United Nations System
Standing Committee on Nutrition

Report on the Meeting of the Working Group on Prevention of Fetal and Infant Malnutrition

Thursday, 13 April 2000, Washington DC
Chair: Nevin Scrimshaw
Rapporteur: Roger Shrimpton

General Introduction

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:

• review current scientific knowledge and effective interventions
• generate recommendations for future research and programme priorities
• develop recommendations for programme strategies and operations research for improving birth weight that can be adopted by future nutrition programmes in Bangladesh.

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:

• Further research on the effects of LBW was agreed to be important for the purposes of better understanding the relative contribution of both genetic imprinting and changes in lifestyle and environment on the onset of certain adult diseases. This will be vitally important in providing better care of LBW infants and advice on adult lifestyles in an effort to reduce their risks of poor health in adult life. Rat studies have confirmed the effects of poor nutrition on gene imprinting and suggest that such gene imprinting continues in later life. Moreover there is some evidence that the effects are inter-generational with LBW rats, giving birth to another generation of LBW rats, again with the same risk of adult disease. (Garza)
• LBW has been said to programme individuals to be at higher risk of adult disease however, this 'programming' only comes into action when lifestyle is changed from one of deprivation to one of excess and poor health habits (eg smoking and low levels of physical activity). This has major implications because as whole communities and countries in the developing world experience greater economic and social development there is likely to be a correspondingly massive increase in populations suffering from adult diseases. The question of the extent to which this process can be reversed is thus of vital importance and it is hypothesized that if LBW can be ameliorated by adequate care and nutrition in the early years, the 'programming' effect may be reduced or even reversed.

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:

• Optimal nutrition - breastfed and appropriate complementary feeding
• Optimal environment - no microbiological contamination
• Optimal health care - immunization and paediatric routines

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:

• Longitudinal component which will follow children from birth to 24 months, 300 children per site
  • Frequent assessment of feeding practices and growth
  • Strong breastfeeding support to ensure high rates of breastfeeding
  • Estimates of incremental growth
  • One year recruitment and two years follow up - the impact of changes in nutrition, care and environment will be assessed
• Cross-sectional component of children 18-71 months
  • Growth of children above three years is mostly linear
  • Feeding mode no longer critical for curve construction
  • Overlap of 6 months with the longitudinal group will allow merging of the two curves

The outcome will be a tool capable of assessing:

• Nutritional status of children
• Motor development milestones
• Nutritional status of lactating mothers
• Under and over nutrition in communities
• Overall health and well-being of populations

The resulting information will provide a strong advocacy tool for promotion of:

• Children's right to achieve their full genetic potential
• Breastfeeding as the healthiest way to feed infants and young children
• Children's right to grow in a smoke-free environment

Preliminary results indicate that children living in different sites grow similarly if health and environmental conditions are the same.

Discussion points included:
It is important to consider the health care and environment of the study children in order to ensure that the new growth curves do not simply reflect optimal growth, but also the optimal health of populations. It was recalled that while breastfed children tend to be smaller than formula-fed infants, they have better health outcomes.

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 adwivedi@unicef.org.

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:

• New awareness of the importance of LBW by UNICEF
• Including prevention of LBW within the UNICEF/Government of Tanzania Cooperation Agreement
• Establishing a national technical working group
• Review of data on micronutrient deficiencies and LBW interventions in Tanzania
• Selecting interventions for nutrition programmes
• Envisioning district level health committees
• Establishing district level programmes - IEC, training, supplies and others.

The overall aim of the pilot programme is to reduce the prevalence of LBW by 20%. The main challenges are that
less than 30% of women deliver in health facilities. For this relatively small proportion the scales available in clinics are of variable quality and health providers have other claims on time and resources and are not able to devote time to "extra" tasks. The strategy to obtain birth weight is to weigh the child when mothers bring infants for BCG soon after birth and then use adjusted birth weight to estimate weight at birth. This type of modeling has proven to be effective. It is important to note that this pilot programme will be incorporated within existing MCH activities.

Interventions at district level include:

• Advocacy - aimed at health workers and community groups
• Dietary advice and reduction of heavy activity
• Multiple micronutrient supplementation for pregnant women
• Special support for first time mothers
• Mebendazole for intestinal helminths
• Praziquanetel in endemic areas (schistosomiasis)
• Weight gain in pregnancy

The following indicators will be monitored:

• Birth weight
• Mothers booking into ante-natal clinics before 20 weeks
• Receipt of interventions (assessed at DPT3)
• Anemia, assessed by WHO colour cards
• Serum vitamin A
• Maternal hemoglobin and maternal weight and height at DPT3

Main discussion points included:

• While participants appreciated that a package of interventions is to be offered, there was significant concern that the nutrition interventions were viewed as being limited to the multiple micronutrient supplement. Concerns were expressed about the iron level in the supplement, about the fact that the supplement should only be a short-term intervention with dietary approaches being the optimal long-term goal and that long-term provision of this supplement may not be sustainable.
• Jane Kusin pointed out that the extent to which pregnancy interventions impact upon birth weight outcomes depends on the nutritional status of the mother prior to and during pregnancy due to the partitioning of available resources. On this basis she emphasized that the nutritional status of the mother during the post natal period was a key determinant and vitally important and should be monitored within the programme. Fernando Viteri further pointed out the importance of addressing the well being of the mother prior to pregnancy. He highlighted that much greater focus must be given to adolescent girls and pre-pregnant women.
• Comments also addressed the importance of adapting interventions on the basis of the food security of the target populations and the difficulties of reaching the under-serviced communities likely to be most at risk.
• The study investigators confirmed that maternal nutritional status is highly variable, and that women could also be weighed at a later stage post-partum to address Jane Kusin's concerns. Additionally they clarified that a key intervention must be a reduction in the proportion of adolescent pregnancies and that improved food based approaches are an integral part of the programme. This is operational research which addresses socio-developmental concerns rather than biomedical constraints.
• On the issue of the sustainability of distribution of supplements, it was clarified that the objective of this research was to first confirm that such a package of interventions could improve maternal well being and reduce LBW. If this package proves effective, it may be feasible for women and families to continue to purchase the multiple micronutrient supplement and/or other treatments (e.g., de-worming tablets) especially if they are sufficiently convinced about the value of the benefits.
• UNICEF confirmed that trials such as the Tanzanian trial are being undertaken in ten other countries (listed above) aimed at identifying packages of interventions that reduce LBW. All trials are being undertaken within on-going programmes, such as Safe Motherhood programmes. The multiple micronutrient supplement forms an integral part of these trials and it is anticipated that increased efficacy may be achieved by replacing routine iron-folate supplementation with the multiple supplement. It was further noted that the incremental cost of moving from iron-folate to multiple supplements would be minimal. A key aspect of these programmes is on-going monitoring of inputs, processes and impacts.

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.

Summit goals

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
Working Group on Prevention of Foetal and Infant Malnutrition

Objectives

To advance operational research and implementation of programmes to reduce the prevalence and ameliorate the consequences of foetal and infant malnutrition, and contribute to understanding its life cycle causes.

Activities

The objective will generally be reached through the following series of activities:

• Critically review relevant current literature and programmatic activities and identify gaps in knowledge required for advocacy and more effective programmes
• Disseminate new knowledge and advocate to policy makers the importance of preventing foetal and infant malnutrition.
• Promote and assist in harmonizing knowledge and actions of UN Agencies, the bilaterals and NGOs at the country level for the prevention of foetal and infant malnutrition.
• Organize or sponsor workshops and task forces as appropriate
• Report on monitoring and evaluation of programme initiatives worldwide.

 Workplan 2000-2001

1. Establish a secretariat at the ICH, University of London that will collect new knowledge and summarize it for periodic electronic dissemination and/or presentation at the annual meeting as appropriate. The secretariat will keep members of the working group informed of activities through email at regular intervals.
2. Develop a programme for the annual meeting that will report on programmatic developments in this field.
3. Develop guidelines to assist in the monitoring and evaluation of low birth weight prevention programmes.
4. Develop guidelines for programmes to evaluate the effectiveness of multiple micronutrient supplementation during pregnancy.
5. Compile programmatic experience on promoting nutritional improvement and weight gain during pregnancy, and the role of communications.