Impact of early childhood health and nutrition on access to education in developing countries

Children in developing countries must negotiate threats from a number of diseases before they reach school age. More than 50% of child deaths are caused by pneumonia, diarrhoea, malaria, measles, malnutrition and human immunodeficiency virus (HIV). For those who survive, health and nutrition can have an impact on their subsequent education, most significantly by affecting their chances of enrolling in school. In many resource-poor countries, physical and mental disabilities can effectively prevent children from attending school. These result most commonly from iodine or folate deficiency or rubella infections in utero or from cerebral malaria, polio or meningitis infections postnatally. Less debilitating conditions can influence the likelihood and timing of enrolment. These include under-nutrition, less severe malaria infection and HIV-related orphanhood. The majority of all these conditions are treatable or preventable. Tackling these health and nutrition problems through programmes during infancy and early childhood has the potential to make a major contribution to ensuring all the world’s children have access to basic education.     

Malnutrition in rural Solomon Islands: An analysis of the problem and its drivers

Solomon Islands, like many Pacific Island nations, suffer from the burden of malnutrition. External drivers including population growth, declining agriculture and fisheries productivity and global food trade have contributed to the transition to greater reliance on imported foods. Globally, diets are recognized as both a cause of and solution to the burden of malnutrition. Using a mixed‐method approach this study assessed nutritional status and key determinants of malnutrition among women and young children in rural Solomon Island communities. Quantitative 24‐hour recall surveys identified diets of women and young children in these communities to be very limited in diversity. Typical daily diets comprised of fish, sweet potato (and/or rice) and slippery cabbage (a leafy green) usually boiled in coconut milk or baked. Participatory research using problem tree and biocultural approaches identified basic determinants of poor diets and opportunities to address these challenges. We highlight three domains of opportunity to improve diets across multiple scales; 1) improve nutrition‐sensitive agriculture and fisheries to produce and distribute diverse, productive and nutrient rich foods; 2) nutrition education and empowerment, focusing on the first 1000 days of life, to influence and inform choices regarding food consumption; and 3) reducing the consumption of imported, energy‐rich nutrient poor foods through national and regional policies. These multi‐scale domains highlight that food system approaches that strengthen integrated policy and empower people are essential for healthy and sustainable diets in Solomon Islands and more broadly in the Pacific region.     

Early child growth: how do nutrition and infection interact?

It is well known that the relationship between child nutrition and infection is bidirectional, i.e. frequent illness can impair nutritional status and poor nutrition can increase the risk of infection. What is less clear is whether infection reduces the effectiveness of nutrition interventions or, vice versa, whether malnutrition lessens the impact of infection control strategies. The objective of this paper is to review the evidence regarding this interaction between nutrition and infection with respect to child growth in low-income populations. Even when there are no obvious symptoms, physiological conditions associated with infections can impair growth by suppressing appetite, impairing absorption of nutrients, increasing nutrient losses and diverting nutrients away from growth. However, there is little direct evidence that nutrition interventions are less effective when infection is common; more research is needed on this question. On the other hand, evidence from four intervention trials suggests that the adverse effects of certain infections (e.g. diarrhoea) on growth can be reduced or eliminated by improving nutrition. Interventions that combine improved nutrition with prevention and control of infections are likely to be most effective for enhancing child growth and development.     

Nutritional status and social behavior in preschool children: the mediating effects of neurocognitive functioning

Early malnutritional status has been associated with reduced cognitive ability in childhood. However, there are almost no studies on the effect of malnutrition on positive social behavior, and no tests of possible mediating mechanisms. This study tests the hypothesis that poor nutritional status is associated with impaired social functioning in childhood, and that neurocognitive ability mediates this relationship. We assessed 1553 male and female 3‐year‐olds from a birth cohort on measures of malnutrition, social behavior and verbal and spatial neurocognitive functions. Children with indicators of malnutrition showed impaired social behavior (p < .0001) as compared with children in the control group with adequate nutritional status. These associations even persisted after controlling for social adversity and parental education. Findings were not moderated by gender or ethnicity, and there was no interaction effect with parental education. A dose–response relationship was observed between degree of malnutrition and degree of social behavior, with increased malnutrition associated with more impaired social behavior. Neurocognitive ability was found to mediate the nutrition–social behavior relationship. The mediation effect of neurocognitive functioning suggests that poor nutrition negatively impacts brain areas that play important roles in developing positive social behavior. Findings suggest that reducing poor nutrition, alternatively promoting good nutrition, may help promote positive social behavior in early childhood during a critical period for social and neurocognitive development, with implications for improving positive health in adulthood.     

Nutritional problems in urban slum children

Nutritional problems like protein energy malnutrition (PEM), anemia and vitamin A deficiency continue to plague a large proportion of Indian children. The diets and nutritional status of urban slum children in India is far away from being satisfactory. The nutritional status of slum children is worst amongst all urban groups and is even poorer than the rural average. Urban migration has not provided them salvation from poverty and undernutrition. Another distressing feature is the lack of any significant improvement over the years in this population. Most common causes of malnutrition include faulty infant feeding practices, impaired utilization of nutrients due to infections and parasites, inadequate food and health security, poor environmental conditions and lack of proper child care practices. High prevalence of malnutrition among young children is also due to lack of awareness and knowledge regarding their food requirements and absence of a responsible adult care giver. With increasing urban migration in the years ahead, the problem of malnutrition in urban slums will also acquire increasing dimension unless special efforts are initiated to mitigate the health and nutrition problems of the urban poor. Improving nutritional status of urban poor requires a more direct, more focused, and more integrated strategy.     

Critical appraisal of the management of severe malnutrition: 3. Complications

Abstract:   The high case-fatality of severe malnutrition is due to infections, dehydration, electrolyte disturbances and heart failure. We focus on the evidence about managing these complications of severe malnutrition. Signs of circulatory collapse in severely malnourished children should be treated with intravenous or bone marrow infusion of Ringer's lactate with additional dextrose and potassium at a rate 20–40 mL/kg fast with close monitoring of vital signs. Recommendations for slow or restricted fluids in the face of shock are unsafe, and hypotonic or maintenance solutions must be avoided to prevent hyponatraemia. However, the evidence that severely malnourished children do not tolerate excessive fluid administration is good, so caution must be exercised with regards to fluids in the initial phase of treatment. There is also good evidence that wide spectrum antibiotics need to be given empirically for severe malnutrition to prevent the otherwise unavoidable early mortality. There is a need for improved protocols for tuberculosis diagnosis, HIV management and treatment of infants under 6 months with severe malnutrition. The contribution of environmental enteropathy to poor growth and nutrition during the weaning period means that there should be more priority on improving environmental health, particularly better hygiene and less overcrowding. A T-cell mediated enteropathy contributes to growth failure and malnutrition, and it is related to environmental contamination of enteric organisms in the weaning period rather than allergic responses.     

Severe acute malnutrition in low- and middle-income countries

Low- and middle-income countries bear the greatest burden of malnutrition, especially those in sub-Saharan Africa and Asia. Children are particularly vulnerable. This article provides an overview for healthcare professionals working with children, giving definitions and practical advice for intervention and management. Severe acute malnutrition (SAM) is diagnosed in under 5s with severe wasting (“marasmus”) and/or nutritional oedema (“kwashiorkor”). Wasting is identified using weight-for-height and comparing the child's value with WHO reference data or by measurement of mid-upper arm circumference. SAM is thought to result from a complex interaction between infections and poor diet or feeding practices occurring in the context of multiple adverse social-economic factors, with poor sanitation and hygiene increasing exposure to infection. The clinical management of SAM depends on whether there are complications such as anorexia and infections. Children with uncomplicated SAM are best managed in community programmes using ready-to-use therapeutic food and with close monitoring. The management of complicated SAM requires in-patient care and presents a huge challenge especially in health facilities with limited resources. Management guided by the WHO “Ten Steps”, which account for the reductive adaptation that occurs in malnutrition reduces case-fatality but this often remains high. Prevention of SAM requires addressing the multifactorial underlying causes associated with poverty and food insecurity. Addressing malnutrition in children is essential to achieving many of the UN Sustainable Development Goals.     

Gastrostomy tube use in children with cancer

Children with cancer are at risk of malnutrition, which can impair critical childhood processes of growth and development and contribute to poor health outcomes. Enteral nutrition can effectively ameliorate malnutrition or weight loss in children with cancer; however, published nutrition support algorithms contain minimal specific information on gastrostomy tube use, and current literature is limited. Decisions about gastrostomy tube insertion in children with cancer can be challenging. Consideration of gastrostomy tube insertion is only appropriate in children with long‐term dependence on enteral nutrition, particularly when nasogastric tube insertion is predicted or proven to be problematic. Specific indications for patient selection are unclear, and referring clinicians may be unaware of important absolute and relative contraindications. Complications are predominantly minor in nature; however, reported rates are high. Morbidity must be weighed carefully against the need and anticipated duration of enteral nutrition support, and further research in this area is needed.     

Factors associated with acute malnutrition among children 6‐59 months in rural Mozambique

Factors associated with acute malnutrition are complex and wide‐ranging particularly in developing countries. In Mozambique, contextual factors associated to children acute malnutrition are yet to be fully investigated and the evidences used to better inform prevention programme. The objective of this study is to identify key factors associated with acute malnutrition among 6‐ to 59‐month‐old children living in nine districts in rural Mozambique assessed in the 2018 seasonal nutrition assessment. We analysed Standardized Monitoring and Assessment for Relief and Transition (SMART) nutrition survey data of 1,116 children from three districts and rapid nutrition assessment (RNA) data of 3,884 children from six districts of Mozambique. We used a multiple logistic regression analysis to respond to the research question. Experiencing diarrhoea [odds ratio (OR) = 4.54; P = 0.001] was the only variable associated with acute malnutrition from the SMART survey dataset, whereas in the RNA, fever (OR = 3.0; P = 0.000) access to sanitation (OR = 0.118; P = 0.037), experiencing shock in the household (OR = 0.5; P = 0.020), diarrhoea (OR = 2.41; P = 0.001) and cough (OR = 1.75; P = 0.030) were the variables with significant association to acute malnutrition. We believe that the findings were influenced by the proportion of acute malnutrition in each survey type. Study findings confirm the association between acute malnutrition and child's health outcomes that are generally linked to poor living conditions and independent effects of shocks. This highlights the need for policy and programme to implement integrated, cross‐sectoral approaches to tackling child acute malnutrition, particularly addressing community level conditions such as water and sanitation.     

Growth and behavior development in rural infants in relation to malnutrition and environment.

A group of 224 children from a rural cohort of 625 children registered from 1981 to 1983 in 10 villages of KV Block, Varanasi was assessed for morbidity, physical growth, and behavior development (Gesell's developmental schedule). By first birthday children of normal nutrition grade were reduced to one fourth and numbers in Grade II and III malnutrition doubled. This deterioration in nutritional status was probably due to high morbidity, i.e., gastrointestinal, respiratory infections, etc. The skull circumference was 43 cm at the age of one year, being lower by 3 cm than the average size. Children having Grades II and III malnutrition showed poor development in all the areas of behavior, i.e., motor, adaptive, language and personal social. Besides malnutrition, environmental factors like mother's involvement in teaching, encouraging the child, talking to him or being within the visual range; the parental education, their caste and the child's birth order contributed significantly to the development of the child during infancy.     

Addressing malnutrition in young children in South Africa. Setting the national context for paediatric food-based dietary guidelines

Despite various national nutrition and primary healthcare programmes being initiated in South Africa over the last decade, child health has deteriorated. This is seen by the rise in infant and child mortality rates, the high prevalence of preventable childhood diseases, e.g. diarrhoea and lower respiratory tract infections, and the coexistence of under-nutrition along with HIV/AIDS. Poor dietary intake, food insecurity and poor quality of basic services prevail within this precarious causal web. The national Integrated Nutrition Programme is a comprehensive nutrition strategy that focuses on children below 6 years old, at-risk pregnant and lactating women, and those affected by communicable and non-communicable diseases. Focus areas relevant to pre-school children include disease-specific nutrition treatment, support and counselling; growth monitoring and promotion (GMP); micronutrient malnutrition control; breastfeeding promotion, protection and support; contributions to household food security; nutrition interventions among HIV-infected children; and nutrition promotion, education and advocacy. Progress towards this includes the Baby-Friendly Hospital Initiative; mandatory fortification of maize meal and wheat flour with multiple micronutrients; vitamin A supplementation coverage and mandatory iodization of salt by legislation; the provision of free road-to-health charts for GMP; and the National School Nutrition Programme. Since 2003, the basis of the nutrition education strategy has been the locally developed food-based dietary guidelines (FBDGs), directed at adults and school-going children. This review sketches the backdrop to and motivation for the introduction of specifically targeted paediatric FBDGs, for mothers and caregivers of children from birth to age 7 years, as a national initiative.     

Programmatic Approaches for Nutritional Care in India: Addressing the Continuum of Care Perspectives

Child health and nutrition is nested within a larger gamut of child care and development, functioning through the health care system. Malnutrition is multidimensional and rooted in poor early childhood care and development that is shaped by environmental, social and economic factors. Current nutrition care interventions are marked by a piecemeal approach, focusing on treating malnutrition but overlooking the need for rehabilitation and care support. Continuum of care (CoC) as an approach aims for a seamless and need-based care, bearing an impact on improved care output, beneficiary participation, care experience and access to care. CoC in nutrition care shall contribute to integration of nutrition and health care services, addressing distal and proximal causes of undernutrition through a gamut of preventive, promotive, treatment and rehabilitative care.     

The Dutch famine and its long-term consequences for adult health

Small size at birth is linked with an increased risk of chronic diseases in later life. Poor maternal nutrition during gestation may contribute to restricted fetal growth, leading to increased disease susceptibility in later life. Animal studies have shown that undernutrition during gestation is associated with reduced life span and increased disease susceptibility. The Dutch famine is a unique counterpart for animal models that study the effects of restricted maternal nutrition during different stages of gestation. This paper describes the findings from a cohort study of 2414 people born around the time of the Dutch famine. Exposure to famine during any stage of gestation was associated with glucose intolerance. We found more coronary heart disease, a more atherogenic lipid profile, disturbed blood coagulation, increased stress responsiveness and more obesity among those exposed to famine in early gestation. Women exposed to famine in early gestation also had an increased risk of breast cancer. People exposed to famine in mid gestation had more microalbuminuria and obstructive airways disease. These findings show that maternal undernutrition during gestation has important effects on health in later life, but that the effects on health depend on its timing during gestation. Especially early gestation seems to be a vulnerable period. Adequate dietary advice to women before and during pregnancy seems a promising strategy in preventing chronic diseases in future generations.     

Interaction of nutrition and infection in clinical practice.

Resistance to infection is determined by a great many interralted factors, but one of the most significant variables is nutritional status of the host. The interaction between nutrition and infection has been described as synergistic, with malnutrition reducing resistance to infection, and infection, in turn, negatively affecting nutritional status. There are qualitative if not quantitative similarities between the evidence that has been gathered from studies of children living in vast areas of the developing countries, in which high rates of both severe malnutrition and infectious diseases are linked with high mortality rates, and evidence from studies of disadvantages children living in the United States in economically depressed migrant camps, Indian reservations, or rural and urban poverty, or children compromised by debilitating chronic diseases. Maternal nutritional status during pregnancy must receive more attention as a factor in the newborn's resistance to infection. Intrauterine malnutrition may cause impaired cellular immune function in the small-for-date infant which persists throughout the first year of life. Further research is needed to clarify this relationship. The optimal management of infections includes management or maintenance of nutritional status, and, in turn, management of nutritional deficiencies include prevention and treatment of infections.     

Infections and malnutrition among poor children

The interactions between malnutrition and infection are mutually adverse. The results of these interactions are of public health importance in developing countries where malnutrition and infection often co-exist. Recent studies highlight the mechanisms involved in these interactions and indicate the necessity for a comprehensive approach to control malnutrition in poor communities.     

The effect of childhood malnutrition on externalizing behavior

PURPOSE OF REVIEW: Childhood externalizing behavior (aggression, hyperactivity, and conduct disorder) has been increasingly viewed as a public health problem because of its etiology and outcome. The association between malnutrition and externalizing behavior has begun to receive attention. This review summarizes recent empirical findings on malnutrition as a risk factor for the development of externalizing behavior, with an emphasis on micronutrient deficiency, and explores brain dysfunction as a possible mechanism. RECENT FINDINGS: Externalizing behavior is associated with both macromalnutrition (e.g. protein) and micromalnutrition (e.g. iron and zinc). Both prenatal and postnatal malnutrition is implicated. The long-term effects of malnutrition on behavior could be reversible. The effects of docosahexaenoic acid/omega-3 long-chain essential fatty acid on externalizing behavior are more mixed. From animal and human findings, it is hypothesized that malnutrition impairs neurocognitive functioning by reducing neurons, alternating neurotransmitter functioning, and increasing neurotoxicity, and that such neurocognitive impairments predispose to externalizing behavior. SUMMARY: Different lines of evidence support the view that poor nutrition contributes to the development of child behavior problems. More randomized, controlled trials that manipulate nutritional intake and evaluate behavior in children are needed to evaluate the etiological role of nutrition in externalizing behavior in order to inform intervention and prevention efforts.     

Drug metabolism in malnourished children: a study with antipyrine.

The effect of malnutrition on hepatic drug-metabolising enzymes was investigated in 8 Sudanese children aged between 9 and 12.5 years using as a model the drug antipyrine. Antipyrine half-life and clearance were measured in the malnourished state and after 3 or 4 weeks of good nutrition. Associated with the improvement in nutritional state was a shortening of antipyrine half-life and an increase in its clearance. There was also a rise in serum triiodothyronine. It is concluded that poor nutrition is associated with impairment of drug metabolic capacity and that many factors are responsible.     

Influence of nutritional and haemoglobin status on malaria infection in children

Anaemia and malnutrition have been suggested to confer some degree of protection against malaria infection. Therefore, the influence of nutritional status as assessed anthropometrically and that of haemoglobin level on the incidence of malaria and the degree of parasitaemia was studied in 330 children in the age range of 1–9 years in Bisra block near Rourkela in Orissa state. Moderate to severe malnutrition as assessed from percentage of ideal weight was found in 48.8% (161/330) of children but only 8.8% (29/330) of children had some degree of malnutrition when assessed as weight for height indicating presence of chronic malnutrition. Similarly, 197 children (59.7%) had various grades of anaemia as estimated by haemoglobin level. prevalence of malaria on initial examination was 27.6% (91/330), while incidence of clinical malaria in children during the year of study was 250/1000. There was no statistical difference in the Prevalence/incidence of malaria or severity ofP. falciparum parasitaemia at different haemoglobin or nutritional levels (p>0.05). No child died or developed severe complications requiring hospitalization. Therefore, anaemia or malnutrition do not appear to provide any protection against malaria or degree of parasitaemia in the children around Rourkela.     

‘It was caused by the carelessness of the parents’: cultural models of child malnutrition in southern Malawi

Parents’ conceptions of child growth, health and malnutrition are culturally bound, making information about local understandings of malnutrition and its causes necessary for designing effective nutrition programmes. This study used ethnographic methods to elucidate cultural models of child care and malnutrition among the Yao of southern Malawi. Data were collected in six rural villages from 28 key informant interviews with village chiefs and traditional healers among others and 18 focus group discussions with parents and grandmothers of young children. For the Yao, lack of parental care is a key cause of poor child health and can lead to thinness (kunyililika) or swelling (kuimbangana). Parents are said to be careless if they are not attentive to the child's needs, are unable to provide adequate quality or quantity of food, or fail to follow sexual abstinence rules. Maintaining abstinence protects the family and failure to do so causes the transfer of ‘heat’ from a sexually active parent to a ‘cold’ child and results in child health problems, including signs and symptoms of malnutrition. These findings indicate that the Yao understanding of care is much broader than the concept of care during feeding described in the nutrition literature. In addition, the Yao note the importance of several key feeding practices supported by international agencies and understand the influence of illness on child nutritional status. These congruencies with the public health frame should be used together with information about the cultural context to design more socially and emotionally relevant care and nutrition programmes among the Yao.     

The contributions of differing degrees of acute and chronic malnutrition to the intellectual development of Jamaican boys

The purpose of this paper is to determine whether differing degrees and types of malnutrition cause differing degrees of mental impairment. Subjects were 59 Jamaican boys hospitalized for malnutrition in infancy and whose intelligence was assessed at school age. The measure used for degree of chronic malnutrition was height for age and for acute malnutrition weight for height. The measure of intelligence was the I.Q. (WISC). Because the social environment in which a child lives influences his intellectual development, a measure of social background was used as an independent variable in addition to the nutrition measures. Social background showed a significant effect on I.Q. but neither measure of nutrition was significant.A further analysis using comparisons who had not been hospitalized for malnutrition suggests that malnutrition may contribute to mental impairment, through a threshold effect rather than acting as a continuous variable where increasing degrees of malnutrition cause increasing degrees of mental impairment.