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Oct 26, 2022 167 likes •574 views

NUTRITIONAL INTERVENTION FOR THE MANAGEMENT OF FALTERING GROWTH AND ITS POTENTIAL RISKS TAN SUE YEE BSc (Hons) Science Nutrition, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia MSc (Merit) Human Nutrition (Sports), London Metropolitan

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NUTRITIONAL INTERVENTION FOR THE MANAGEMENT OF FALTERING GROWTH AND ITS POTENTIAL RISKS

TAN SUE YEE

BSc (Hons) Science Nutrition, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia MSc (Merit) Human Nutrition (Sports), London Metropolitan University, UK PhD in Nutrition, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

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OVERVIEW

Introduction Malnutrition and growth issues Undernutrition - statistics, types, causes and consequences of undernutrition Growth assessment and monitoring Growth faltering Nutritional intervention ‘Catch-up growth’ - risks and management Conclusion

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INTRODUCTION

Nutrition is the cornerstone to a child’s growth and health 3

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MALNUTRITION AND GROWTH ISSUES

  • Underweight
  • Stunting
  • Wasting

(Undernourished)

  • Overweight
  • Obesity

(Overnourished)

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Source: https://tech2.org/malaysia/a-unicef-study-puts-malaysias-poor-nutritional-status-under-the-spotlight/

(NHMS 2016)

Statistics: Undernutrition

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urce: https://www.thestar.com.my/news/nation/2018/11/29/report-msias-triple-burden-of-malnutrition-overweight-anaemic-and-stunted-growth/

Cont…

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Growth Issues - Types of undernutrition

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Causes of Undernutrition

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Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

Figure: Probable risk factors for stunting, wasting, or both

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Consequences of Undernutrition

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References: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd. de Onis M & Branca F. Childhood stunting: a global perspective. Matern Child Health. 2016. Suppl 1:12-26.

  • Increased morbidity and

mortality in early childhood e.g. infections

  • Impaired behavioural

development in early life e.g. motor skills, cognitive ability

  • Lower height at 2 years of

age

  • Permanent short adult

stature

  • Impaired cognitive

development

  • Lower income and poorer

productivity

  • Increased risk of NCDs in

adulthood

  • Depression, anxiety and

hyperactivity in adolescence

Short term impact Long term impact

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GROWTH ASSESSMENT AND MONITORING

References: Portal MyHEALTH. Ministry of Health Malaysia. http://www.myhealth.gov.my/pengawasan-tumbesaran-2/ Paul Garner, Ratana Panpanich, Stuart Logan .Is routine growth monitoring effective? A systematic review of trials. Arch Dis Child 2000;82:197-201.

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Cont…

Source: https://www.who.int/childgrowth/standards/en/

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Promote optimum growth Create awareness about growth progression Detect early growth retardation Identify those at risk of malnutrition Enhance delivery of primary health care

Reference: Kapil U1, Joshi A, Nayar D. Utility of growth monitoring: its relevance in the promotion of child health.Indian Pediatr. 1994 Feb;31(2):239-44. .

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Importance of Growth Assessment and Monitoring

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GROWTH FALTERING

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Source: Faltering growth in children: summary of NICE guidance. BMJ 2017;358:j4219

  • describes a pattern of slower weight or height gain

than expected for age and sex in infants and preschool children

  • most often due to inadequate nutritional intake
  • complex and often multifactorial

Undernutrition causes poor growth in children

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Pattern of Growth Faltering

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Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

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Source: de Onis M & Branca F. Childhood stunting: a global perspective. Matern Child Health. 2016. Suppl 1:12-26.

Timing of Growth Faltering

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Prevent growth faltering Promote recovery from period of poor growth/ ‘catch-up growth’

Reference: Singhal A. Long term adverse effects of early growth acceleration or catch-up growth. 2017. Ann Nutr Metab. 70:236-240.

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Importance to rectify undernutrition

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Reference: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

NUTRITIONAL INTERVENTION

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STUNTING WASTING Prenatal macro- and micronutrient supplementation* Therapeutic diet Promotion of breastfeeding Supplementary/ formulated foods Complementary feeding e.g. energy and nutrient density Promotion of healthy eating Food provision e.g. dairy protein Food provision e.g. dairy protein Micronutrient fortification and supplementation e.g. zinc

* For prevention purposes as causes of stunting can begin as early as during pregnancy

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Source: Faltering growth in children: summary of NICE guidance. BMJ 2017;358:j4219

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early growth acceleration

  • ften known as the recovery phase of growth in

children (Singal 2017)

‘CATCH-UP GROWTH’

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Reference: Singhal A. Long term adverse effects of early growth acceleration or catch-up growth. 2017. Ann Nutr Metab. 70:236-240.

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New science and knowledge

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Reference: Singhal A. Long term adverse effects of early growth acceleration or catch-up growth. 2017. Ann Nutr Metab. 70:236-240.

“Compelling evidence that ‘accelerated’ and too fast growth during critical or sensitive windows in early life has detrimental effects on long term health, and particularly the risk of obesity and CVD”

  • Atul Singhal, 2017
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Infants At Risk of Later Life NCDs

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Maternal GDM Maternal obesity LGA SGA Preterm

Postnatal Growth

Large at 1 year Increased adiposity Imbalanced growth in 1st year of life Undernourished (stunting, wasting)

Prenatal environment

Source: Eline van der Beek. 6th International Conference on Nutrition and Growth, March 7-9, 2019. Valencia, Spain.

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Catch-up growth in term SGA

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Source: Lei X, Chen Y, Ye J, Ouyang F, Jiang F, Zhang J. The optimal postnatal growth trajectory for term small for gestational age babies: a prospective cohort study. J Pediatr. 2015. 166(1):54-8.

Suggestions: Rapid catch-up growth to about 30th percentile in the first several months, followed by modest growth, maintained at 50th percentile seem to be the ideal for optimal growth.

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Source: Lei X, Chen Y, Ye J, Ouyang F, Jiang F, Zhang J. The optimal postnatal growth trajectory for term small for gestational age babies: a prospective cohort study. J Pediatr. 2015. 166(1):54-8.

Cont…

  • No catch-up growth had increased risk of infection, growth restriction and low IQ at 7 years.
  • Excessive catch-up growth had elevated BP and risk of OW/OB at 7 years.
  • Regression at 4 months had growth restriction at 7 years.
  • Slow catch-up growth had low IQ at 7 years.
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Risk Factors for Later Obesity

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Source: Iguacel I, Escartín L, Fernández-Alvira JM, Iglesia I, Labayen I, Moreno LA, Samper MP, Rodríguez G; CALINA study group. Early life risk factors and their cumulative effects as predictors of overweight in Spanish children. Int J Public Health. 2018;63(4):501-512.

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Source: Iguacel I, Escartín L, Fernández-Alvira JM, Iglesia I, Labayen I, Moreno LA, Samper MP, Rodríguez G; CALINA study group. Early life risk factors and their cumulative effects as predictors of overweight in Spanish children. Int J Public Health. 2018;63(4):501-512.

Cont…

The risk and impact of obesity are more pronounced in later years of life.

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Determinants of postnatal growth trajectory

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References: Lei X, Chen Y, Ye J, Ouyang F, Jiang F, Zhang J. The optimal postnatal growth trajectory for term small for gestational age babies: a prospective cohort study. J Pediatr. 2015. 166(1):54-8. Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

  • Birth weight
  • Gestational age
  • Race
  • Mother’s education level
  • Mother’s marital status
  • Mode of infant feeding
  • Complementary feeding
  • Dietary composition

Non-modifiable factors Modifiable factors

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Mode of Infant Feeding

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Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

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Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

Cont…

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Complementary Feeding

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  • Current WHO recommendation:

6 months of age

  • Marked changes in diet -

exposure to new foods, tastes and feeding experiences

  • May induce programming effects

that influence later health

  • utcome and also direct effects
  • n food preferences, appetite

and eating behaviour

References: Fewtrell MS. Can Optimal Complementary Feeding Improve Later Health and Development? Nestle Nutr Inst Workshop Ser. 2016;85:113-23. Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

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Complementary Feeding

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  • Some evidence suggest that very early introduction of solid foods

i.e. <3 - 4 months

  • increase risk of weight gain and childhood obesity
  • especially among formula-fed infants
  • Infants who are weaned at 6 months of age or later show slower
  • verall growth rate
  • Other factors to consider:
  • timing of breastfeeding cessation
  • food allergy risk etc.

References: Fewtrell MS. Can Optimal Complementary Feeding Improve Later Health and Development? Nestle Nutr Inst Workshop Ser. 2016;85:113-23. Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.

Cont…

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Dietary Composition

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Source: Weber M, Grote V, Closa-Monasterolo R, Escribano J, Langhendries JP, Dain E, Giovannini M, Verduci E, Gruszfeld D, Socha P, Koletzko B; European Childhood Obesity Trial Study

  • Group. Lower protein content in infant formula reduces BMI and obesity risk at school age: follow-up of a randomized trial. Am J Clin Nutr. 2014. 99(5):1041-51.
  • No significant difference in mean BMI

and obesity risk between low protein and breastfed children.

  • Adjusted odds of being obese at 6

years of age is 2.43 times higher in high protein than breastfed group.

  • More rapid weight gain in formula-fed

might be mediated through enhanced secretion of insulin and IGF-I.

  • Early adiposity rebound was observed

in high protein group; earlier adiposity rebound is associated with increased risk of later obesity.

Protein intake

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Cont…

Source: Rolland-Cachera MF, Deheeger M, Maillot M, Bellisle F. Early adiposity rebound: causes and consequences for obesity in children and adults. Int J Obes (Lond). 2006. Suppl 4:S11-7.

Age 4 to 6 years old

Adiposity rebound

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Cont…

Reference: Rolland-Cachera MF, Maillot M, Deheeger M, Souberbielle JC, Péneau S, Hercberg S. Association of nutrition in early life with body fat and serum leptin at adult age. Int J Obes (Lond). 2013. ;37(8):1116-22.

Fat intake

  • At 10 months, fat intake was negatively associated with BMI and FM at 20 years.
  • Protein intake had a positive association trend with adult subscapular skinfold,

indicating body fat at trunk site.

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Cont…

Reference: Rolland-Cachera MF, Maillot M, Deheeger M, Souberbielle JC, Péneau S, Hercberg S. Association of nutrition in early life with body fat and serum leptin at adult age. Int J Obes (Lond). 2013. ;37(8):1116-22.

  • At 2 years, fat intake was negatively associated with adult subscapular skinfold, FM and

leptin concentration at 20 years.

  • Low-fat intakes in the first 2 years of life were associated with higher body fat, particularly

at the trunk site, and higher serum leptin concentration at adult age.

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Cont…

Source: Zivkovic AM, German JB, Lebrilla CB, Mills DA. Human milk glycobiome and its impact on the infant gastrointestinal microbiota.Proc Natl Acad Sci U S A. 2011. 15;108 Suppl 1:4653-8.

Human milk composition

  • Lipids provide 45-60% of energy in human milk.
  • The lipid concentration is stable over the course of

lactation.

  • There is substantial amount of leptin in breast milk - helps

regulate body weight by modulating appetite and fat

  • xidation .

Reference: Rolland-Cachera MF, Maillot M, Deheeger M, Souberbielle JC, Péneau S, Hercberg S. Association of nutrition in early life with body fat and serum leptin at adult age. Int J Obes (Lond). 2013. ;37(8):1116-22.

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Nutrition is crucial for a child’s growth and development. Children with growth issue(s) should received tailored nutritional intervention via qualified health professionals. with undernutrition, the focus is to provide sufficient energy and nutrients to promote growth. rapid growth (accelerated growth) in early stages of life causes adverse effects. risk-balance benefit

CONCLUSION (1)

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Growth assessment and monitoring essential to be emphasised as part of routine paediatric care. monitor the progress of dietary intervention/ management on those with malnutrition/ growth faltering. follow the curve of the growth chart - as long as there is progress. to minimise adverse effects of accelerated growth/ ‘catch-up growth’.

CONCLUSION (2)

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Cont…

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