Transcript Evidence Based Interventions For Improving Maternal And Child

Evidence Based Interventions for Improving Maternal and
Child Nutrition:
What Can be Done and at What Cost?
Zulfiqar A Bhutta1,2, Jai K Das1, Arjumand Rizvi1, Michelle Gaffey2, Neff Walker3, Sue Horton4, Patrick
Webb5, Anna Lartey6, Robert E Black for Lancet Maternal and Child Nutrition & Interventions Review
Groups
1
The Aga Khan University and Medical Center, Karachi, Pakistan
Hospital for Sick Children (Sick Kids), Toronto , Canada
3 Johns Hopkins University, Baltimore, USA
4 University of Waterloo, Canada
5 Tufts University, Boston, USA
6 University of Ghana, Ghana
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Nutrition-Specific Interventions and Programs:
How can they Help Accelerate Progress in Improving
Maternal and Child Nutrition?
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Furthering the Evidence Base to Improve
Maternal and Child Nutrition
 Since 2008 Lancet Series, many nutrition interventions
have been successfully implemented at scale, and the
evidence base for effective interventions and delivery
strategies has grown; coverage rates for other
interventions are either poor or non-existent
 The evidence base for nutrition specific and sensitive
interventions was updated & enhanced
 Ten nutrition-specific interventions across the life cycle
to address undernutrition and micronutrient
deficiencies in women and children were modelled to
assess impact and cost of scaling up
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Interventions Across the Lifecycle
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Nutrition Interventions Reviewed
Women of
reproductive age
and pregnancy
Neonates
• Folic acid
supplementation
• Delayed cord
clamping
• Iron and iron-folate
supplementation
• Neonatal vitamin K
administration
• MMN
supplementation
• Vitamin A
supplementation
• Calcium
supplementation
• Kangaroo mother
care and promotion
of breastfeeding
• Iodine through
iodisation of salt
• Maternal
supplementation with
balanced energy
protein
Infants and children
Disease prevention
and management
• Complementary
feeding promotion (624 months)
• WASH interventions
• Preventive vitamin A
supplementation (6
months – 5 years)
• Deworming in
children
• Maternal deworming
• Iron supplementation
• Feeding practices in
diarrhoea
• MMN
supplementation
• Zinc therapy for
diarrhoea
• Zinc supplementation
• IPTp/ITN for malaria
in pregnancy
• Malaria prophylaxis in
children
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Delivery Platforms Reviewed
Community delivery platforms
for nutrition education and
promotion
• Improve rates of facility births by
28%
• Doubling of initiation of
breastfeeding within 1 h and EBF
• Substantial potential to improve
the uptake of child health and
nutrition outcomes among
difficult to reach populations
Reduction of financial barriers
Integrated Management of
Childhood Illness (IMCI)
• Policy strategies to ameliorate
poverty, reduce financial barriers,
and improve population health
• Includes both curative and
preventive interventions at
health facilities and at home
• Promote increased coverage of
child health interventions
• Various benefits in health
services, quality, mortality
reduction, and health-care cost
savings
• Pronounced effects achieved by
those that directly removed user
fees for access to health services
• Significant increase in EBF and
comparatively faster reduction in
the prevalence of stunting
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Delivery Platforms Reviewed
Fortification strategies
• MMN: Increase in haemoglobin
concentrations and reduced risk
of anaemia by 57%
• Iron fortification - 41%
reduction in anaemia and 52%
reduction in iron deficiency
• Vitamin D fortification increased
serum 25-OH D concentration
Child health days
• Introduced in weak health
systems to rapidly enhance
coverage of essential child
survival interventions
• Promote increased coverage
than stand alone campaigns
• Overall equity effect of these
approaches are uncertain and
further studies are needed
School-based delivery
platforms
• Two tier- Improve attendance
and health
• Improve school attendance by
4-6 days annually and weight
gains 0.39 kg over 11 months
and 0.71 kg over 19 months
• Evidence scarce- Enormous
opportunity
• Zinc fortification- higher serum
and erythrocyte zinc
concentration and lower serum
copper
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Breast Feeding Promotion-Effects on breast feeding
rates
Effects on exclusive breastfeeding rates
Outcome
Estimates
EBF at Day 1
43% RR: 1.43 (1.09-1.87) increase
EBF at 4-6 weeks
30% (RR: 1.30, 95% CI: 1.19-1.42) increase
EBF at 6 month
90% (RR: 1.90, 95% CI: 1.54-2.34) increase
Effects on NOT breastfeeding
Outcome
Estimates
Not breast feeding at Day 1
32% (RR: 0.68, 95% CI: 0.54-0.87) decrease
Not Breast feeding at 1 month
30% (RR: 0.70, 95% CI: 0.62-0.80) decrease
Not breast feeding at 6 months
18% (RR: 0.82, 95% CI: 0.77-0.89) decrease
Behavior Change Communication for Improved
Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Behavior Change Communication for Improved
Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Complementary Feeding education alone in food insecure populations
HAZ
SMD: 0·25 (95% CI 0·09, 0·42)
Stunting
RR: 0·68 (95% CI 0·60, 0·76)
WAZ
SMD: 0·26 (95% CI 0·12, 0·41)
Behavior Change Communication for Improved
Complementary Feeding
Outcome
Estimates
Complementary Feeding education alone in food secure populations
WAZ
SMD: 0.20 (95% CI: 0.07, 0.33)
Height Gain
SMD: 0.35 (95% CI: 0.08, 0.62)
Weight Gain
SMD: 0.40 (95% CI: 0.02, 0.78)
Complementary Feeding education alone in food insecure populations
HAZ
SMD: 0·25 (95% CI 0·09, 0·42)
Stunting
RR: 0·68 (95% CI 0·60, 0·76)
WAZ
SMD: 0·26 (95% CI 0·12, 0·41)
Complementary food provision with education in food insecure populations
HAZ
SMD: 0.39 (95% CI: 0.05, 0.73)
WAZ
SMD: 0·26 (95% CI 0·04–0·48)
underweight
RR: 0.35 (95% CI: 0.16, 0.77)
Micronutrient interventions in childhood
•
Vitamin A Supplementation: Reduces all-cause mortality (RR 0·76, 95% CI 0·69–0·83),
diarrhoea-related mortality (RR 0·72, 95% CI 0·57–0·91), incidence of diarrhoea (RR
0·85, 95% CI 0·82–0·87) and incidence of measles (RR 0·50, 95% CI 0·37–0·67)
•
Preventive Zinc Supplementation: Reduces incidence of diarrhoea RR: 0.87 (95% CI
81–94) and pneumonia RR: 0.81 (95% CI 0.73–0.90) and improves mean height gain by
0·37 cm (SD 0·25)
•
Iron Supplementation: Reduces anaemia (RR 0·51, 95% CI 0·37–0·72), increases
haemoglobin concentration (MD 5·20 g/L, 95% CI 2·51–7·88) and ferritin concentration
(MD 14·17 mcg/L, 95% CI 3·53–24·81). Developmental benefits mainly in school age
children.
•
Micronutrient Powders: Reduce anaemia (RR 0·66, 95% CI 0·57–0·77), retinol
deficiency (RR 0·79, 95% CI 0·64–0·98) and improve haemoglobin concentrations (SMD
0·98, 95% CI 0·55–1·40). Further evaluation of safety needed when used at scale
LiST modeling effects on mortality for
34 high burden countries: revised model
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80
60
40
0
Main outcomes (mortality and
stunting impact) reported across the
under 5 period as opposed to point
impact at 36 months of age
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% of birth cohort
Major component remains a cohort
model, following children from birth
to 36 months, with stunting and death
as outcomes. Wasting is also included
in the model
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Modeling the Impact of Interventions: What’s New?
0
12
24
36
Age in months
Died
Not stunted
Stunted
Target coverage 90% (compared to
99% in 2008) in 34 countries with
maximum burden
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Countries With High Burden of Malnutrition
These 34 countries account for 90% of the global burden
of malnutrition
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Effect of Scale-up Interventions on
Cause-specific Deaths
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Impacts
Mortality in children younger than 5 years could be reduced by 15%
(range 9-19%)
• 35% (19-43) reduction in diarrhoea-specific mortality
• 29% (16-37) reduction in pneumonia-specific mortality
• 39% (23-47) reduction in measles-specific mortality
• Reduced deaths due to asphyxia and congenital anomalies
• Little effect on maternal mortality
Stunting overall reduced by at least 20.3% (range 11.1-28.9%)
Severe wasting reduced overall by 61.4% (range 35.7-72%)
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Effect of Scale-up Interventions on Deaths in Children
Younger than 5 Years
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Packages of Nutrition Interventions
Optimal maternal nutrition during pregnancy
•
•
•
•
Maternal multiple micronutrient supplements to all
Calcium supplementation to mothers at-risk of low intake3
Maternal balanced energy protein supplements as needed
Universal salt iodization
Infant and young child feeding
• Promotion of early, exclusive breastfeeding for 6 months; continued breastfeeding until 24 months
• Appropriate complementary feeding education in food secure populations and additional
complementary food supplements in food insecure populations
Micronutrient supplementation in children at risk
• Vitamin A supplementation between 6-59 months age
• Preventive zinc supplements between 12-59 months of age
Management of acute malnutrition
• Supplementary feeding for moderate acute malnutrition
• Management of severe acute malnutrition
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Effect of Packages of Nutrition Interventions
at 90% Coverage
Number of lives
saved
Cost per life-year
saved
Optimum maternal nutrition during pregnancy
102,000
(49,000-146,000)
$571
(398-1,191)
Infant and young child feeding
221,000
(135,000-293,000)
$175
(132-286)
Micronutrient supplementation in children at risk
145,000
(30,000-216,000)
$159
(106-766)
Management of acute malnutrition
435,000
(285,000-482,000)
$125
(119-152)
Nutrition interventions
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Can community based nutrition programs reach the poor?
All Community Platforms
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•
•
•
•
Maternal mortality (RR 0.81; 95% CI: 0.59 to 1.11)
Maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92)
Neonatal deaths (RR 0.74; 95% CI 0.66 to 0.83)
Stillbirths (RR 0.79; 95% CI 0.70 to 0.90)
Perinatal mortality (RR 0.74; 95% CI 0.66 to 0.84)
All Community Platforms
•
•
•
•
•
Maternal mortality (RR 0.81; 95% CI: 0.59 to 1.11)
Maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92)
Neonatal deaths (RR 0.74; 95% CI 0.66 to 0.83)
Stillbirths (RR 0.79; 95% CI 0.70 to 0.90)
Perinatal mortality (RR 0.74; 95% CI 0.66 to 0.84)
•
•
•
•
Facility births (RR 1.28; 95% CI 1.04 to 1.59)
Breastfeeding rates 125% (RR 2.25; 95% CI 1.70 to 2.97)
Skilled care births (RR 1.59; 95% CI 0.64 to 3.95)
Iron/folate supplementation (RR 1.47; 95% CI 0.99 to 2.17).
Community based Interventions Modeled
1.
2.
3.
4.
5.
6.
7.
Multiple micronutrient supplementation in pregnancy
Promotion of breastfeeding
Promotion of appropriate complementary feeding
Vitamin A supplementation
Preventive zinc supplementation
Treatment of diarrhoea with zinc
Recognition and management of severe acute malnutrition
Equity Analysis of Effect of Scale Up Nutrition
Interventions
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Potential Impact of Scaling Up
10 Proven Interventions
Continued investment in nutrition-specific interventions and
delivery strategies to reach poor segments of the population
at greatest risk can make a significant difference
If these 10 proven nutrition-specific interventions were
scaled-up from current population coverage to 90%, we could:
• Save an estimated 900,000 lives in 34 high burden
countries (where 90% of the world’s stunted children
live)
• Reduce the number of children with stunted growth
and development by 33 million
On top of existing trends, the WHA targets for 2025 are
reachable
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Total Additional Annual Cost of Achieving 90% Coverage
with Nutrition Interventions
Nutrition interventions
Cost
Salt iodisation
$68
Multiple micronutrient supplementation in pregnancy (includes iron-folate)
Calcium supplementation in pregnancy
$472
$1914
Energy-protein supplementation in pregnancy
$972
Vitamin A supplementation in childhood
$106
Zinc supplementation in childhood
$1182
Breastfeeding promotion
$653
Complementary feeding education
$269
Complementary feeding supplementation
$1359
SAM management
$2563
Total
$9559
Data are 2010 international dollars, millions.
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Paper 2 Key Messages
Promising interventions exist to improve maternal nutrition and reduce fetal growth
restriction and small-for-gestational age (SGA) births in appropriate settings in
developing countries, if scaled up
A set of 10 evidence-based interventions if implemented at scale can save at least
15% of under 5 child deaths (i.e. 1 million lives saved) and avert a fifth of all stunting
Delivery strategies exist to especially target undernutrition and impact child mortality
among the poorest
The costs for scaling up these nutrition specific interventions globally is $9.6 billion,
affordable given the gains
A clear need and opportunity exists to introduce promising evidence-based
interventions in the preconception period and adolescents and also address the
impact on long-term neurodevelopmental outcomes
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