GH Week 2

How can early nutrition and other factors have an impact throughout the lifespan?

How early nutrition has an impact throughout the lifespan • Starts from early pregnancy • Brain cells - connections - refinement • Nutrition important • Early stimulation important • Touch and nurturing and attachment to parents • High stress leads to changes - increased cortisol and affects development and growth Just nutrition is not enough for normal development

Natural sources of Vitamin D

fish liver oils and dairy products

What does a country with a very high level of stunting suggest?

may suggest the nutrition of children from 0-5 y/o may not be adequate

Name some populations at higher risk of Vitamin D deficiency

- Babies of mothers with darker skin types - Living in high latitude - Babies and mothers who wear concealing clothing - Babies and mothers who spend a lot of time indoors - Babies of obese mothers (BMI > 30) • Rickets is prevalent in most Middle Eastern countries in a geographic band going from Morocco to Pakistan and can occur as far south as Ethiopia. - Also common in parts of eastern Europe • Populations living in desert areas where atmospheric dust acts as a filter for ultra- violet light are susceptible to vitamin D deficiency, particularly when people stay inside to avoid the heat of the day and wear extensive clothing. • Populations who are forced to remain inside due to shelling or fighting are also at risk • Common in those living at high latitudes (where there is less sunlight) • Unusual in babies born at term to mothers with adequate vitamin D status • Most can synthesise vitamin D through normal exposure to sun Rare in Australia, much more common in other countries

3 grades of a goitre

- Grade 0 - No enlarged thyroid can be felt (palpable) or visibly noticed - Grade 1 - A palpable but not visibly enlarged thyroid with the neck in a normal position - Grade 2 - A palpably and visibly enlarged thyroid with the neck in a normal position

Why has there been a drop in IMR in the Indigenous Australian population?

- Large drops in mortality rates better prenatal care, better nutrition of mothers

What ages are the WHO growth charts used for?

0-24 months

8 possible causes of poor growth

1. Given inadequate food Quantity/quality 2. Inadequate intake - eg swallowing problem, cerebral palsy (has a strong gag reflex and can't swallow) 3. Malabsorption - eg cystic fibrosis, coeliac disease 4. Excessive losses - eg diarrhoea, vomiting, protein loss in urine etc. 5. Increased caloric requirement - chronic infection, Heart disease, etc 6. Endocrine - eg Hypothyroidism 7. Genetic - eg Turners Syndrome 8. Fetal effects - IUGR, FASD

Basic causes of maternal and child undernutrition

1. HOusehold access to adequate quantity and quality of resources: land, education, employment, income, technology 2. Inadequate financial, human, physical and social capital 3. Sociocultural, economic and political context

Underlying causes of maternal and child undernutrition

1. Household food insecurity 2. Inadequate care and feeding practices 3. Unhealthy household environment and inadequate health services

Immediate causes of maternal and child undernutrition

1. Inadequate dietary intake 2. Disease

Which 5 countries account for more than half of the global low birthweight burden?

1. India - 7.5 million 2. Pakistan - 1.5 million 3. Nigeria - 0.8 million 4. Philippines - 0.5 million 5. Bangladesh - 0.7 million Rest of the world - 9.5 million

3 common micronutrient deficiencies

1. Iodine 2. Vitamin A 3. Vitamin D

7 examples of nutritional interventions to aid child development

1. Maternal nutrition and prevention of low birth weight 2. Infant & young child feeding - breast feeding (1 hour of birth) and continued exclusive breast feeding for 6 months followed by continued feeding to 2 years 3. Complementary feeding from 6 months 4. Prevent micronutrient deficiency 5. Prevent and treat acute severe malnutrition 6. Sanitation and clean drinking water 7. Healthy practices and use of health services

What should you do if you have a consultation with a child with failure to thrive?

1. Medical History 2. Social History 3. Examinations - Measurements

4 features of Fetal Alcohol Syndrome

1. Poor growth 2. Facial features 3. Neuro-developmental abnormalities 4. Exposure to alcohol

3 features in early life that predict good health at age 33... (British cohort study - • Over 17000 people born in the UK in one week of March in 1958 were followed at age 33 years - Looked at what happened from 0-5 years of age)

1. Proportion of final height reached by age 7 measure of nutrition over those early years (good nutrition good growth) 2. Being read to several times each week stimulation of brain development and attachment to the parents 3. Fitting into and adjusting well on starting school measure of strong attachment, early development, stimulation, etc. • There are many confounding factors (e.g. occupation, social security, etc.)

Normal weight BMI value

18.5 - 24.9

What ages should the CDC growth charts be used for?

2-18 y/o

Overweight BMI value

25 - 29.9

Underweight BMI value

< 18.5

Obese BMI value

> 30

What are some different categories of the CDC growth charts?

BOYS AND GIRLS: Weight for age Height (stature) for age BMI for age

How were the CDC growth charts developed?

Based on health surveys of children in the US and included: • Mainly formula fed infants • Very few measurements of young infants • Tendency towards higher weights, especially in the older age groups Increasing rates of obesity

How were the WHO growth charts developed?

Based on measurements of children from birth to 5 years of age, from 6 countries representing different regions of the world: Brazil, Ghana, India, Norway, Oman and the United States. The families met strict eligibility criteria

3 factors that can impact on child development

Child development can't just think about nutrition • Language and stimulation • Social/Cultural • Physical - nutrition • Factors should be given equal importance and together have a lifelong impact on health, wellbeing and coping skills

4 domains of child thriving

Early years studies have emphasised that thriving includes domains of: 1. Physical 2. Emotional 3. Cognitive 4. Ability to respond to stress

What are some different categories of the WHO growth charts?

GIRLS AND BOYS: Head circumference Weight for age Length for age

In 2011, what proportion of children < 5 y/o were stunted? In which countries is stunting the most prevalent?

In 2011 almost a quarter of children under 5 years were stunted • 80% are in 14 countries. • Biggest ones India, Nigeria, Pakistan, etc.

What is vitamin D necessary for?

Necessary for the development of strong bones

Examples of non-organic factors that may affect child development

Possible reasons - food not available, money a problem, attachment problem, maternal depression, family violence, drug and alcohol use by carers or in household. child neglect. mental health problems in household. • In almost every child, there are organic and non-organic causes to their failure to thrive (e.g. CF patients may have faltered growth, not just because of their disease, but maybe because they haven't been given their pancreatic enzymes by their parent, etc.)

What is iodine deficiency the single greatest cause of?

Preventable mental retardation

Define stunting What is the definition of moderate and severe stunting?

Stunting = low height for age. Describes failure to grow both physically and cognitively and is the result of chronic or recurrent malnutrition. below -2 standard deviations from median height for age of reference population

True or false? • Children who are undernourished in the first 2 years of life and who put on weight rapidly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition

TRUE

On the WHO growth charts, what is 2 standard deviations similar to?

The 97th percentile

What is vitamin A essential for?

The functioning of the immune system

True or False? • rapid weight or length gain in the first 2 years of life increases the risk of chronic disease, even in children with poor fetal growth

There is no evidence for this - FALSE

What are the types of WHO growth charts? How do the WHO Growth charts function? When were they released?

WHO growth charts include: weight for age, length for age, head circumference • Percentile - compare to 100 healthy girls of different weight • Created by measuring lots of children • Came out in the mid-2000s 5 percentile lines to refer to: 1. 97th - 2 SDs above the median 2. 85th - 1 SD above the median 3. 50th 4. 15th - 1 SD below the median 5. 3rd - 2 SD below the median • E.g. 97th percentile - approximately 3 in 100 children are above this line • This is how children living in optimal conditions would grow • Examples of weight-for-age charts • Use these for 0-2 y/o

What are the types of CDC growth charts? When are CDC growth charts used and how were they made?

Weight for age, Height for age, BMI for age • Used for 2-18 y/o in Australia • Obtained by measuring many American children - weren't very restricted by feeding practices or health - Compares how your child is growing compared to an average American child - Used older data the average was actually an overweight child????

Are infants who are not breastfed at a greater risk of death from diarrhoea or pneumonia than infants who are breastfed? Does this happen much in Australia?

Yes • Relative risks for different levels of breastfeeding and the incidence of pneumonia and diarrhoea incidence and mortality • Not much mortality in Australia because: - Protection from breastmilk may prevent diarrhoea - May be contamination from breastmilk if there is no clean water and safe environments

Do • Undernourished children have higher risk of death from diarrhoea or pneumonia?

Yes - Underweight children with diarrhoea have an odds ratio of 9.5 for mortality

What countries are most likely to have iodine deficiency problems?

• Countries most likely to have Iodine deficiency problems PNG, places away from the coast (e.g. in the mountains) • 2000 Dairy farmers used iodine disinfectant to wash out their stalls did a survey on children - children in Australia eat lots of processed foods that don't have much iodine in them

Clinical signs of vitamin D deficiency

• Deficiency results in rickets affects young children - Rachitic children show reduced bone growth, are anaemic and prone to respiratory infections • Delayed closure of fontanelles (soft spots on a baby's head) • Swollen wrists and ankles • Squared head caused by swelling of frontal bone structure • can get abnormal exposure of the ribs

Examples of key proven practices, services and policy interventions for the prevention and treatment of stunting and other forms of undernutrition at birth...

• Early initiation of breastfeeding within one hour of delivery (including colostrum) Appropriate infant feeding practices for HIV-exposed infants, and antivirals (ARV)

How can iodine deficiency be prevented?

• Easily preventable by ensuring that salt consumed by households is adequately iodized • Yet 38 million newborns worldwide remain unprotected and there are still 36 countries where fewer than half of households consume iodized salt

Examples of key proven practices, services and policy interventions for the prevention and treatment of stunting and other forms of undernutrition at 0-5 months...

• Exclusive breastfeeding • Appropriate infant feeding practices for HIV-exposed infants, and ARV • Vitamin A supplementation in first 8 weeks after delivery • Multi-micronutrient supplementation Improved use of locally available foods, fortified foods, micronutrient supplementation/home fortification for undernourished women

Components of a social history with a child with failure to thrive

• Family - genogram • Household • Money • Maternal age, health incl mental health • Family drug, alcohol and mental health issues • Domestic violence • Social support • Food availability

Name some food products that contain vitamin A

• Found in dairy products, liver, yellow and red fruits and vegetables as well as green leafy vegetables

What percentage of children are overweight?

• Globally, 7% of children are overweight • Townsville - 30% of children are overweight or obese

What is IMR?

• IMR = Infant Mortality Rate = number of deaths under one year of age occurring among the live births in a given year, per 1,000 live births occurring among the population during the same year.

Examples of key proven practices, services and policy interventions for the prevention and treatment of stunting and other forms of undernutrition in adolescence pregnancy...

• Improved use of locally available foods • Food fortification, including salt iodisation • Micronutrient supplementation and deworming • Fortified food supplements for undernourished mothers Antenatal care, including HIV care

What are some clinical features of iodine deficiency?

• Iodine deficiency causes a range of abnormalities including goitre (swelling of the thyroid gland in the neck) and cretinism (stunted physical and mental growth), which occurs in the offspring of women with severe deficiency

Give an example of an adult chronic disease of fetal origin

• Link between low birth weight and heart disease as an adult

What is wasting and what is it a strong predictor of?

• Low weight for height • Strong predictor of mortality among children under 5

When using a growth chart, is it reasonable to take just a single measurement at a particular point in time?

• Need to see if they are following the curve - not just taking a single measurement at a point in time

What is low birthweight an indicator of?

• Nutritional problem at a population level - Indication of nutritional status and health outcomes

What damages can poor fetal growth or stunting in the first 2 years of life cause?

• Poor fetal growth or stunting in the first 2 years of life leads to irreversible damages, including shorter adult height, lower attained schooling, reduced adult income, and decreased offspring birthweight

Components of a medical history with a child with failure to thrive

• Pregnancy - infection, medical illness, drugs & alcohol • Birth - weight, health • Feeding, diet history • Development history • Systems review - GIT, resp, CVS etc.

5 reasons why good nutrition is important for children

• Relationship to infant/child mortality - 1000 days before and after birth are important to set the children up • Physical growth potential • Brain development - psychomotor development links to education outcomes, employment opportunities, social development etc etc • Adult chronic disease (foetal origins hypothesis) may contribute to things like stokes and diabetes • Children development pattern of diet (risk of obesity, diabetes etc. in later life)

Outline the main principles of management for severe acute malnutrition (SAM)

• SAM defined as a very low weight for height (below -3 z score), by visible severe wasting, or by the presence of nutritional oedema. - Scales can be hard to come by

Outline the main principles of management for severe acute malnutrition (SAM)

• SAM defined as a very low weight for height (below -3 z score), by visible severe wasting, or by the presence of nutritional oedema. - Scales can be hard to come by • Correct dehydration by using a rehydration fluid (less osmolarity) - has less salt in it - helps correct the electrolyte abnormalities (if the kidneys are still working) • Micronutrient - Vitamin A is the first one given, and give the other ones over time - Ready to eat foods - Folate - Measles vaccines - Antibiotics to treat infections - Deworming • Begin feeding slowly (after day 3,4 or 5 after a child gains their appetite, that they begin to eat larger amounts of food)

What can severe iodine deficiencies cause?

• Severe deficiencies cause cretinism, stillbirth and miscarriage, while even mild deficiency can significantly affect the learning ability of populations.

Is there a relationship between infant nutrition and adult height?

• Strong relationship • There can be big differences across a single country

How many countries have wasting rates of 10% or more?

• There are 24 developing countries with wasting rates of 10% or more, indicating a serious problem urgently requiring a response.

Examples of key proven practices, services and policy interventions for the prevention and treatment of stunting and other forms of undernutrition at 6-23 months...

• Timely introduction of adequate, safe and appropriate complementary feeding • Continued breastfeeding • Appropriate infant feeding practices for HIV-exposed infants, and ARV • Micronutrient supplementation, including vitamin A, multi-micronutrients; zinc treatment for diarrhoea; deworming • Community-based management of severe acute malnutrition; management of moderate acute malnutrition • Food fortification, including salt iodinisation • Prevention and treatment of infectious disease; hand washing with soap and improved water and sanitation practices Improved use of locally available foods, fortified foods, micronutrient supplementation/home fortification for undernourished women, hand washing with soap

What is wasting usually the result of?

• Usually the result of acute significant food shortage and/or disease

What are some complications of vitamin A deficiency? What can vitamin A prevent?

• Vitamin A deficiency (VAD) causes blindness and renders children susceptible to common childhood killers: measles, diarrhoea, malaria and pneumonia • Increasing the vitamin A intake of populations with VAD can decrease childhood deaths from such illnesses by 25% • Vitamin A also helps prevent maternal mortality and may reduce mother-to-child transmission of HIV

What eye condition can Vitamin A deficiency cause and what are the 4 levels of severity of this condition?

• Vitamin A deficiency results in xerophthalmia, which affects the eyes - The main signs in order of severity (from XN to X3) are: 1. Night blindness (XN) Impaired vision, particularly in reduced light 2. Bitot's spots (X1B) Foamy accumulations on the conjunctiva (inner eyelids), that often appear near the outer edge of the iris 3. Corneal Xerosis (X2) Dryness, dullness or clouding (milky appearance) on the cornea 4. Keratomalacia (X3) Softening and ulceration of the cornea. This is sometimes followed by the perforation of the cornea, which leads to permanent blindness

What is stunting and what are its consequences?

• ow height for age - traps people into a lifelong cycle of poor nutrition, illness, poverty and inequity - The damage to physical and cognitive development (especially during the first 2 years of a child's life) is largely irreversible - A child's poorer school performance results in future income reduction of up to 22% on average - As adults, they are also at increased risk of obesity, diabetes and cardiovascular disease.

What are some natural sources of iodine?

• seafood has a fair bit of natural iodine richest source • Present in soil to varying degrees • Plants contain a variable amount of iodine depending on the levels in the soil in which they are grown

Components of examinations with a child with failure to thrive

• weight, height, MUAC, HC • plot on growth chart - also plot historical data • examine for hydration, general condition • look for muscle wasting, bulk & fat stores • look for infection - respiratory, skin, ent • Look for evidence of micronutrient deficiency - anaemia, dermatitis etc.