Victor M. Aguayo

Vitamin A Deficiency and Child Survival in Sub-Saharan Africa: A Reappraisal of Challenges and Opportunities:

Background Children with vitamin A deficiency have higher risk of morbidity and mortality than vitamin A–sufficient children. Estimates on the potential child survival benefits of vitamin A deficiency control are needed for policy and program advocacy. Objective To determine the current prevalence of children at risk for vitamin A deficiency in sub-Saharan Africa in order to estimate the potential child-survival benefits of effective and sustained policies and programs for the control of vitamin A deficiency in this region. Methods Estimates of the prevalence of vitamin A deficiency generated in 1998, data from 11 nationally representative vitamin A deficiency surveys conducted in sub-Saharan Africa between 1997 and 2003, and the measured effects of vitamin A deficiency on child mortality were combined to estimate the prevalence of children at risk for vitamin A deficiency in sub-Saharan Africa and the potential child-survival benefits of effective and sustained policies and programs for the control of vitamin A deficiency in this region. Results Our analysis shows that in the absence of effective and sustained policies and programs for the control of vitamin A deficiency, an estimated 42.4% of children 0 to 59 months of age in sub-Saharan Africa (43.2 million children) are at risk for vitamin A deficiency. Such effective and sustained policy and program action for the control of vitamin A deficiency can bring about a potential 25% reduction in mortality in children 0 to 59 months with respect to 1995 mortality levels (i.e., before the onset of large-scale vitamin A supplementation programs in sub-Saharan Africa). Conclusions Effective and sustained control of vitamin A deficiency has the potential to be among the most cost-effective and high-impact child-survival interventions in sub-Saharan Africa. A stronger political commitment and a more appropriate level of investment in the effective control of vitamin A deficiency could make a large contribution toward the attainment of the Millennium Development Goal for the reduction of child mortality rates by two-thirds between 1990 and 2015. Among the many challenges that Africa will need to face in the coming years, vitamin A deficiency is one that can be overcome. The need is urgent, and the solutions are known, effective, and affordable.

Monitoring compliance with the International Code of Marketing of Breastmilk Substitutes in west Africa: multisite cross sectional survey in Togo and Burkina Faso

Abstract Objectives: To monitor compliance with the International Code of Marketing of Breastmilk Substitutes in health systems, sales outlets, distribution points, and the news media in Togo and Burkina Faso, west Africa. Design: Multisite cross sectional survey. Participants: Staff at 43 health facilities and 66 sales outlets and distribution points, 186 health providers, and 105 mothers of infants aged ≤5 months in 16 cities. Results: Six (14%) health facilities had received donations of breast milk substitutes. All donations were being given to mothers free of charge. Health providers in five (12%) health facilities had received free samples of breast milk substitutes for purposes other than professional research or evaluation. Health professionals in five (12%) health facilities had received promotional gifts from manufacturers. Promotional materials of commercial breast milk substitutes were found in seven (16%) health facilities. Special displays to market commercial breast milk substitutes were found in 29 (44%) sales and distribution points. Forty commercial breast milk substitutes violated the labelling standards of the code: 21 were manufactured by Danone, 11 by Nestlé, and eight by other national and international manufacturers. Most (148, 90%) health providers had never heard of the code, and 66 mothers (63%) had never received any counselling on breast feeding by their health providers. Conclusion: In west Africa manufacturers are violating the code of marketing of breast milk substitutes. Comparable levels of code violations are observed with (Burkina Faso) or without (Togo) regulating legislation. Legislation must be accompanied by effective information, training, and monitoring systems to ensure that healthcare providers and manufacturers comply with evidence based practice and the code. What is already known on this topic All member states of the World Health Assembly have reaffirmed their support for the International Code of Marketing of Breastmilk Substitutes Violations by manufacturers of breast milk substitutes have been reported in industrialised and developing countries What this study adds Manufacturers of breast milk substitutes are violating the code in Togo and Burkina Faso The levels of code violations are similar in a country with (Burkina Faso) and one without (Togo) legislation on the marketing of breast milk substitutes Legislation must be accompanied by effective information, training, and monitoring systems to ensure compliance with the code

Prenatal Multiple Micronutrient Supplementation has Greater Impact on Birthweight than Supplementation with Iron and Folic Acid: A Cluster-Randomized, Double-Blind, Controlled Programmatic Study in Rural Niger

Background Micronutrient deficiencies during pregnancy are associated with adverse pregnancy outcomes, including reduced birthweight. Low birthweight is associated with increased risk of infant mortality and growth failure. Objectives To assess the effects of prenatal supplementation with UNIMMAP (United Nations International Multiple Micronutrient Preparation) compared with iron/folic acid on average birthweight and incidence of low birthweight. Methods Pregnant women from 78 villages in Niger were included in a cluster-randomized, double-blinded, controlled supplementation trial. Baseline, monthly follow-up, and birth data were collected. Cluster analysis was conducted to assess differences in mean birthweight and incidence of low birthweight between groups using multiple linear regression models. Analyses were stratified by nutrition status and duration of supplementation. Results Of the 3,670 women recruited, 2,550 completed the study and provided complete birthweight data (1,328 received multiple micronutrients and 1,222 received iron/folic acid). Mean birthweight was significantly higher (67 g, p < .001) with multiple micronutrients (3,092 ± 190 g) than with iron/folic acid (3,025 ± 205 g); this corresponded to a 14% fall in the incidence of low birthweight (from 8.4% with multiple micronutrients to 7.2% with folic acid fortification). The impact of multiple micronutrients was greater when the supplements were taken for more than 150 days. The incidence of low birthweight was further reduced in women who entered pregnancy with a poorer nutrition status. Conclusions Prenatal supplementation with multiple micronutrients had a greater positive impact on birthweight than supplementation with iron/folic acid. Our data suggest that prenatal supplementation with multiple micronutrients as part of a prenatal care package in addition to interventions to promote improved maternal prepregnancy nutrition status is an important strategy to increase birthweight and reduce the incidence of low birthweight.

Household sanitation and personal hygiene practices are associated with child stunting in rural India: a cross-sectional analysis of surveys

Objectives Increasing evidence suggests that water, sanitation and hygiene (WASH) practices affect linear growth in early childhood. We determined the association between household access to water, sanitation and personal hygiene practices with stunting among children aged 0–23 months in rural India. Setting India. Participants A total of 10 364, 34 639 and 1282 under-2s who participated in the 2005–2006 National Family Health Survey (NFHS-3), the 2011 Hunger and Malnutrition Survey (HUNGaMA) and the 2012 Comprehensive Nutrition Survey in Maharashtra (CNSM), respectively, were included in the analysis. Primary outcome measures The association between WASH indicators and child stunting was assessed using logistic regression models. Results The prevalence of stunting ranged from 25% to 50% across the three studies. Compared with open defecation, household access to toilet facility was associated with a 16–39% reduced odds of stunting among children aged 0–23 months, after adjusting for all potential confounders (NHFS-3 (OR=0.84, 95% CI 0.71 to 0.99); HUNGaMA (OR=0.84, 95% CI 0.78 to 0.91); CNSM (OR=0.61, 95% CI 0.44 to 0.85)). Household access to improved water supply or piped water was not in itself associated with stunting. The caregivers self-reported practices of washing hands with soap before meals (OR=0.85, 95% CI 0.76 to 0.94) or after defecation (OR=0.86, 95% CI 0.80 to 0.93) were inversely associated with child stunting. However, the inverse association between reported personal hygiene practices and stunting was stronger among households with access to toilet facility or piped water (all interaction terms, p<0.05). Conclusions Improved conditions of sanitation and hygiene practices are associated with reduced prevalence of stunting in rural India. Policies and programming aiming to address child stunting should encompass WASH interventions, thus shifting the emphasis from nutrition-specific to nutrition-sensitive programming. Future randomised trials are warranted to validate the causal association.

Management of children with severe acute malnutrition: Experience of Nutrition Rehabilitation Centers in Uttar Pradesh, India

ObjectiveTo assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in Nutrition Rehabilitation Centers (NRC).DesignReview of data.Setting12 NRCs in Uttar Pradesh, India.ParticipantsChildren admitted to NRCs (Jan 1, 2010 — Dec 31, 2011).InterventionDetection and treatment of SAM with locally-adapted protocols.OutcomesSurvival, default, discharge, and recovery rates.Results54.6% of the total 1,229 children admitted were boys, 81.6% were in the age group 6–23 months old, 86% belonged to scheduled tribes, scheduled castes, or other backward castes, and 42% had edema or medical complications. Of the 1,181 program exits, 14 (1.2%) children died, 657 (47.2%) children defaulted, and 610 (51.7%) children were discharged The average (SD) weight gain was 12.1 (7.3) g/kg body weight/day and the average (SD) length of stay was 13.2 (5.6) days. 206 (46.8%) children were discharged after recovery (weight gain ≥15%) while 324 (53.2%) were discharged, non-recovered (weight gain <15%)ConclusionsNRCs provide life-saving care for children with SAM; however, the protocols and therapeutic foods currently used need to be improved to ensure the full recovery of all children admitted.

Maintaining High Vitamin A Supplementation Coverage in Children: Lessons from Niger

In 1997, the reduction of child mortality became a policy priority for the Government of Niger because Nigers child mortality rate was the highest in the world. The Ministry of Public Health, Helen Keller International (HKI), and UNICEF spearheaded a coalition-building process linking vitamin A deficiency (VAD) control to national child survival goals. An evidence-based advocacy strategy was developed around the child survival benefits of adequate and sustained VAD control with one unambiguous message: “VAD control can avert over 25,000 child deaths per year.” As a result, in 1997 Niger became one of the first countries in Africa to effectively integrate vitamin A supplementation into National Immunization Days (NIDs) for polio eradication. The challenge was then to provide children with a second annual dose of vitamin A. This led in 1999 to the first ever National Micronutrient Days (NMDs) in Africa. NMDs are mobilization campaigns in which caregivers are actively encouraged to take their children for the delivery of vitamin A supplements. Since 1999, the combination of NIDs and NMDs has ensured that over 80% of children 6 to 59 months of age receive two vitamin A doses annually. The success of NIDs/NMDs has relied on five pillars: leadership and ownership by the Ministry of Public Health; district-level planning and implementation; effective training and flexible delivery mechanisms; effective social information, communication, and mobilization; and responsiveness and flexibility of Ministry of Public Health and development partners. This successful approach has been widely disseminated, notably through the West African Nutrition Focal Points Network.

Determinants of stunting and poor linear growth in children under 2 years of age in India: an in-depth analysis of Maharashtra's comprehensive nutrition survey.

Abstract We use a representative sample of 2561 children 0–23 months old to identify the factors most significantly associated with child stunting in the state of Maharashtra, India. We find that 22.7% of children were stunted, with one‐third (7.4%) of the stunted children severely stunted. Multivariate regression analyses indicate that children born with low birthweight had a 2.5‐fold higher odds of being stunted [odds ratio (OR) 2.49; 95% confidence interval (CI) 1.96–3.27]; children 6–23 months old who were not fed a minimum number of times/day had a 63% higher odds of being stunted (OR 1.63; 95% CI 1.24–2.14); and lower consumption of eggs was associated with a two‐fold increased odds of stunting in children 6–23 months old (OR 2.07; 95% CI 1.19–3.61); children whose mothers height was < 145 cm, had two‐fold higher odds of being stunted (OR 2.04; 95% CI 1.46–2.81); lastly, children of households without access to improved sanitation had 88% higher odds of being severely stunted (OR 1.88; 95% CI 1.17–3.02). Attained linear growth (height‐for‐age z‐score) was significantly lower in children from households without access to improved sanitation, children of mothers without access to electronic media, without decision making power regarding food or whose height was < 145 cm, children born with a low birthweight and children 6–23 months old who were not fed dairy products, fruits and vegetables. In Maharashtra childrens birthweight and feeding practices, womens nutrition and status and household sanitation and poverty are the most significant predictors of stunting and poor linear growth in children under 2 years. Key messages One in five (22.7%) of children 0–23 months old in the state of Maharashtra were stunted, and one‐third (7.4%) of the stunted children were severely stunted. Birthweight, child feeding, womens nutrition and household sanitation were the most significant predictors of stunting and poor linear growth in children under 2 years. Children born to mothers whose height was below 145 cm, had two‐fold higher odds of being stunted; children born with a low birthweight had a 2.5‐fold higher odds of being stunted. Low feeding frequency and low consumption of eggs, dairy products, fruits and vegetables were associated with stunting and poor linear growth in children 6–23 months old. Children of households without access to improved sanitation had 88% higher odds of being severely stunted.

Providing care for children with severe acute malnutrition in India: new evidence from Jharkhand

OBJECTIVE To assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in malnutrition treatment centres (MTC). DESIGN Early detection and treatment of SAM using locally adapted protocols; assessment of programme outcomes, including survival, default, discharge and recovery rates. SETTING All forty-eight MTC in Jharkhand, India. SUBJECTS Children (n 3595) with SAM admitted to MTC (1 July 2009-30 June 2011). RESULTS Of children admitted, 55·0% were girls, 77·7% were 6-23 months old and 68·6% belonged to scheduled tribes or castes; 34·4% had oedema or medical complications. Of the 3418 programme exits, the proportion of children who died was 0·6% (n 20), the proportion of children who defaulted was 18·4% (n 628) and the proportion of children discharged was 81·0% (n 2770). Childrens average weight gain was 9·6 (sd 8·4) g/kg body weight per d and their average length of stay was 16·0 (sd 5·7) d. Among the 2770 children who were discharged from the programme, 39·4% (n 1090) gained 15 % or more of their initial weight while 60·6% (n 1680) gained less than 15 % of their initial weight. CONCLUSIONS MTC provide live-saving care for children with SAM as demonstrated by high survival rates. However, the protocols and therapeutic foods currently used need to improve to ensure the recovery of all discharged children. MTC should be reserved for children with complicated SAM; children with uncomplicated SAM should be admitted to a community-based programme for the management of SAM, at a lesser risk to children and a lesser cost to families and the health system.

Stop stunting: improving child feeding, women's nutrition and household sanitation in South Asia.

Abstract The latest available data indicate that 38% of South Asias children aged 0–59 months are stunted. Such high prevalence combined with the regions large child population explain why South Asia bears about 40% of the global burden of stunting. Recent analyses indicate that the poor diets of children in the first years of life, the poor nutrition of women before and during pregnancy and the prevailing poor sanitation practices in households and communities are important drivers of stunting, most likely because of underlying conditions of womens status, food insecurity, poverty, and social inequalities. With this evidence in mind, UNICEF Regional Office for South Asia convened the Regional Conference: Stop Stunting: Improving Child Feeding, Womens Nutrition, and Household Sanitation in South Asia (New Delhi, November 10–12, 2014). The Conference provided a knowledge‐for‐action platform with three objectives: (1) share state‐of‐the‐art research findings on the causes of child stunting and its consequences for child growth and development and the sustainable growth and development of nations; (2) discuss better practices and the cost and benefits of scaling up programmes to improve child feeding, womens nutrition, and household sanitation in South Asia; and (3) identify implications for sectoral and cross‐sectoral policy, programme, advocacy and research to accelerate progress in reducing child stunting in South Asia. This overview paper summarizes the rationale for the focus on improving child feeding, womens nutrition, and household sanitation as priority areas for investment to prevent child stunting in South Asia. It builds on the invited papers presented at or developed as a follow on to the Stop Stunting Conference.

The monetary value of human milk in Francophone west Africa: a PROFILES analysis for nutrition policy communication.

Using a simple and conservative methodology, we estimated the volume and monetary value of the human milk produced by lactating women in Francophone West Africa. in that region, children zero to 35.9 months old consume over 1.1 billion liters of human milk per year. However, suboptimal breastfeeding practices account for the loss of 175 million liters of human milk annually. If the human milk consumed by children zero to 35.9 months old were to be adequately replaced using commercial breastmilk substitutes, an annual expenditure of about 2 billion US dollars would be needed. At the household level, the annual replacement cost of human milk would amount to US