage, mortality in children younger than 5 years could be reduced by 15% (range 9 19), with a 35% (19 43) reduction in diarrhoea-specific mortality, a 29% (16 37) reduction in pneumonia-specific mortality, and a 39% (23 47) reduction in measles specific mortality.
It further says, The analysis suggested that the interventions with the largest potential affect on mortality in children younger than 5 years are management of SAM, preventive zinc supplementation, and promotion of breastfeeding. BUT Other interventions for disease prevention and management were not modeled though some of them have been found significantly effective (table no. 4). Few such interventions are WASH interventions, Deworming in children, feeding practices in diarrhea, management of malaria in pregnant women and prevention of malaria in children
Panel 2: Intervention to address adolescent nutrition and preconception care Topics Comments Adressing maternal wasting andfoodinsecurity with balanced energy and protein Folic acid supplementation Iron and Iron folate supplementation MMN supplementation Iodine through iodization of salt Maternal supplementation with balanced energy protein This is notsupplementation but sustainable home based cultural acceptable diet Risk ± benefit Birth wt is not issue Government and WHO program Nutrition education vs complication LBW is not factor WHO program Not by supplementation but ensure usual diversified diet Conti
Issues Comments Delayed cord clamping Ok practice Neonatal vitamin K administration Ok Vitamin A supplementation Ok, Kangaroo mother care for promotion of breastfeeding and care of preterm and SGA infants Ok Conti
Issues Neonatal vitamin A supplementation Kangaroo mother care Promotion of diversity and complementary feeding Breastfeeding promotion in infants Question result Comments Need program of Government and private health care systems and center Need in government program Highlight this positive effect Improve HAZ 60% WAZ increased 74% Ok Complementary feeding promotion in Ok children 6 24 months of age Preventive vitamin A supplementation in children 6 months to 5years of age Iron supplementation in children OK Compared of Dietary Diversity Conti
Issues MMN supplementation including iron in children Zinc supplementation WASH intervention Deworming in children (for soiltransmitted intestinal worms ) This is treatment Dietary diversity Comments This is treatment Food and promotion Program by Government This is treatment Ok Feeding practice in diarrhea Zinc therapy for diarrhea This is treatment This is treatment IPTp/ITN for malaria in pregnancy This is treatment t t Malaria prophylaxis in children This is treatment Conti
Issues Comments Intervention for prevention and management of obesity Ok Bh Behavioral llife style tl change Delivery platforms and strategies for implementation of nutrition specific interventions Fortification VS do Diversity Knowledge and practice
Panel 3: Effect of fortification strategies Community based platforms for nutrition education and promotion Integrated management of childhood illnesses Delivery of nutrition interventions in humanitarian emergency settings What be done most desired food from home sustainable not intervention but program Treatment of illness Food as eaten and improve to area of energy No RUTF link Conti
Panel 4: nutrition in emergencies Issues Comments Delivery ofnutrition interventions in humanitarian emergency settings Foodaseaten Improve to area of emergency
Panel 5:Evidance for emerging interventions Household air pollution Issues Comments Maternal vitamin D supplementation Maternal Zinc supplementation Omega 3 fatty acid supplementation Role of massage for promoting growth in preterm infants Vitamin D supplementation in children Zinc supplementation for treatment of newborn infections and childhood d pneumonia Lipid based nutrient supplementation ok Effect all amount nil no new Not new coverage of small effect No new No effect Ok benefit Not necessary Not necessary Not necessary Scientific reasons are only 60% energy, fat as fat deposit
Issues Comments Panel 6: Overview of the lives Saved Tool (LiST) Emergency interventions that need future evidence Modelling the effect of scaling up coverage of nutrition interventions in countries with the highest burden Effect of scale up of interventions on deaths in children than younger 5 years Effect of packages off nutrition intervention at 90% coverage Vitamin D; Zinc; Omega 3; RUTF SUW; Nutrition; SAM RUTF vs Food available SAM 4% U5 deaths 10% SUW 11% U5 deaths 36% Diversified foods waives need of intervention, ensure Food security Discussion Health infrastructure Delivery system to use for promoting knowledge on natural food containing all nutrients Ensure use of health care system and promoting nutrition not for product base commercial promotion
Policy Implications of Lancet Series on Nutrition, 2013: Guard against Commercial Exploitation of Malnutrition (Statement of Dr Arun Gupta) Important observational evidence with nutritional implications (for example, safe water supply, sanitation and hygiene, family planning, literacy and other development aspects) has not been modeled while prioritizing ten most important interventions (Chapter 2). This produces bias for the selection of product based solutions (particularly Ready to Use Therapeutic or Supplementary Foods and single ormultiple li l micronutrients) i ) For some interventions, the computed effect estimates have excluded or ignored relevant, contemporary, and high quality evidence. For example, the estimate of the null effect of mega dose Vitamin A supplement on child mortality from a trial on million subjects in Uttar Pradesh has not been aptly modeled and negative trials of zinc supplementation on growth (from SouthAsia) have been excluded.
The modeling basis for management of MAM as the fifth most effective intervention ti is unclear. Further, the textt in the section on Acute Malnutrition will create intense pressure for introducing specific products marketed by multinational corporations (RUTF and RUSF) without supporting high quality evidence. A just published Cochrane Review concludes current evidence is limited; either RUTF or standard diet such as flour porridge can be used to treat severely malnourished children at home. Decisions should be based on availability, cost and practicality. It would therefore be prudent to adhere to the Government s stated position in the Parliament of India of not utilizing commercial RUTF for community treatment of severe malnutrition.
In the zeal for advocacy, safety concerns with some interventions, particularly in some heterogeneous groups, have receded in the background; These must constitute an integral part of the decision making process. For example, the recently reported increased risk of diarrhea, bloody diarrhea and chest indrawing with multiple micronutrient supplementation in children and the potential risk in some situations of increased perinatal and neonatal mortality and large for gestational age babies with multiple micronutrient pregnant women. supplementation in
For engaging with the private sector and unregulated marketing of commercial foods for preventing malnutrition in children raises serious concerns. The inherent conflict of interest will ensure that commercial considerations override sustainable nutritional goals.