United Nations System
Report on the Meeting of the Working Group on Prevention of Fetal and Infant Malnutrition
Thursday, 13 April 2000, Washington DC
Nevin Scrimshaw summarized the growing evidence that from conception onward nutritional factors damage future health. Folate deficiency (neural tube defects) and iodine deficiency (cognitive impairment) in early pregnancy and iron deficiency in infancy (cognitive impairment) are well-established examples. A beneficial effect on growth and cognitive performance has been reported in many young child supplementation studies, but reports from Guatemala (Martorell and colleagues) and Mexico (Chaves and Martinez) demonstrate that supplementary feeding during the weaning period results in robust improvement in growth, schooling and cognition in young adults.
A life-span study of Civil War veterans by Robert Fogel and collaborators showed a strong relationship between height at induction of recruits from widely varying social and economic backgrounds and the subsequent onset of chronic disease. The series of studies by David Barker and colleagues in the UK, finding a strong association between low birth weight and stunting at one year of age and chronic disease (hypertension, cardiovascular disease, adult onset diabetes and auto-immune thyroid disease) in adult life, has given impetus to the concept of fetal origins of adult disease. A smaller study in India gave similar results for heart disease. As long as developing-country populations remain lean, active and consume a low fat diet an increased tendency to high blood pressure and heart disease may not be expressed. However, they may be at far greater risk with rising affluence.
To evaluate these issues and their significance, an SCN working group on the Life Cycle Consequences of Foetal and Infant Malnutrition first met in 1999 with the principal aims of reviewing the longitudinal relationship between intra-uterine growth retardation (IUGR) and longer-term consequences. The group also looked at the possibilities of undertaking interventions to prevent low birth weight and build consensus on how the research and programme community can move forward on the basis of the life cycle consequences. This is the second meeting of the working group.
Report of the Dhaka LBW Meeting, held in June 1999
presented by Roger Shrimpton
The purpose of the meeting was to:
As such, this meeting offered the first opportunity for scientists and programme people to discuss together the scientific consequences and possible interventions to address this neglected issue. George Fuchs (ICDDR,B), organizer of the meeting, using the life cycle approach facilitated the coming together of various perspectives, including research and programme application. Participants at the meeting concluded that LBW prevention requires a package of interventions at various stages of the life cycle and that UNICEF's Care Initiative could be used as a basis for developing an integrated programme.
Report on the Technical Consultation on LBW, held in Washington in March 2000
presented by Eileen Kennedy
This consultation was organized to develop a broader coalition of researchers, organizations and donors working together to move the LBW agenda forward. Specifically the objective was to review the literature and identify existing programmes that have successfully reduced low birth weight, and to determine how these and other actions can be used to address the problem in the future. A key recognition was that LBW has to be addressed through interventions focussing on female adolescents and pre-pregnant women.
Replication of the Barker study in the USA
presented by Nevin Scrimshaw on behalf of Dora Costa
The economic historian, Robert Fogel, has secured funds to replicate and expand on the Barker studies. Arrangements have been made to access hospital data on pregnancy weight gain, measurements at birth and related pediatrics and obstetrical data for children born from 1920 to 1940 in hospitals in four U.S cities. The Fogel group will use their experience linking early physical data of Civil War recruits to subsequent censuses, medical records, social security and death records. The purpose is to obtain data to replicate and expand on the Barker hypothesis. There are contradictions in the interpretation of the Barker findings and possible mechanisms are poorly understood. In order to guide this and similar studies there is a need for a small meeting to critically probe weaknesses in the experimental design used for the Barker studies and suggest ways in which the design may be improved. Such a group would be charged with identifying additional data that might be obtained or alternative analytical approaches. An objective would be improved understanding of the mechanisms by which early growth and development affect adult health and the extent to which these processes might be reversed or ameliorated. It was agreed that IDECG would be an appropriate group to organize the review of this data.
Main discussion points following these presentations were:
New growth reference curves
presented by Cutberto Garza
This study, undertaken jointly by WHO, UNU and UNICEF, will aim to build a set of growth curves of children below five years of age who experience optimal conditions for growth and development. These curves will then be adopted as new international references for assessing growth and nutritional status of populations and individual children. The new growth curves are expected to be ready by 2003. These optimal conditions are:
The study populations are generally middle-to-high income families and will enable the development of curves that depict optimal growth, rather than maximal growth. The study is underway in six countries: Brazil, Ghana, India, Norway, Oman and USA, thus representing all regions of the world. It will measure the growth and development of more than 12,000 infants and children.
The study will be undertaken in two components:
The outcome will be a tool capable of assessing:
The resulting information will provide a strong advocacy tool for promotion of:
Preliminary results indicate that children living in different sites grow similarly if health and environmental conditions are the same.
Discussion points included:
A workshop on multiple micronutrient supplements and UNICEF's LBW pilot programmes
presented by Archana Dwivedi
A workshop was held to define the composition of a multiple micronutrient supplement for pregnant women in developing countries to be used in effectiveness trials in pilot programmes. The workshop concluded a) that a suitable multiple micronutrient supplement should not be withheld from pregnant women from developing countries and b) that the proposed supplement should be distributed in LBW pilot programmes. There was agreement on the composition of the supplement (which includes 15 nutrients). The selection of nutrients was based on available evidence of deficiency, possible consequences of deficiencies for mother and child, weighing of risks versus advantages and on nutrient-nutrient interactions. Other issues such as cost, size and side effects were also considered. The proposed supplement was based on US and Canadian recommended daily allowances. The schedule for intake was also proposed. A final report of the meeting is available from email@example.com.
A presentation on UNICEF's LBW initiative followed. The nutrition strategy as applied in most countries had concentrated on improving child nutrition almost to the exclusion of maternal nutrition. The UNICEF Care Initiative, however, included "Care for Women" as one of the six components of care. Using the Care Initiative, it is possible to construct an indicative set of low birthweight interventions as an integrated package of activities. It also fits in well with UNICEF's new agenda for children in the 21st century, referred to as Early Childhood Care, Survival, Growth and Development (ECC/SGD). This approach includes improved foetal and infant growth, and places child growth and child development as an important precursor for human development.
UNICEF is conducting trials to reduce the prevalence of LBW through eleven of its country programmes: Indonesia, Philippines, Vietnam, China, Bangladesh, India, Pakistan, Nepal, Tanzania, Mozambique, and Madagascar. This was incorporated into the Programme Priorities approved by the Executive Board in September 1999. UNICEF will incorporate the multiple micronutrient supplements into ongoing programmes in each of these countries, in line with the nutrition strategy and the ECC/SGD approach. In addition to the multiple micronutrient supplement, other interventions will include attention to early marriage and child bearing, promotion of increased child spacing, increased rest and food during pregnancy, improved reproductive health, de-worming, and malaria control as appropriate. As important indicators of programme success, pre-pregnancy weight, weight gain during pregnancy and birth weight will all receive special attention and will be measured using the UNISCALE.
These 11 pilot programmes will be monitored and evaluated to ascertain through adequacy evidence that programmes are working. More intensive effectiveness trials (plausibility evidence) will be conducted in three of the eleven countries - Tanzania, Bangladesh and Indonesia. For these pilot programmes, local scientific institutions will receive support and guidance on data collection and analysis from several scientific institutions in industrialized countries.
LBW Pilot Programme in Tanzania
presented by Andrew Tomkins and Wilbald Lorri
Dr. Lorri discussed the collaboration of the Tanzania Food and Nutrition Centre and UNICEF in developing the LBW prevention pilot programme. The processes in developing the programme involved the following:
The overall aim of the pilot programme is to reduce the
prevalence of LBW by 20%. The main challenges are that
Interventions at district level include:
The following indicators will be monitored:
Main discussion points included:
The SIDA/ACC-SCN informal survey on women's nutrition
presented by Ted Greiner
Concern was expressed at the sense of frustration that women's nutrition receives so little attention. It is important to identify approaches that are programmatically feasible. SIDA will fund a meeting next year if it is felt by the Working Group to be useful. Questionnaires were sent to all SCN day-to-day contacts, however, so far there were few respondents. Participants encouraged Dr. Greiner to try to increase the number of responses to the questionnaire, through a follow-up email letter. His report will be submitted to the SCN Secretariat, and follow-up can then be determined by the new chair of the working group.
Terms of Reference
presented by Roger Shrimpton
Draft terms of reference and modus operandi were presented and briefly discussed.
Although not discussed in depth during the working group meeting itself, some participants felt that the working group might in due course forward these revised goals to the organizers of the Summit for Children to be held in the fall of 2001:
1. Reduce the prevalence of low birth weight to less than 10 % in all countries.
2. Reduce the prevalence of stunting in young children under two to less than 20 %, or by one half as appropriate.
Terms of Reference