Malnutrition and child survival Prof Dr. Patrick Kolsteren Nutrition and Child Health Unit Institute of Tropical Medicine Antwerp

Malnutrition and mortality Malnutrition is the underlying cause of 3.5 million deaths 35 % of the disease burden in children under five due to malnutrition 11 % of the total mortality and disability

Major Causes of Death among Children around the World Deaths associated with undernutrition 60% Sources: EIP/WHO, Caulfield LE, Black RE. Year 2000

Expression of malnutrition Thinness or acute severe/ moderate malnutrition Sub-optimal growth: stunting or short stature Micronutrient deficiencies –Vitamin A –Zinc –Iron –Iodine

Stunting Lancet series maternal and child nutrition 19 January 2008

Vitamin A deficiency Lancet series maternal and child nutrition 19 January 2008

Zinc deficiency Lancet series maternal and child nutrition 19 January 2008

Health effects Decreased immunity “nutritional immune deficiency syndrome” Frequent infections Psycho-motor development delays School performance Lower IQ Blindness Neurological malformations Short adults pregnancy complications

Immediate causes of malnutrition Low birth weight / maternal nutrition No breastfeeding or non exclusive breastfeeding Complementary feeding: –Low quantity –Low energy density –Low quality: diversity, fruit and vegetables Low quality diet : family dish Micronutrient deficiencies Infection pressure

DANGERS WITH COMPLEMENTARY FOODS 1.Diarrhea 2.Food allergies and atopic (in particular before 4 months of age) 3.Not enough: - Composition (Fat = 40 %) - Poor density (150 CC /meal ) - Time and frequency 4.Too salty

DANGERS WITH COMPLEMENTARY FOODS 5. Low quality - Poor in micronutrients - Low-bioavailability - Low fat :ADEK - Little variation -Qualilty of proteins ( 2/3 cereals and 1/3 tubers) cereals are rich in lysine, poor in methionine and cysteine) - No fruits and vegetables -No animal protein

DANGERS WITH COMPLEMENTARY FOODS 6.Contamination Mycotoxine: aflatoxine and fumonisins Little research : In tanzania 20 % of infant in the Kilimanjaro region have intakes above the recommended safety levels. Large seasonal variation. CF is largely cereal based.

Infection pressure Drop in maternal immunological protection at 6 months Environmental sanitation : –Diarrhoea –Worm infections –Parasites : vector borne diseases (malaria) Cause of malnutrition and a result of malnutrition

What works? Promotion of exclusive breastfeeding Improve complementary feeding and nutrition support Hand-washing and hygiene interventions

How to improve complementary feeding? Food based approach: food diversity, accept new food sources in CF Increase fat content Role of ω3 and ω6 fatty acids is not clear. Invest in toxine analyses

What works ? Treatment of malnutrition, severe and moderate Focus on identification of malnourished children Vitamin A fortification Iodisation of salt Zinc supplementation Improve maternal nutritional status pregnancy

How to get there in operational terms? Coverage means access to infrastructures Infrastructures exist : health care system Most interventions can be delivered through health system if they focus on child health Health systems needs to be supported with a particular emphasis on child health and health promotion

Way forward Accept that we know what to do Focus on what works and increase coverage Use existing structures Find ways to deliver the interventions in a local context. Support local initiatives in research and development. Who drives the agenda??? 99 % grants for “new solutions” that can reduce mortality by 22% 1 % for solutions that increase coverage that can reduce mortality by 66 %

Thank you