Micronutrient needs of malnourished children

Appetite and childhood malnutrition: A narrative review identifying evidence gaps between clinical practice and research

Severe Acute Malnutrition (SAM) is a critical global health issue, contributing to approximately one-half of all child mortality worldwide. SAM management guidelines recommend the use of appetite assessment determined by an "appetite test" to distinguish between complicated and uncomplicated SAM, subsequently guiding clinical decisions regarding outpatient versus inpatient care and discharge from hospital. Despite the widespread utilization of this recommendation, its validity lacks substantial evidence within the existing literature. Hence, the aims of this narrative review were to provide an overview of the SAM diagnostic and management guideline recommendations concerning the use of appetite assessment; to review the existing knowledge base supporting this clinical practice. The review identified gaps between the clinical use of appetite assessment in SAM management and the available supporting scientific evidence. Additionally, both the opportunities and challenges associated with appetite assessment methods used in clinical practice were highlighted and discussed in relation to existing literature. Further studies with more rigorous methods are needed to bridge these gaps and formulate evidence-based clinical practice. There is also a need to adapt and validate the existing appetite assessment tools to ensure they are tailored to the specific population, setting, and primary purpose of assessing appetite in children who have already developed SAM.

Satisfaction of mothers with supplementary nutritional services through Anganwadi centres in an urban area of Meerut, India

Background

Undernutrition in children under 5 years of age is still a great public health burden. Integrated child development services (ICDS) were launched with an idea of making a dent on this age-old issue. Various studies in the past have been done to identify lacunae in the programme, but very few studies are done focussing on the satisfaction of mothers with the supplementary nutrition provided through ICDS programme. The utilisation of the programme depends on various factors, one of which is client satisfaction.

Methods and Material

The Anganwadi centres of urban areas of Meerut were line-listed after taking a list of Anganwadis from the Child Development Office. There are 297 Anganwadis in urban areas of Meerut. With help of random number tables, three Anganwadis were selected, and to complete the sample of 152, 51 children from two Anganwadis and 50 from one Anganwadi centre were selected with help of simple random tables. The data thus collected were analysed using Epiinfo version 7.2.3.1.

Results

The prevalence of underweight was found to be 34.2%, wasted 19.7%, and stunted 11.2%. Among the characteristics assessed, a majority of mothers, 58.5%, were dissatisfied with the frequency at which supplementary nutrition was provided from the Anganwadis. All children were provided Take Home Ration, and 100.0% of mothers reported using it for all family members. Still 63.2% of mothers were unaware about the iron supplementation in childhood and only 65.8% of mothers had satisfactory handwashing practices.

Conclusions

In this study, a majority of mothers were dissatisfied with the frequency at which supplementary nutrition was provided to their children. Also, the prevalence of underweight children was significantly higher when mothers were not aware about the factors affecting nutrition in children. The Take Home Ration given for children was shared among family members in 100.0% families.

A qualitative assessment of facility readiness and barriers to the facility-based management of childhood severe acute malnutrition in the public healthcare settings in Bangladesh

OBJECTIVE

To assess facility readiness and identify barriers to the facility-based management of childhood severe acute malnutrition (SAM) in public healthcare settings.

DESIGN

Qualitative methods were applied to assess readiness and identify different perspectives on barriers to the facility-based management of children with SAM. Data collection was done using in-depth interviews, key informant interviews, exit interviews and pre-tested observation tools.

SETTINGS

Two tertiary care and four district hospitals in Rangpur and Sylhet Divisions of Bangladesh.

PARTICIPANTS

Healthcare professionals and caregivers of children with SAM.

RESULTS

Anthropometric tools, glucometer, medicines, F-75, F-100 and national guidelines for facility-based management of childhood SAM were found unavailable in some of the hospitals. Sitting and sleeping arrangements for the caregivers were absent in all of the chosen facilities. We identified a combination of health system and contextual barriers that inhibited the facility-based management of SAM. The health system barriers include inadequate manpower, rapid turnover of staff, increased workload, lack of training and lack of adherence to management protocol. The major facility barriers were insufficient space and unavailability of required equipment, medicines and foods for hospitalised children with SAM. The reluctance of caregivers to complete the treatment regimen, their insufficient knowledge regarding proper feeding, increased number of attendants and poverty of parents were the principal contextual barriers.

CONCLUSIONS

The study findings provide insights on barriers that are curbing the facility-based management of SAM and emphasise policy efforts to develop feasible interventions to reduce the barriers and ensure the preparedness of the facilities for effective service delivery.

Impact of Supplementary Nutrition on Undernourished Children In An Urban Area Of Meerut- A Longitudinal Study

Background: Infants and pre-school are most susceptible to undernutrition. Integrated Child Development Services is the programme focussing undernourished children by providing them supplementary nutrition. Aim& Objective: To study prevalence of undernutrition in 0-6 year old children and to study factors associated with it. To study impact of supplementary nutrition on undernourished children. Settings and Design: A longitudinal study. Methods and Material: The present longitudinal study was conducted in randomly selected Anganwadis of urban Meerut. Children found to be suffering from under nutrition were followed up at interval of six months to see the impact of supplementary nutrition provided to them at the anganwadi centre. A detailed history of relevant underlying factors responsible for causation of under nutrition were taken from mothers of these children. Statistical analysis used: chi square test was used to find out association between risk factors and undernutrition. Risk factor found statistically significant were further analysed using step wise multiple logistic regression analysis. The impact of supplementary nutrition was assessed using paired t test. Results: Iron folic acid supplementation during pregnancy, exclusive breast feeding in children, immunization and time of initiating complementary feed were found statistically significant on both chi-square and multiple logistic regression analysis. No impact of supplementary nutrition was found on anthropometric measurements of children. Conclusions: The main focus for fighting undernutrition in children (0-6 years) should be on preventing risk factors associated with mothers in antenatal period and during child rearing practices

The Evaluation and Management of Macronutrient Deficiency Dermatoses

In industrialized countries, nutritional dermatoses are likely underdiagnosed and result in increased disease morbidity and utilization of hospital resources. These findings underscore the need for physicians to be able to correctly identify these deficiencies. Nutritional dermatoses may be split into micronutrient deficiencies and macronutrient deficiencies. This article is intended to serve as a supplement to a two-part review of micronutrient deficiency dermatoses and highlights cutaneous findings in patients with protein-energy malnutrition and essential fatty acid deficiency. This article reviews the evaluation, cutaneous manifestations, and management of macronutrient deficiencies.

Could Japonica Rice Be an Alternative Variety for Increased Global Food Security and Climate Change Mitigation?

The growing importance of rice globally over the past three decades is evident in its strategic place in many countries' food security planning policies. Still, its cultivation emits substantial greenhouse gases (GHGs). The Indica and Japonica sub-species of Oryza sativa L. are mainly grown, with Indica holding the largest market share. The awareness, economics, and acceptability of Japonica rice in a food-insecure Indica rice-consuming population were surveyed. The impact of parboiling on Japonica rice was studied and the factors which most impacted stickiness were investigated through sensory and statistical analyses. A comparison of the growing climate and greenhouse gas emissions of Japonica and Indica rice was carried out by reviewing previous studies. Survey results indicated that non-adhesiveness and pleasant aroma were the most preferred properties. Parboiling treatment altered Japonica rice's physical and chemical properties, introducing gelatinization of starch and reducing adhesiveness while retaining micronutrient concentrations. Regions with high food insecurity and high consumption of Indica rice were found to have suitable climatic conditions for growing Japonica rice. Adopting the higher-yielding, nutritious Japonica rice whose cultivation emits less GHG in these regions could help strengthen food security while reducing GHGs in global rice cultivation.

Fortification of Rice Noodles with Vitamin A: Quality, Sensory Evaluation, and Enhancement of Vitamin A Intakes

Vitamin A deficiency is common in many countries where rice is the staple food. Food fortification is an important strategy to address this problem. As rice noodle is the second principal form of rice products widely consumed in Asia, rice noodles could be a potential vehicle for fortification of vitamin A. In this study, rice noodles were prepared from 0, 300, 600, 1,050, and 1,500 μg of vitamin A per 100 g of rice flour. Samples were analyzed for quality, sensory evaluation, and enhancement of vitamin A intakes. Increasing level of vitamin A fortification did not influence quality and sensory properties of the rice noodles, except for the ash content, color, and appearance of the noodles. Rice noodle that was fortified with the highest level of vitamin A was found to be the darkest in color. However, this sample received scores higher than 6 (like slightly) for appearance. Furthermore, sample fortified with the highest level of vitamin A produced rice noodles with the highest level of vitamin A retention suggesting that noodles were good vehicle for vitamin A fortification. Fortification of rice flour with 1,500 μg of vitamin A produced rice noodles with 24.88% of the RDI for vitamin A per serving and provided an effective means of enhancing vitamin A intake.

Refrigeration and child growth: What is the connection?

Child stunting in Latin America and the Caribbean (LAC) decreased from 22.9% in 1990 to 9.6% in 2017. While stunting rates in the region were falling, access to electricity and refrigeration were on the rise. Despite a large body of evidence surrounding the effects of refrigeration on food consumption, and separately of the importance of food consumption for child health and nutrition, surprisingly few studies explore the potential effects of refrigeration on child nutrition. We studied the relationship between refrigeration and child nutrition outcomes using rich panel data for 1298 low-income households with children younger than 12 months at baseline in El Alto, Bolivia. We estimated the effects of refrigerator ownership on diet and nutrition outcomes using a difference-in-difference approach. Owning a refrigerator was associated with increased food expenditures and improved child nutrition. We found evidence that households that acquired a refrigerator were more likely to buy food that requires refrigeration, and children in households that acquired refrigerators were 0.17 standard deviations taller for their age after 2 years. We also found that refrigeration was associated with a 0.26 standard deviation decline in BMI-for-age, an effect driven by increased height rather than lower weight. These results suggest that refrigeration may play a role in explaining reductions in undernutrition observed in low- and middle-income countries in recent decades.

Child Feeding Practice and Primary Health Care as Major Correlates of Stunting and Underweight among 6- to 23-Month-Old Infants and Young Children in Food-Insecure Households in Ethiopia

BACKGROUND

Child undernutrition is a major public health problem in Ethiopia. Stunting is highest in food-insecure areas and insufficient evidence may impair the design of suitable interventions.

OBJECTIVES

This study aimed to identify key factors contributing to undernutrition among 6- to 23-mo-old children.

METHODS

A community-based cross-sectional study in food-insecure areas of Amhara and Oromia regions in April-June, 2018, enrolled 464 mother-child dyads. Bivariate and multivariate logistic regression analyses were conducted.

RESULTS

The prevalence of stunting (43.1%), wasting (12.3%), and underweight (27.3%) were high. Factors significantly associated with both stunting and underweight were child age of 12-23 mo (vs 6-11 mo), female, more siblings, lack of zinc supplement for diarrhea, inadequate diet diversity, and lack of iodized salt in complementary food. Conclusions: Our findings support the need to emphasize appropriate child feeding practices and iodized salt utilization. Improvement of primary health care services related to micronutrient supplementation and family spacing also are important to address child undernutrition in the study area.

Experience in treatment of comorbid pathologies in calves in the neonatal period

The article describes an integrated approach in the treatment of hypotrophic calves with transindromal comorbid anemia. The clinical status of the calves was established and the therapeutic effect of the combined use of Carnitine chloride, Actovegin and Taurine on the metabolic status of calves with comorbid diseases in the neonatal period, restoration of hematopoiesis, energy status and reduction of imbalance of immunological parameters was studied. As a result, a decrease in the sensitivity of young animals to adverse environmental factors was found.

Food fortification with multiple micronutrients: impact on health outcomes in general population

BACKGROUND

Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

OBJECTIVES

To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

SEARCH METHODS

We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

MAIN RESULTS

We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

AUTHORS' CONCLUSIONS

The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

Combined consumption of a single high-dose vitamin A supplement with provision of vitamin A fortified oil to households maintains adequate milk retinol concentrations for 6 months in lactating Moroccan women

In Morocco, postpartum women systematically receive a single, high dose of vitamin A (VA; 200 000 IU) within the first month of giving birth and vegetable oil is fortified to increase the VA intake. The efficacy of this combined approach of supplementation and fortification for increasing maternal VA status during lactation is not known. The purpose of the study is to evaluate the effect of postpartum high dose VA supplementation and provision of VA fortified oil for household consumption on plasma and milk retinol concentrations of lactating Moroccan women during the first 6 months after giving birth. Postpartum women aged 19-40 years received a VA supplement and thereafter were randomly assigned to one of two groups to receive weekly vitamin A fortified oil (FO) or non-fortified oil (NFO) for 6 months. Serum retinol concentration was higher in the FO group than in the NFO group at 6 months after giving birth (p < 0.0001). Milk retinol per gram fat at baseline did not differ by group; by 3 months after giving birth, milk retinol per gram fat was higher in the FO group than in the NFO group (p = 0.02) and remained higher throughout the 6 months (p < 0.0001). The combination of supplementation and fortification has a more sustained impact on milk retinol concentrations than supplementation alone, which did not have a sustained impact on milk VA concentrations. The fortification approach seems to be more effective for maintaining adequate milk VA concentrations among lactating Moroccan women. Fortification seems to be a long-term solution for the problem of VA deficiency, especially among women in low-income communities.

Nutrition-specific and sensitive drivers of poor child nutrition in Kilte Awlaelo-Health and Demographic Surveillance Site, Tigray, Northern Ethiopia: implications for public health nutrition in resource-poor settings

Background: Child undernutrition is a prevalent health problem and poses various short and long-term consequences. Objective: This study seeks to investigate the burden of child undernutrition and its drivers in Kilte Awlaelo-Health and Demographic Surveillance Site, Tigray, northern Ethiopia. Methods: In 2015, cross-sectional data were collected from 1,525 children aged 6-23 months. Maternal and child nutritional status was assessed using the mid upper arm circumference. Child's dietary diversity score was calculated using 24-hours dietary recall method. Log-binomial regression and partial proportional odds model were fitted to examine the drivers of poor child nutrition and child dietary diversity (CDD), respectively. Results: The burden of undernutrition and inadequate CDD was 13.7% (95% CI: 12.1-15.5%) and 81.3% (95%CI: 79.2-83.1%), respectively. Maternal undernutrition (adjusted prevalence ratio, adjPR = 1.47; 95%CI: 1.14-1.89), low CDD (adjPR = 1.90; 95%CI: 1.22-2.97), and morbidity (adjPR = 1.83; 95%CI: 1.15-2.92) were the nutrition-specific drivers of child undernutrition. The nutrition-sensitive drivers were poverty (compared to the poorest, adjPR poor = 0.65 [95%CI:0.45-0.93], adjPR medium = 0.64 [95%CI: 0.44-0.93], adjPR wealthy = 0.46 [95%CI: 0.30-0.70], and adjPR wealthiest = 0.53 [95%CI: 0.34-0.82]), larger family size (adjPR = 1.10; 95%CI: 1.02-1.18), household head's employment insecurity (adjPR = 2.10; 95%CI: 1.43-3.09), and residing in highlands (adjPR = 1.93; 95%CI: 1.36-2.75). The data show that higher CDD was positively associated with wealth (OR wealthy = 3.06 [95%CI: 1.88-4.99], OR wealthiest = 2.57 [95%CI: 1.53-4.31]), but it was inversely associated with lack of diverse food crops production in highlands (OR = 0.23; 95%CI: 0.10-0.57]). Conclusions: Our findings suggest that the burden of poor child nutrition is very high in the study area. Multi-sectoral collaboration and cross-disciplinary interventions between agriculture, nutrition and health sectors are recommended to address child undernutrition in resource poor and food insecure rural communities of similar settings.

First national iodine survey in Madagascar demonstrates iodine deficiency

Universal salt iodization (USI) was adopted in Madagascar in 1995 within the framework of a worldwide policy to eliminate iodine deficiency disorders. Despite early USI adoption, there are no representative data on the iodine status of the Malagasy population. The aims of this study were to determine the iodine status of the Malagasy population and to assess the use of adequately iodized salt among households. We randomly sampled women of reproductive age (WRA) using a national, two-stage, stratified cross-sectional survey in 2014. Casual urine from WRA and salt samples from the household containing WRA were collected to measure urinary iodine concentration (UIC) and to assess household salt iodine content. Data from 1,721 WRA in 1,128 households were collected and analysed. The national median UIC was 46 μg L^-1 (interquartile range [IQR]: 13-98 μg L^-1 ), indicating a moderate iodine deficiency. The median UIC was 53 μg L^-1 (IQR: 9-89 μg L^-1 ) in pregnant women and 46 μg L^-1 (IQR: 13-98 μg L^-1 ) in non-pregnant women. The national median iodine concentration of household salt was 10 mg kg^-1 (IQR: 6.3-15.8 mg kg^-1 ) and 26.2% (95% CI [22.1, 31.0]) of households containing WRA used adequately iodized salt (≥15 mg kg^-1 ). Women living in households with adequately iodized salt had higher median UIC (72 vs. 50 μg L^-1 ). Iodine status was significantly lower among women from low socio-economic households. Madagascar's USI program needs to be revitalized. Implementing strategies to provide adequately iodized salt and enhancing iodized salt legislation to prevent severe complications resulting from iodine deficiency in the Malagasy population are essential.

The WHO recommendation of home fortification of foods with multiple-micronutrient powders in children under 2 years of age and its effectiveness on anaemia and weight: a pragmatic cluster-randomized controlled trial

OBJECTIVE

To assess under real community settings the effectiveness of the WHO strategy of home fortification of foods (HFF) with multiple-micronutrient powders on Hb change, anaemia and weight in children.

DESIGN

A pragmatic cluster-randomized controlled trial.

SETTING

Forty villages in the Nioro Circle in Mali and 722 children aged 6-23 months were randomized to the intervention or control group. The intervention consisted of a daily dose of multiple-micronutrient powder for 3 months; in the control group, no supplement was given. In both groups, mothers received group education on child complementary feeding. Changes in weight, Hb concentration and anaemia were assessed as primary outcomes at baseline and 3 months. The HFF effect was determined using regression analyses and quantile regression with standard errors taking account of the cluster design.

SUBJECTS

Children aged 6-23 months.

RESULTS

Overall prevalence of anaemia in the sample was high: 90 %. HFF provided a modest but statistically significant Hb change v. no intervention (0·50 v. 0·09 g/dl, P=0·023). Prevalence of anaemia changed little: 91·3-85·8 % (P=0·04) in the intervention group v. 88·1-87·5 % % (P=0·86) in the control group. Proportion of severe anaemia was reduced by 84 % (from 9·8 to 1·6 %) in the intervention group, but increased in the control group (from 8·5 to 10·8 %). No effect was observed on weight.

CONCLUSIONS

The WHO HFF strategy to fight anaemia showed a modest change on Hb concentration and significantly reduced the rate of severe anaemia.

Malnutrition in South Asia-A Critical Reappraisal

Malnutrition continues to be a major public health challenge especially in South Asian developing countries. The aim of the present review is to spotlight the magnitude of the prevalence of malnutrition and its dynamics in South Asian region and to suggest potential approaches for the prevention and control of this issue of public health significance. An extensive review of literature, covering malnutrition and its determinants, health and economic consequences and pragmatic preventive strategies was performed on computer based bibliographic databases (PubMed, Google Scholar, Scopus, Medline and Sciencedirect.com ) to retrieve abstracts and full texts for India, Pakistan, Bangladesh, Sri Lanka and Nepal. All relevant titles and abstracts were examined and evaluated for malnutrition and its prevalence in South Asia. The results revealed malnutrition to be a major public health problem and a potential cause of high disease burden and mortality in South Asia. Compelling evidence suggests malnutrition to be the leading cause of stunting, wasting and underweight with drastic economic consequences among vulnerable populations. Reduced cognitive performance and low productivity have also been associated with micronutrients malnutrition. Suboptimal breastfeeding, inadequate food supply, micronutrient deficiencies, low household income, poor health care system, increased healthcare costs, illiteracy, unhygienic and substandard living, inappropriate child's care and the caregiver, food insecurity and on top of that vicious cycle of poverty, have been recognized as principal indicators for growing malnutrition prevalence in South Asia. Global organizations, local governments, program managers, NGOs, academia, industry in particular and the society at large need to take up the challenge to completely confiscate malnutrition from the region for economic prosperity and a healthier future.

Evaluation of Trace Elements and Their Relationship with Growth and Development of Young Children

This study was conducted to assess the levels of trace elements and their relationship with growth and development of children in Shanghai, China, to offer scientific evidence for supplementing trace elements in children. A stratified, clustered, random sampling method was used in the study. Blood samples were taken from 2141 Shanghai children from 0 to 6.0 years old, and the concentrations of zinc (Zn), calcium (Ca), iron (Fe), copper (Cu), and magnesium (Mg) were measured using inductively coupled plasma mass spectrometry (ICP-MS). Nutritional status was determined and Z-scores of anthropometric parameters, such as height for age (HFA), weight for age (WFA), and body mass index (BMI) were calculated, indicated by HAZ, WAZ, and BMIZ, respectively. The overall median blood levels of Zn, Ca, Fe, Cu, and Mg were 8.83, 79.02, 9.49, 1.04, and 15.45 mg/L, respectively. Fe, Cu, and Mg increased with age and Zn, Fe, and Cu differed by sex. HAZ and WAZ were positively correlated with Zn (r (2) = 0.072 and 0.053, respectively; P < 0.05). Trace elements were significantly related to children's growth and development. Dietary supplementation and screening of nutritional states are potential solutions to improve children's growth and development.

Developmental risk factors in Vietnamese preschool-age children: Cross-sectional survey

BACKGROUND

Early childhood development (ECD) strongly influences children's basic learning, school success, economic participation, social citizenry and health. Although some risk factors related to childhood development are documented, further exploration is necessary considering various sociodemographic, nutritional, and psychosocial factors. This study investigated factors affecting ECD in Vietnamese preschoolers.

METHODS

We used data from the representative, cross-sectional round of the Vietnam Multiple Indicator Clusters Survey 2011. Early Childhood Development Index questionnaires were administered to mothers of all children aged 36-59 months in the household (n = 1459). Descriptive statistics and multivariate logistic regression were used in the analysis.

RESULTS

In Vietnam, 17.2% of children did not reach their full developmental potential within the first 5 years. Children who had been breast-fed (AOR, 2.78; 95%CI: 1.28-6.02), attended preschool (AOR, 1.75; 95%CI: 1.28-2.39), were of major ethnicity (AOR, 2.41; 95%CI: 1.55-3.74), had a mother with secondary or higher education (AOR, 1.69; 95%CI: 1.19-2.38) and had relatives who engaged with them in four or more activities that promote learning (AOR, 1.55; 95%CI: 1.13-2.14) were more likely to have a normal developmental trajectory. Furthermore, children who experienced physical punishment and stunting were 0.69-fold (95%CI: 0.51-0.95) and 0.71-fold (95%CI: 0.51-0.98) less likely to be on track for ECD, respectively.

CONCLUSIONS

The risk factors associated with delayed ECD were low level of maternal education; family ethnicity; lack of preschool attendance; relatives who did not engage with them in learning; physical punishment; not being breast-fed; and stunting.

Nutritional status in children with Shwachman-diamond syndrome

OBJECTIVE

In Shwachman-Diamond syndrome (SDS), pancreatic insufficiency can lead to malabsorption of fat-soluble vitamins and trace elements. The aim of this study was to assess the serum concentrations of vitamins A and E, zinc, copper, and selenium and their deficiencies.

METHODS

This retrospective review was performed in 21 children (12 were male; median age, 7.8 years) with genetically confirmed SDS at a tertiary pediatric hospital. Pancreatic enzyme replacement therapy (PERT) and vitamin or trace elements supplements were documented.

RESULTS

Twenty patients (95%) had pancreatic insufficiency receiving PERT, 10 (47%) had a combined vitamin and trace element deficiency, 6 (29%) had an isolated vitamin deficiency, and 4 (19%) had an isolated trace element deficiency. Vitamins A and E deficiency occurred in 16 (76%) and 4 (19%) of 21, respectively. Low serum selenium was found in 10 (47%), zinc deficiency in 7 (33%), and copper deficiency in 5 (24%). Eleven patients (52%) were on multivitamin supplementation, and 2 (10%) on zinc and selenium supplements. No statistical differences were found between repeated measurements for all micronutrients.

CONCLUSIONS

More than 50% of the children had vitamin A and selenium deficiencies despite adequate supplementation of PERT and supplements. Micronutrients should be routinely measured in SDS patients to prevent significant complications.

The role of health systems and policy in producing behavior and social change to enhance child survival and development in low- and middle-income countries: an examination of the evidence

Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.

Effectiveness of Micronutrient Powders (MNP) in women and children

Introduction

More than 3.5 million women and children under five die each year in poor countries due to underlying undernutrition. Many of these are associated with concomitant micronutrient deficiencies. In the last decade point of use or home fortification has emerged to tackle the widespread micronutrient deficiencies. We in this review have estimated the effect of Micronutrient Powders (MNPs) on the health outcomes of women and children.

Methods

We systematically reviewed literature published up to November 2012 to identify studies describing the effectiveness of MNPs. We used a standardized abstraction and grading format to estimate the effect of MNPs by applying the standard Child Health Epidemiology Reference Group (CHERG) rules.

Results

We included 17 studies in this review. MNPs significantly reduced the prevalence of anemia by 34% (RR: 0.66, 95% CI: 0.57-0.77), iron deficiency anemia by 57% (RR: 0.43, 95% CI: 0.35-0.52) and retinol deficiency by 21% (RR: 0.79, 95% CI: 0.64, 0.98). It also significantly improved the hemoglobin levels (SMD: 0.98, 95% CI: 0.55-1.40). While there were no statistically significant impacts observed for serum ferritin and zinc deficiency. Our analysis shows no impact of MNPs on various anthropometric outcomes including stunting (RR: 0.92, 95% CI: 0.81, 1.04), wasting (RR: 1.13, 95% CI: 0.91, 1.40), underweight (RR:0.96, 95% CI: 0.83, 1.10), HAZ (SMD: 0.04, 95% CI: -0.13, 0.22), WAZ (SMD: 0.05, 95% CI: -0.12, 0.23) and WHZ (SMD: 0.04, 95% CI: -0.13, 0.21), although showing favorable trends. MNPs were found to be associated with significant increase in diarrhea (RR: 1.04, 95% CI: 1.01, 1.06) with non-significant impacts on fever and URI.

Conclusion

Our analysis of the effect of MNPs in children suggests benefit in improving anemia and hemoglobin however the lack of impact on growth and evidence of increased diarrhea requires careful consideration before recommending the intervention for implementing at scale.

Micronutrient fortification of food and its impact on woman and child health: a systematic review

BACKGROUND

Vitamins and minerals are essential for growth and metabolism. The World Health Organization estimates that more than 2 billion people are deficient in key vitamins and minerals. Groups most vulnerable to these micronutrient deficiencies are pregnant and lactating women and young children, given their increased demands. Food fortification is one of the strategies that has been used safely and effectively to prevent vitamin and mineral deficiencies.

METHODS

A comprehensive search was done to identify all available evidence for the impact of fortification interventions. Studies were included if food was fortified with a single, dual or multiple micronutrients and impact of fortification was analyzed on the health outcomes and relevant biochemical indicators of women and children. We performed a meta-analysis of outcomes using Review Manager Software version 5.1.

RESULTS

Our systematic review identified 201 studies that we reviewed for outcomes of relevance. Fortification for children showed significant impacts on increasing serum micronutrient concentrations. Hematologic markers also improved, including hemoglobin concentrations, which showed a significant rise when food was fortified with vitamin A, iron and multiple micronutrients. Fortification with zinc had no significant adverse impact on hemoglobin levels. Multiple micronutrient fortification showed non-significant impacts on height for age, weight for age and weight for height Z-scores, although they showed positive trends. The results for fortification in women showed that calcium and vitamin D fortification had significant impacts in the post-menopausal age group. Iron fortification led to a significant increase in serum ferritin and hemoglobin levels in women of reproductive age and pregnant women. Folate fortification significantly reduced the incidence of congenital abnormalities like neural tube defects without increasing the incidence of twinning. The number of studies pooled for zinc and multiple micronutrients for women were few, though the evidence suggested benefit. There was a dearth of evidence for the impact of fortification strategies on morbidity and mortality outcomes in women and children.

CONCLUSION

Fortification is potentially an effective strategy but evidence from the developing world is scarce. Programs need to assess the direct impact of fortification on morbidity and mortality.

Global nutrition epidemiology and trends

In the year 2011, 6.9 million children under the age of 5 years died worldwide, one third of them related to increased susceptibility to illnesses due to undernutrition. An estimated 178 million children under 5 years are stunted, 55 million are wasted, and 19 million of these are severely affected and are at a higher risk of premature death, the vast majority being from sub-Saharan Africa and South-Central Asia. Globally, over 2 billion people are at risk for vitamin A, iodine, and/or iron deficiency. Other micronutrient deficiencies of public health concern include zinc, folate, and the B vitamins. The risk factors for undernutrition include low birth weight, inadequate breastfeeding, improper complementary feeding, and recurrent infections. Infectious diseases often coexist with micronutrient deficiencies and exhibit complex interactions leading to the vicious cycle of malnutrition and infections. Diarrhea along with the poor selection and intake of complementary food are the major contributors to undernutrition. Possible strategies to combat malnutrition include promotion of breastfeeding, dietary supplementation of micronutrients, prevention of protein-energy malnutrition, and improvement in the standard of preparation and hygiene of available weaning foods. The universal coverage with the full package of these proven interventions at observed levels of program effectiveness could prevent about one quarter of child deaths under 36 months of age and reduce the prevalence of stunting at 36 months by about one third. The median coverage rate of interventions along the continuum of care for Countdown countries has however been ≥80% for vaccination and vitamin A supplementation. However, for several interventions, including early initiation and exclusive breastfeeding below 6 months of age and case management of childhood illnesses, the median coverage rate hovers at or below 50%. This suggests that interventions requiring strong health systems or behavior change appear to be stalled and need to be re-examined to find more effective ways of delivery.

Meeting the challenges of micronutrient malnutrition in the developing world

BACKGROUND

Malnutrition still remains one of the major public health challenges, particularly in developing countries. Major risk factors for undernutrition such as suboptimal breastfeeding and micronutrient deficiencies (vitamin A and zinc) are responsible for more than one-third of all under five child deaths and 11% of the global total disease burden.

SOURCES OF DATA

Several strategies have been employed to supplement micronutrients. These include education, dietary modification, food provision, supplementation and fortification either alone or in combination.

AREAS OF AGREEMENT

Supplementation is the most widely practiced intervention while fortification can also be a potentially cost-effective public health intervention and target a larger population through a single strategy. Universal coverage with the full bundle of interventions including micronutrient provision, complementary foods, treatments for worms and diarrheal diseases and behavior change programs package could be the way forward in achieving the Millennium Development Goals (MDGs).

AREAS OF CONTROVERSY

Bio-fortification and agricultural interventions including home and school gardening are relatively newer strategies and require further research as they have the potential to impact nutritional status of populations at large.

GROWING POINTS

Effectiveness of the various interventions is well recognized; however, consensus needs to be built around approaches to scale up coverage and delivery strategies to reduce disparities and provide equitable access.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future studies should focus on evaluating various approaches to address malnutrition with a standard methodology and defined outcomes. This will help gauge the actual morbidity and mortality impacts of these specific interventions and the long-term viability of these programs. On a broader scale, strategies to address food insecurity and poverty alleviation are the key as these are complex sustainable development issues, linked to health through malnutrition, but also to sustainable economic development, environment and trade.

Practical dietary management of protein energy malnutrition in young children with cow's milk protein allergy

Cow's milk protein allergy (CMPA) affects between 1.9 and 4.9% of infants and young children. This food allergy requires the complete elimination of cow's milk and its derivatives, impacting on nutritional status. The risk of having protein energy malnutrition (PEM) in children with CMPA has been well documented. In 2007, the World Health Organisation published guidelines on the dietary management of PEM, which has impacted on the recommendations and composition on specialist feeds for many chronic diseases, but not on CMPA. The main change in management of the child with PEM is the protein energy ratio and energy requirements. The ideal protein energy ratio lies between 8.9 and 11.5%, which would ensure a deposition of about 70% lean and 30% fat mass. In addition, for optimal catch-up growth between 5 and 10 g/kg/day, energy requirements should be between 105 and 126 kcal/kg/day. Although most current hypoallergenic formulas fall well within the recommendation for protein, there is a problem in achieving energy requirements. As a result, modular additions are often made, disturbing the protein energy ratio or feeds are concentrated, which impacts on osmolality. We therefore aimed to review current guidelines on PEM and how these can be applied in the management of the malnourished child with CMPA.

Biofortification for combating 'hidden hunger' for iron

Micronutrient deficiencies are responsible for so-called 'hidden undernutrition'. In particular, iron (Fe) deficiency adversely affects growth, immune function and can cause anaemia. However, supplementation of iron can exacerbate infectious diseases and current policies of iron therapy carefully evaluate the risks and benefits of these interventions. Here we review the approaches of biofortification of valuable crops for reducing 'hidden undernutrition' of iron in the light of the latest nutritional and medical advances. The increase of iron and prebiotics in edible parts of plants is expected to improve health, whereas the reduction of phytic acid concentration, in crops valuable for human diet, might be less beneficial for the developed countries, or for the developing countries exposed to endemic infections.

Evidence-based prevention of childhood malnutrition

PURPOSE OF REVIEW

Childhood malnutrition is prevalent in developing countries and contributes to one-third of all deaths in these countries. There have been advances in prevention of childhood malnutrition and the purpose of this article was to review the current evidence in the field.

RECENT FINDINGS

Multiple micronutrient (MMN) supplements during pregnancy reduce the incidence of maternal anemia and small for gestational-age babies. Recent evidence suggest that combined supplementation of MMNs with protein energy supplement is more effective than MMN supplementation alone. It is now recommended that HIV-infected mothers can exclusively breast-feed their infants for 6 months when the mother or infant is on effective antiretroviral therapy. Home fortification of complementary foods reduces the prevalence of anemia in infancy and combined supplementation of MMNs with lipid-based supplements improves growth in young children. Ready-to-use therapeutic foods have been successfully used to manage severe acute malnutrition in the community. Zinc supplementation is associated with a reduction in diarrhea and respiratory disease morbidity and improves linear growth. Vitamin A supplementation decreases the incidence of diarrhea and measles. Water supply, sanitation, and hygiene are important for the prevention of malnutrition because of their direct impact on infectious disease.

SUMMARY

There is clear evidence on the causes and consequences of malnutrition as well as effective interventions to prevent undernutrition. The next step is to implement these packages of interventions at large scale. A global effort is required that should entail unified and compelling advocacy among governments, lead organizations, and institutions.

Nutritional deficiencies in the developing world: current status and opportunities for intervention

Several contributory factors such as poverty, lack of purchasing power, household food insecurity, and limited general knowledge about appropriate nutritional practices increase the risk of undernutrition in developing countries. The synergistic interaction between inadequate dietary intake and disease burden leads to a vicious cycle that accounts for much of the high morbidity and mortality in these countries. Three groups of underlying factors contribute to inadequate dietary intake and infectious disease: inadequate maternal and child care, household food insecurity, and poor health services in an unhealthy environment.

Essential role of vitamin C and zinc in child immunity and health

With the progressive elimination of dietary protein-energy deficits, deficiencies of micronutrients are emerging as the limiting factors in ensuring children's optimal health. Data from several countries in Asia and Latin America indicate that deficiencies of vitamin C and zinc continue to be at alarming levels. This article reviews the roles of vitamin C and zinc in supporting children's growth and development, with a particular focus on the complementary roles they play in supporting immune functions and combating infections. The contemporary relevance of vitamin C and zinc deficiency in the Asian and Latin American regions, both undergoing a rapid nutritional transition, are also discussed. Overall, there is increasing evidence that deficiency of vitamin C and zinc adversely affects the physical and mental growth of children and can impair their immune defences. Nutrition should be the main vehicle for providing these essential nutrients; however, supplementation can represent a valid support method, especially in developing regions.

Effects of combination of zinc and vitamin A supplementation on serum fasting blood sugar, insulin, apoprotein B and apoprotein A-I in patients with type I diabetes

BACKGROUND AND AIM

There is accumulating evidence that shows the metabolism of zinc and vitamin A are altered in diabetes mellitus type I (DMTI), thus the present study was conducted to evaluate the effects of combination of zinc and vitamin A supplementation on serum fasting blood sugar (FBS), insulin, apoprotein B and apoprotein A-I in patients with DMTI.

DESIGN

Forty-eight, 7-year-old to 20-year-old patients with at least 2 years of DMTI history, without any metabolic condition or medicine intake with insulin treatment, participated in a randomized double-blind clinical trial for 12 weeks. They were divided into zinc and vitamin A (VAZ)-supplemented (10 mg elemental zinc per day and one-half of a 25,000 IU vitamin A tablet every other day) and/or placebo groups after matching for sex, age and DMTI duration. Nutrient intake was estimated using 24 h recall and was analyzed by food processor program. Serum apoproteins B and A-I, FBS and insulin levels were determined at the beginning and end of the trial.

RESULTS

There was significant increase in apoprotein A-I (P < 0.0001) and a significant decrease in apoprotein B (P < 0.0001) and apoprotein B/apoprotein A-I ratio (P < 0.0001) at the end of the study compared with baseline values in the VAZ group but apoprotein A-I had a significant increase (P < 0.0001) and the apoprotein B/apoprotein A-I ratio had a significant decrease (P = 0.02) at the end of study in the VAZ group compared with the control group

CONCLUSION

It seems that combined zinc and vitamin A supplementation can improve serum apoprotein A-I, apoprotein B and the apoprotein B/apoprotein A-I ratio in patients with DMTI.

Effect of multiple micronutrient supplementation on survival of HIV-infected children in Uganda: a randomized, controlled trial

BACKGROUND

Micronutrient deficiencies compromise the survival of HIV-infected children in low-income countries. We assessed the effect of multiple micronutrient supplementation on the mortality of HIV-infected children in Uganda.

METHODS

In a randomized, controlled trial, 847 children aged one to five years and attending HIV clinics in Uganda were stratified by antiretroviral therapy (ART, n = 85 versus no ART, n = 762). The children were randomized to six months of either: twice the recommended dietary allowance of 14 micronutrients as the intervention arm (vitamins A, B1, B2, niacin, B6, B12, C, D and E, folate, zinc, copper, iodine and selenium); or the standard recommended dietary allowance of six multivitamins (vitamins A, D2, B1, B2, C and niacin) as a comparative "standard-of-care" arm. Mortality was analyzed at 12 months of follow up using Kaplan Meier curves and the log rank test.

RESULTS

Mortality at 12 months was 25 out of 426 (5.9%) children in the intervention arm and 28 out of 421 (6.7%) in the comparative arms: risk ratio 0.9 (95% CI 0.5 - 1.5). Two out of 85 (2.4%) children in the ART stratum died compared with 51 out of 762 (6.7%) in the non-ART stratum. Of those who died in the non-ART stratum, 25 of 383 (6.5%) were in the intervention arm and 26 of 379 (6.9%) in the comparative arm; risk ratio 1.0 (95% CI 0.6 - 1.6). There was no significant difference in survival at 12 months (p = 0.64, log rank test). In addition, there was no significant difference in mean weight-for-height at 12 months; 0.70 +/- 1.43 (95% CI 0.52 - 0.88) for the intervention versus 0.59 +/- 1.15 (95% CI 0.45 - 0.75) in the comparative arm. The mean CD4 cell count; 1024 +/- 592 (95% CI 942 - 1107) versus 1060 +/- 553 (95% CI 985 - 1136) was also similar between the two groups.

CONCLUSIONS

Twice the recommended dietary allowance of 14 micronutrients compared with a standard recommended dietary allowance of six multivitamins for six months was well tolerated, but it did not significantly alter mortality, growth or CD4 counts. Future intervention studies should carefully consider: (1) the composition and dosing of the supplements; and (2) the power needed to detect a difference between arms.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00122941.

Viewpoint: childhood undernutrition: a failing global priority

Undernutrition remains a significant underlying cause of death among children worldwide. Although alleviating hunger is part of the first United Nation's Millennium Development Goal and a declared global priority, undernutrition continues to be prevalent in low-income and middle-income countries throughout the world. The authors review the problem and policies and recommend how, particularly in this time of global economic difficulties, to improve policies to prevent undernutrition. They advocate even greater urgency.

Pediatric lymphoma: a 10-year experience at a tertiary care hospital in Pakistan

Lymphoma is the third most common childhood malignancy. Less information is available on this disease and its outcome from our country. We present here a single institute experience. A retrospective study was carried out at Aga Khan University Hospital, Karachi on children (<15 y) diagnosed with lymphoma from 1998 to 2007. Sixty-eight patients were identified. Fifty-one children were diagnosed as non-Hodgkin lymphoma (NHL). Mean age of presentation was 8.4 years with male-to-female ratio of 5.8 : 1. Most common histopathologic subtype of NHL was Burkitt lymphoma (55%). Abdominal mass was the main presenting feature of Burkitt and diffuse large B cell lymphoma. T-lymphoblastic lymphoma presented mainly as mediastinal mass. Ten children died, 4 secondary to tumor lysis syndrome, 5 because of disease progression, and 1 with chemotherapy-induced toxicity. One-third of the patients left without treatment. Seventeen children were diagnosed as Hodgkin lymphoma with mixed cellularity as the commonest subtype (65%). Overall survival of children with NHL and Hodgkin lymphoma was 62% and 94%, respectively. A greater proportion of NHL, advanced stage, and profound male preponderance were observed. Improvement in survival can only be achieved with increasing awareness, identifying and tackling causes of abandonment, early referral, and better supportive care.

Understanding the role of nutrition in the brain and behavioral development of toddlers and preschool children: identifying and addressing methodological barriers

The preschool years (i.e. 1-5 years of age) is a time of rapid and dramatic postnatal brain development (i.e. neural plasticity), and of fundamental acquisition of cognitive development (i.e. working memory, attention and inhibitory control). Also, it is a time of transition from a direct maternal mediation/selection of diet-based nutrition to food selection that is more based on self-selection and self-gratification. However, there have been fewer published studies in preschool children than in infants or school-aged children that examined the role of nutrition in brain/mental development (125 studies versus 232 and 303 studies, respectively during the last 28 years). This may arise because of age-related variability, in terms of individual differences in temperament, linguistic ability, and patterns of neural activity that may affect assessment of neural and cognitive development in pre-school children. In this review, we suggest several approaches for assessing brain function in children that can be refined. It would be desirable if the discipline developed some common elements to be included in future studies of diet and brain function, with the idea that they would complement more targeted measures based on time of exposure and understanding of data from animal models. Underlining this approach is the concept of 'window of sensitivity' during which nutrients may affect postnatal neural development: investigators and expert panels need to look specifically for region-specific changes and do so with understanding of the likely time window during which the nutrient was, or was not available.

Protein energy malnutrition

Protein energy malnutrition (PEM) is a common problem worldwide and occurs in both developing and industrialized nations. In the developing world, it is frequently a result of socioeconomic, political, or environmental factors. In contrast, protein energy malnutrition in the developed world usually occurs in the context of chronic disease. There remains much variation in the criteria used to define malnutrition, with each method having its own limitations. Early recognition, prompt management, and robust follow up are critical for best outcomes in preventing and treating PEM.