Family influences on child nutritional outcomes in Nairobi's informal settlements.

BACKGROUND: Improving child nutritional status is an important step towards achieving the Sustainable Development Goals 2 and 3 in developing countries. Most child nutrition interventions in these countries remain variably effective because the strategies often target the child's mother/caregiver and give limited attention to other household members. Quantitative studies have identified individual level factors, such as mother and child attributes, influencing child nutritional outcomes. METHODS: We used a qualitative approach to explore the influence of household members on child feeding, in particular, the roles of grandmothers and fathers, in two Nairobi informal settlements. Using in-depth interviews, we collected data from mothers of under-five children, grandmothers, and fathers from the same households. RESULTS: Our findings illustrate that poverty is a root cause of poor nutrition. We found that mothers are not the sole decision makers within the household regarding the feeding of their children, as grandmothers appear to play key roles. Even in urban informal settlements, three-generation households exist and must be taken into account. Fathers, however, are described as providers of food and are rarely involved in decision making around child feeding. Lastly, we illustrate that promotion of exclusive breastfeeding for 6 months, as recommended by the World Health Organization, is hard to achieve in this community. CONCLUSIONS: These findings call for a more holistic and inclusive approach for tackling suboptimal feeding in these communities by addressing poverty, targeting both mothers and grandmothers in child nutrition strategies, and promoting environments that support improved feeding practices such as home-based support for breastfeeding and other baby-friendly initiatives.

Clinical significance of neuropsychological improvement after supplementation with omega-3 in 8-12 years old malnourished Mexican children: a randomized, double-blind, placebo and treatment clinical trial.

It has been shown that supplementation with omega-3 improves cognitive performance, especially in infants and toddlers, but it is unknown whether these results are effective in older malnourished children. The aims of this study, therefore, were to investigate the omega-3 supplementation effects in 8- to 12-year-old children and to know which neuropsychological functions improve after three months of intervention in a sample of Mexican children with mild to moderate malnutrition. This study was a randomized, double-blind, treatment and placebo study of 59 children aged 8-12 years who were individually allocated to 2 groups. The duration of the intervention lasted 3 months. Neuropsychological performance was measured at baseline and at 3 months. Results show that more than 50% of children in the treatment group had greater improvement in 11 of the 18 neuropsychological variables studied. Processing speed, visual-motor coordination, perceptual integration, attention and executive function showed improvement in more than 70% of the omega-3 supplemented children. This trial was registered at clinicaltrials.gov as NCT01199120.

Annual Research Review: Improved nutrition--pathway to resilience.

BACKGROUND: Early child nutritional deficiencies are prevalent in low- and middle-countries with consequences linked not only to poor survival and growth, but also to poor development outcomes. Children in disadvantaged communities face multiple risks for nutritional deficiencies, yet some children may be less susceptible or may recover more quickly from malnutrition. A greater understanding is needed about factors which moderate the effects of nutrition-related risks and foster resilience to protect against or ameliorate poor development outcomes. METHODS: A literature review was undertaken from August to December 2011 and updated in August 2012. Key word searches using terms Nutrition, Malnutrition, Child Development, Responsive Care, Stimulation, Low and Middle Income Countries and Resilience were undertaken using PubMed and Psychinfo. RESULTS: Dietary adequacy is critical for growth and development, but current evidence indicates that nutrition supplementation alone is insufficient to foster resilience to protect against, mitigate, and recover from nutritional threats and to promote healthy development. The combination of nutrition interventions with stimulation and responsive care is necessary. Combined nutrition and psychosocial stimulation approaches can potentially work effectively together to promote protective factors and mitigate risks for poor cognitive, motor, social, and affective functioning helping children to adapt in times of adversity. However, there are gaps in our existing knowledge to combine nutrition and psychosocial stimulation interventions effectively and promote these interventions at scale. CONCLUSIONS: Research needs to address barriers at the level of family, community, programme, and policy which have prevented thus far the uptake of combined nutrition and psychosocial intervention strategies. Further investigations are needed on how to provide support to caregivers, enabling them to implement appropriate care for feeding and stimulation. Finally, the effect of combined interventions on pathways of care and protective mediators that foster resilience need to be better understood to determine focus areas for content of combined intervention curricula which help families in high-risk settings.

[Eat a citrus fruit, stay healthy--a case report of scurvy].

Scurvy is a disease that results from a vitamin C deficient diet. Since vitamin C is available in many food products, and especially in citrus fruits, the disease is rare in developed countries. Clinical manifestations of scurvy include general weakness, cutaneous and gum bleeding, pain in the lower limbs and inability to stand and walk (pseudo paralysis). The diagnosis of scurvy requires a high level of clinical suspicion, typical radiographic features and low Levels of vitamin C in the plasma. We report a case of a 7-year-old patient with a medical history of hydrocephalus, failure to thrive and severe psychomotor retardation due to complications of prematurity. On admission she had gum bleeding, severe anemia, pain in the lower limbs and refused to stand and walk. According to her parents, her diet was restricted, without vegetables or fruit consumption. Our investigation ruled out coagulopathy, malignancy and infection. Serum vitamin C levels were low and radiographic findings were consistent with the diagnosis of scurvy. The patient improved rapidly after the initiation of vitamin C supplements. Despite being rare, scurvy should be considered in the differential diagnosis of bleeding and pain in the lower limbs, especially in a malnourished patient.

Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomised trial.

BACKGROUND/OBJECTIVE: Psychosocial stimulation (PS) and food supplementation (FS) improve development of malnourished children. This study evaluates the effects of a community-based approach of PS and FS on growth and development of severely malnourished children. SUBJECTS/METHODS: Severely underweight hospitalised children aged 6-24 months (n = 507) were randomly allocated on discharge to five groups: (i) PS, (ii) FS, (iii) PS+FS, (iv) clinic-control and (v) hospital-control. PS included play sessions and parental counselling on child development. This was done at each fortnightly follow-up visit, that is, every second week, for 6 months at community clinics. FS included distribution of cereal-based food packets (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplementation, health-education and growth monitoring. Children's development was assessed using revised version of Bayley Scales of Infant Development at baseline and after 3 and 6 months of intervention. Anthropometry was measured using standard procedure. RESULTS: Comparing groups with any stimulation with those with no stimulation there was a significant effect of stimulation on children's mental development index (group*session interaction P = 0.037, effect size = 0.37 s.d.) and weight-for-age Z-score (group*session interaction P = 0.02, effect size=0.26 s.d.). Poor levels of development and nutritional status were sustained, however, due to their initial very severe malnutrition. There was no effect on motor development and linear growth. CONCLUSION: Children receiving any stimulation showed a significant benefit to mental development and growth in weight. More intensive intervention with longer duration is needed to correct their poor developmental levels and nutritional status.

Early childhood stunting is associated with poor psychological functioning in late adolescence and effects are reduced by psychosocial stimulation.

Stunting is associated with deficits in cognition and school achievement from early childhood to late adolescence; however, there has been little investigation of emotional and behavioral outcomes. The objective of this study was to determine whether linear growth retardation (stunting) in early childhood is associated with poorer psychological functioning in late adolescence. The study was a prospective cohort study of stunted and nonstunted children. Participants were identified at age 9-24 mo by a survey of poor neighborhoods in Kingston, Jamaica, and a 2-y intervention trial of supplementation and stimulation was conducted in the stunted children. Psychological functioning was assessed at age 17 y in 103 of 129 stunted children enrolled and 64 of 84 nonstunted participants. Anxiety, depressive symptoms, self-esteem, and antisocial behavior were reported by participants using interviewer-administered questionnaires and attention deficit, hyperactivity, and oppositional behavior were reported by parent interviews. The stunted participants reported significantly more anxiety (regression coefficient = 3.03; 95% CI = 0.99, 5.08) and depressive symptoms (0.37; 95% CI = 0.01, 0.72) and lower self-esteem (-1.67; 95% CI = -0.38, -2.97) than nonstunted participants and were reported by their parents to be more hyperactive (1.29; 95% CI = 0.12, 2.46). Effect sizes were 0.4-0.5 SD. Participants who received stimulation in early childhood differed from the nonstunted group in hyperactivity only. Children stunted before age 2 y thus have poorer emotional and behavioral outcomes in late adolescence. The findings expand the range of disadvantages associated with early stunting, which affects 151 million children <5 y old in developing countries.

Esophagogastric dissociation versus fundoplication: Which is best for severely neurologically impaired children?

PURPOSE: Neurologically impaired children (NIC) often have swallowing difficulties, severe gastroesophageal reflux, recurrent respiratory infections, and malnutrition. Bianchi proposed esophagogastric dissociation (EGD) as an alternative to fundoplication and gastrostomy. The authors compared these 2 approaches. METHODS: Twenty-nine consecutive symptomatic NIC refractory to medical therapy were enrolled in a prospective study and divided into 2 groups: A (n = 12), NIC who underwent fundoplication and gastrostomy; B (n = 14), NIC who underwent EGD. Three were excluded because of previous fundoplication. Anthropometric (percentage of the 50th percentile/age of healthy children) and biochemical parameters, respiratory infections per year, hospitalization (days per year), feeding time (minutes), and "quality of life" (parental psychological questionnaire, range 0 to 60), were analyzed (t test and Mann-Whitney test) preoperatively and 1 year postoperatively. Complications were recorded. RESULTS: Compared with group A, group B presented a statistically significant increase of all anthropometric and nearly all biochemical parameters with a statistical difference in terms of respiratory infections, hospital stay, feeding time, and psychological questionnaire. In group A, 2 bowel obstructions, 1 tight fundoplication, 1 dumping syndrome, and 3 failures of fundoplication occurred. Group B presented 1 anastomotic stricture, 1 paraesophageal hernia, and 1 bowel obstruction. CONCLUSIONS: Compared with fundoplication and gastrostomy, EGD offered better nutritional rehabilitation, reduction in respiratory infections, and improved quality of life. EGD can be rightfully chosen as a primary procedure.

Nutrition in early life and the fulfillment of intellectual potential.

The effects of early supplementary feeding on cognition are investigated using data collected during two periods in four Guatemalan villages. The first was the Institute of Nutrition of Central America and Panama (INCAP) longitudinal study from 1969 to 1977 and the second was a cross-sectional follow-up of former participants carried out in 1988-1989. The principal objective of these studies was to assess the differential effect of two dietary supplements, Atole containing 163 kcal/682 kJ and 11.5 g protein per cup or 180 mL and Fresco containing 59 kcal/247 kJ and 0 g protein per cup, that were given to mothers, infants and young children. Performance was assessed on a battery of psychoeducational and information processing tests that were administered during adolescence. Consistent differences between groups were observed on psychoeducational tests. Subjects receiving Atole scored significantly higher on tests of knowledge, numeracy, reading and vocabulary than those given Fresco. Atole ingestion also was associated with faster reaction time in information processing tasks. In addition, there were significant interactions between type of dietary supplement and socioeconomic status (SES) of subjects. In Atole villages, there were no differences in performance between subjects in the lowest and highest SES categories. On the other hand, performance in Fresco villages was best in the highest compared with the lowest SES group. After close scrutiny of alternative hypotheses, it is concluded that dietary changes produced by supplementation provide the strongest explanation for the test performance differences observed in the follow-up between subjects exposed to Atole and those exposed to Fresco supplementation.

PIP: A longitudinal study conducted during 1969-77 by the Institute of Nutrition of Central America and a cross-sectional follow-up of former participants carried out during 1988-89 investigated the effects of early supplementary feeding. The objective of these two studies was to assess the differential effect of two dietary supplements--Atole, containing 163 kcal/683 kJ and 11.5 g protein per cup or 180 ml, and Fresco, containing 59 kcal/247 kJ and 0 g protein per cup--on cognition. The dietary supplements were given to mothers, infants, and young children. Performance was assessed on a battery of psychoeducational and information processing tests that were administered during adolescence. Consistent differences between groups were observed on psychoeducational tests. Findings revealed that subjects receiving Atole scored significantly higher on tests of knowledge, numeracy, reading, and vocabulary than those given with Fresco. Atole ingestion also was associated with faster reaction time in information processing tasks. In addition, there were significant interactions between type of dietary supplements and socioeconomic status (SES) of subjects. In Atole villages, there were no significant differences in performance between subjects in the lowest and highest SES categories. On the other hand, performance in Fresco villages was best in the highest compared with the lowest SES group.

Nutrition, health and psychosocial profile of institutionalized children.

A study was undertaken to assess the health, nutrition and psychosocial profile of Institutionalized children in four States--Uttar Pradesh, Andhra Pradesh, Karnataka and West Bengal. A sample of 3,822 children from 70 institutions in 6-18 years age group formed the subjects of the study. It was observed that the destitute children were mainly taken care of in three types of institutions, viz, Voluntary, Government Aided and Government run institutions. Calorie deficiency and deficiency of Vitamins and minerals characterized the diets of these children. In general, there was no deficit of protein in their diets. Growth wise, these children were retarded both in height and weight compared to standards. However, they fared better in comparison to their age and sex counterparts in the rural and urban poor. Psychosocial profile of these children indicated that the prevailing environment in the institutions is less conducive for intellectual stimulation but not so for the development of skills of self-help, locomotion, socialization and imagery.