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 1
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 2
INTRODUCTION Nutrition is the cornerstone to a child’s growth and health 3
MALNUTRITION AND GROWTH ISSUES • Underweight • Overweight • Stunting • Obesity • Wasting (Overnourished) (Undernourished) 4
Statistics: Undernutrition (NHMS 2016) 5 Source: https://tech2.org/malaysia/a-unicef-study-puts-malaysias-poor-nutritional-status-under-the-spotlight/
Cont… 6 urce: https://www.thestar.com.my/news/nation/2018/11/29/report-msias-triple-burden-of-malnutrition-overweight-anaemic-and-stunted-growth/
Growth Issues - Types of undernutrition 7
Causes of Undernutrition 8 Figure: Probable risk factors for stunting, wasting, or both Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.
Consequences of Undernutrition Long term impact Short term impact • Permanent short adult • Increased morbidity and stature mortality in early childhood • Impaired cognitive e.g. infections development • Impaired behavioural • Lower income and poorer development in early life productivity e.g. motor skills, cognitive • Increased risk of NCDs in ability adulthood • Lower height at 2 years of • Depression, anxiety and age hyperactivity in adolescence 9 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.
GROWTH ASSESSMENT AND MONITORING References: Portal MyHEALTH. Ministry of Health Malaysia. http://www.myhealth.gov.my/pengawasan-tumbesaran-2/ 10 Paul Garner, Ratana Panpanich, Stuart Logan . Is routine growth monitoring effective? A systematic review of trials. Arch Dis Child 2000;82:197-201.
Cont… 11 Source: https://www.who.int/childgrowth/standards/en/
Importance of Growth Assessment and Monitoring Promote optimum growth Create awareness about growth progression Detect early growth retardation Identify those at risk of malnutrition Enhance delivery of primary health care 12 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. .
GROWTH FALTERING Undernutrition causes poor growth in children • 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 13 Source: Faltering growth in children: summary of NICE guidance. BMJ 2017;358:j4219
Pattern of Growth Faltering 14 Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.
Timing of Growth Faltering 15 Source: de Onis M & Branca F. Childhood stunting: a global perspective. Matern Child Health. 2016. Suppl 1:12-26.
Importance to rectify undernutrition Prevent growth faltering Promote recovery from period of poor growth/ ‘catch - up growth’ 16 Reference: Singhal A. Long term adverse effects of early growth acceleration or catch-up growth. 2017. Ann Nutr Metab. 70:236-240.
NUTRITIONAL INTERVENTION STUNTING WASTING Prenatal macro- and Therapeutic diet micronutrient supplementation* Promotion of breastfeeding Supplementary/ formulated foods Complementary feeding e.g. Promotion of healthy eating energy and nutrient density 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 17 Reference: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.
Source: Faltering growth in children: summary of NICE guidance. BMJ 2017;358:j4219
‘CATCH - UP GROWTH’ early growth acceleration often known as the recovery phase of growth in children (Singal 2017) 20 Reference: Singhal A. Long term adverse effects of early growth acceleration or catch-up growth. 2017. Ann Nutr Metab. 70:236-240.
New science and knowledge “ 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 21 Reference: Singhal A. Long term adverse effects of early growth acceleration or catch-up growth. 2017. Ann Nutr Metab. 70:236-240.
Infants At Risk of Later Life NCDs Prenatal environment Maternal obesity Maternal GDM LGA SGA Preterm Postnatal Growth Increased Imbalanced growth in Undernourished Large at 1 year adiposity 1st year of life (stunting, wasting) 22 Source: Eline van der Beek. 6th International Conference on Nutrition and Growth, March 7-9, 2019. Valencia, Spain.
Catch-up growth in term SGA 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. 23 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. 24 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.
Risk Factors for Later Obesity 25 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. 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 26 predictors of overweight in Spanish children. Int J Public Health. 2018;63(4):501-512.
Determinants of postnatal growth trajectory Non-modifiable Modifiable factors factors • Birth weight • Mode of infant feeding • Gestational age • Complementary feeding • Race • Dietary composition • Mother’s education level • Mother’s marital status 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. 27 166(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.
Mode of Infant Feeding 28 Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.
Cont… 29 Source: Growth in Early Life: Growth Trajectory and Assessment, Influencing Factors and Impact of Early Nutrition. 2016. John Wiley and Sons Australia Ltd.
Complementary Feeding • 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 outcome and also direct effects on food preferences, appetite and eating behaviour 30 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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