Ten steps to recovery

Severe malnutrition in children results in severe wasting and/or edema (swollen limbs). Severely malnourished children often are very ill and have complications. Health workers need to follow 10 steps first to stabilize these children and then to move them into a rehabilitation phase. During days 1-2 of the stabilization phase, health workers need to treat and/or prevent hypoglycemia (blood sugar 3 mmol/l), hypothermia (35 degrees Celsius [underarm]), and dehydration. Children with hypoglycemia should receive 50 ml of 10% glucose solution or sugar water then be fed every 2 hours round-the-clock. Health workers should either feed or start rehydration of children with hypothermia immediately, place the child on the mother's bare chest or abdomen, and cover them. They must use a modified oral rehydration salts solution and encourage feeding to rehydrate the severely malnourished child. During days 2-14 and stopping at day 14, health workers need to give broad-spectrum antibiotics to all severely malnourished children and a measles vaccine to non-immunized children and to start cautious feeding practices whereby the frequency of feeding decreases and the volume increases. Conditions that need to be addressed throughout the stabilization and rehabilitation phases include electrolyte imbalance and micronutrient deficiencies. Health workers must never treat electrolyte imbalance with a diuretic. They should not provide iron during the stabilization phase and not until a good appetite has returned and the child begins to gain weight. Health workers need to encourage sensory stimulation (tender, loving care; structured play and physical activity; stimulating environment; and mother's involvement) throughout both phases. They must focus on rebuilding tissues (catch-up growth) and preparing for follow-up during the rehabilitation phase (weeks 2-6). Once the child's appetite has returned, health workers must make a gradual transition from starter to catch-up formula and encourage continued breast feeding if the child is breast fed. They should prepare the child and parents for discharge through education on a healthy diet and eating patterns.     

Micronutrients as adjunct therapy of acute illness in children: impact on the episode outcome and policy implications of current findings

Role of micronutrients namely vitamin A, zinc and folate, as adjunct therapy of illness episodes in children in developing countries have been discussed in the light of health policy. Apart from a selective review, attempts have been made to statistically combine results of several studies to address policy issues. In children, vitamin A supplementation during illness has (a) a profound effect in reducing mortality in measles, (b) possibly a significant effect in reducing persistent diarrhea episodes in children with acute diarrhea, and (c) no benefit in pneumonia. Use of large dose vitamin A is recommended during measles episodes but not in non-measles pneumonia. Its use in acute diarrhea is debatable but recommended in persistent diarrhea and in severe malnutrition as a component of a micronutrient mixture. Large dose vitamin A supplementation should be used with caution in young infants as there are unresolved concerns about its safety particularly, bulging fontanelle observed in infants when co-administered at immunization. In children, zinc supplementation during illness, (a) had a marked effect in reducing prolonged episodes and a modest effect on episode duration in acute diarrhea, (b) resulted in reduced rate of treatment failure and death in persistent diarrhea, (c) had no effect in measles and non-measles pneumonia, and (d) probably had a detrimental effect of increasing death rate when a large dose was used in severely malnourished children. The desirability of routine zinc supplementation therapy of undernourished children with acute diarrhea should be assessed further. Concerning policy, zinc supplementation as a component of a micronutrient mixture is recommended in the rehabilitation of severely malnourished children and in persistent diarrhea. However, recommendation for its routine use in all cases of acute diarrhea in children needs additional studies on effectiveness, cost, operations and safety. In two randomized controlled trials folate has been evaluated in acute and persistent diarrhea and found to have no beneficial effect. Folate is not recommended as adjunct therapy of diarrhea. Role of folate in preventing severe disease and/or death deserves further evaluation.     

"CLAPSEN", a global approach to the rehabilitation of severe childhood malnutrition in Bolivia

The "CLAPSEN" approach was developed at the Hospital Materno Infantil German Urquidi in Cochabamba, to provide a global response for the study and treatment of childhood malnutrition. "CLAPSEN" is short for Clinical, Laboratory, Anthropometry, Psychology, Sociology, Nursing (Enfermera in Spanish) and Nutritional care. Most of the malnourished children admitted to Cochabamba Hospital are from poor families, more than three quarters of whom have only recently arrived in the city. Acute malnutrition is just one of the manifestations of a generally unfavorable environment. Malnutrition should not be considered as a simple deficiency in energy, protein or micronutrients, but rather as a multi-deficiency syndrome, also involving a lack of basic health and social care. This study demonstrates that malnourished children display a considerable degree of psychological retardation and of immune system depression. After five weeks of rehabilitation, the children were considered to have recuperated physically, as assessed by anthropometry, but not psychologically, as assessed by the adapted Dewer Score, or immunologically, as shown by the size of the thymus or the extent of maturation of lymphocytes. This strategy was not designed as a long-term approach for treating malnutrition, but rather as a research project to characterize the children arriving at the hospital, to determine the reasons for their malnutrition and to identify strategies that could be implemented earlier by health centers of social services, to prevent deterioration in the condition of these children to severe malnutrition requiring hospital admission. We believe that, in this Latin American context, in which the rate of acute malnutrition is low, the hospital should continue to be involved in the treatment of severely malnourished children with associated diseases. The child's stay in hospital should be short and once the child has recovered clinically, he should be sent home. In light of the observed levels of social deprivation, psychosocial and immune deficits, there appears to be a need for continued support for the family, to ensure the full recovery of the child and to prevent relapses.     

Plasma zinc and the clinical features of malnutrition.

Human protein-energy malnutrition and zinc deficiency have common clinical features. These were related to the plasma zinc concentrations in 42 severely malnourished children. A low plasma zinc concentration was strongly associated with nutritional edema but not with the degree of edema or the plasma albumin concentration. In the absence of edema, there were significant relationships between plasma zinc concentrations and stunting, skin ulceration, and wasting. Infection was not necessarily associated with a lower zinc concentration. From these data it can be predicted that a malnourished child with edema, skin ulceration, stunting, or severe wasting, will have a low plasma zinc concentration.     

Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso

BACKGROUND: Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach. METHODS: Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used. RESULTS: From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD. CONCLUSION: The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.     

New concepts on nutritional management of severe malnutrition: the role of protein

Current guidelines for the management of severe malnutrition are mainly based on new concepts regarding the causes of malnutrition and on advances in our knowledge of the physiological roles of micronutrients. In contrast to the early 'protein dogma', there is a growing body of evidence that severely malnourished children are unable to tolerate large amounts of dietary protein during the initial phase of treatment. Similarly, great caution must be exercised to avoid excessive supply of iron and sodium in the diet, while keeping energy intake at maintenance levels during early treatment. Because severely malnourished children require special micronutrients, a mineral-vitamin mix is added to the milk-based formula diets, which are specially designed for the initial treatment and the rehabilitation phase. To further improve nutritional rehabilitation and reduce cases of relapse, 'ready-to-use therapeutic food' and 'ready-to-eat nutritious supplements' with relatively low protein (10% protein calories) and high fat content (54-59% lipidic calories) have been developed. Although current dietary recommendations do not differentiate between oedematous and nonoedematous forms of malnutrition or between adults and children, there are indications that further clarification is still needed for applying dietary measures for specific target groups.     

Infections associated with severe protein-calorie malnutrition in hospitalized infants and children

One hundred Bangladeshi children admitted to hospital for treatment of severe protein-calorie malnutrition were systematically evaluated for the presence of infections. Ninety percent of children had some evidence of systemic infection at the time of admission and 75% had pneumonia, bacteruria, diarrhea in association with a known enteric pathogen, bacteremia, meningitis, or more than one of these major infections. Forty-nine percent of patients had pneumonia, including 14% of admissions with clinical evidence of pulmonary tuberculosis. Forty-three percent of admissions had diarrhea and 40% had evidence of enteric infections, most commonly shigellae or rotavirus. Bacteruria occurred in 30% of admissions, but bacteremia was identified in only 2% of patients initially. The prevalence of intestinal parasites increased with age, both among inpatients and comparison subjects with less severe grades of malnutrition. There did not appear to be important differences in the parasite loads or prevalences between the 2 groups.Twenty-one inpatients died; deaths were more common in younger children. The cause of death was most frequently related to infections. The identification and appropriate treatment of infections must be considered a major component of the rehabilitation of severely malnourished children.     

Infections associated with severe malnutrition among hospitalised children in East Africa

Severe protein-energy malnutrition (PEM) predisposes affected children to various infections, which either worsens their nutritional status or causes malnutrition, hence complicating their management and outcome. This study was carried out to determine the infections associated with severe malnutrition among children admitted at Kilifi District Hospital (KDH) in Kenya and Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. Data was collected from hospital register books and online system database. A total of 1121 children with severe malnutrition were admitted during a period of one year (2004-2005) (MNH = 781; KDH = 340). The proportion of male children with malnutrition was higher than that of female children. Non-oedematous malnutrition was more prevalent at MNH (N = 504; 64%) than KDH (N = 130; 38%). Conversely, oedematous was more prevalence than non-oedematous malnutrition among children admitted at KDH (N = 2 10; 61.7%). More than 75% of all patients with severe PEM were children < 2 years old. Thirty-six per cent of all severe PEM cases had malaria in both hospitals. Forty-five per cent of all admitted patients with severe PEM at KDH had diarrhoea. Two hundred twenty two (28%) and 64 (19%) of the children with severe malnutrition died at MNH and KDH, respectively. Oedematous PEM was associated with a higher case fatality rate than non-oedematous one (P < 0.05). At MNH, 86% of the patients who died with severe malnutrition had other co-morbidities. More (46%) oedematous malnourished patients with co-infections died at MNH than non-oedematous malnourished patients (19%). At KDH, septicaemia was the leading cause of death (55%) among severely malnourished patients. In conclusion, coinfections complicate the management of severe malnutrition and are associated with higher death rate. Management of such infections is of paramount importance to reduce case fatality rates.     

Pattern of vitamin deficiencies among the malnourished preschool children in ICDS blocks of Jaipur city

In India, researchers compared data on 1000 malnourished preschool children from ICDS blocks of Jaipur slums with data on 5000 well-nourished preschool children attending well-baby clinics of Zenana Hospital and Mahila Chikitsalya and from kindergarten classes of 2 public schools of Jaipur. They aimed to compare the prevalence of vitamin deficiencies among the 2 groups of children. The well-nourished children had a much lower prevalence of vitamin deficiencies than the malnourished children: vitamin A deficiency = 1.8% vs. 15.7%, vitamin B = 0.4% vs. 7.6%, vitamin D deficiency = 2% vs. 11.9%, and vitamin C deficiency = 0 vs. 1.1%. Sex did not affect vitamin deficiency status. Vitamin D deficiency manifests itself in severe malnutrition only when dietary improvement causes a growth spurt.     

Infections in malnourished infants and children

Malnutrition, one of the world's greatest health problems, is a factor in the death of millions of children each year. Infection is the cause of death in over half these cases. Dietary deficiency, especially of protein, causes serious disturbances in the immune system. The mucus and cutaneous surfaces are the first affected. Studies of the respiratory mucus demonstrate frequent breaches which allow germs to penetrate. Antibodies are synthesized in reduced quantities, lymphocyte counts are often diminished, and reaction with infectious agents is poor. The phagocyte function of polynucleated cells is poor. Malnutrition is often associated with war, ignorance, poverty, and poor hygiene. Deficiencies of iron, vitamin A, and zinc may aggravate immune deficits. Ingestion of contaminated water is the main cause of diarrhea, which is very frequent among the malnourished and may be more serious than among adequately nourished individuals. Colibacillus and salmonella are most frequently isolated. Germs such as shigella, campylobacter, and rotavirus have the same incidence as in well nourished children. Pneumonia is responsible for 4 million deaths in children under 5 annually and is more common in the malnourished. The pathogenic agents may be pneumococci, Hemophilus, or staphylococci. Tuberculosis is also frequent, especially in zones with a prevalence of AIDS. Diagnosis of tuberculosis with cutaneous tests is difficult in the malnourished. Regardless of the pathogenic agent, pneumonia is more serious in the malnourished, and the need for treatment is more urgent. Urinary infections may occur in 10-25% of malnourished children vs. 2% of healthy children. The colibacillus is the most frequent cause. Specticemias, the most severe of infections, are not rare in the malnourished and are usually caused by Salmonella or the colibacillus. 20% of malnourished children are affected by infections acquired in the hospital. Among viral infections affecting them are measles and herpes. The fatality rate from measles may reach 25% in malnourished children. Parasitoses are frequent, but they do not seem to be more serious in malnourished children than in the general population. It is imperative in treating malnourished children to observe rigorous hygiene, use clean water, treat infections early, avoid hospital infections, and apply all available vaccines.     

Approaches to Intervention Among Children and Adolescents

An analysis of current dietary intakes of preschool and school children and adolescents belonging to poor income groups in India indicate that they suffer from deficiencies of several nutrients with associated clinical and functional consequences. The observed deficiencies include energy, calcium, iron, zinc, vitamin A, riboflavin, ascorbic acid, and folate. Some degree of protein deficiency is also present. The best strategy to correct the deficiencies of these nutrients is the food-based approach where nutrient-rich food supplements are formulated with nutrient-rich familiar foods and given to children at the household level. Another strategy for helping mothers and preschool children to achieve the recommended daily intakes is to fortify with micronutrients the supplementary foods currently targeted to them for improving their energy and protein intake. This can be achieved by expanding the current supplementary feeding program to school children and adolescents.     

Fighting malnutrition from hospital to home

At a Children's Nutrition Unit in Bangladesh, a screening process has been developed to determine the type of care which should be provided to malnourished children. Malnourished children receive an initial period of full-time medical attention if they exhibit apathy and anorexia, dehydration, severe anemia, life-threatening infection, hypoglycemia, hypothermia, or severe Vitamin A deficiency. Also, malnourished children under 12 months old are given preference for in-patient care. Children may be hospitalized for three to five weeks until they are reasonable recovered and have reached a target weight-for-height or they may be discharged early and receive continued treatment through day care or home visits. Goals of the minimum stay (one to two weeks) should include restored appetite, treatment of clinical complications, and teaching the mother about appropriate feeding. Hospitalization and day care in the hospital may be very difficult for a family to manage. Home-based treatment, on the other hand, produces good, although slower, results and is the most cost-effective approach. Success of home care depends upon the quality of care and advice given during home visits by health personnel and an effective referral system if the children need more attention. In this program, while the provision of a Vitamin and mineral mixture is considered helpful, food supplements are not distributed. Even very poor families can adapt family foods to provide better nutrition. Less malnourished children also need attention, and their mothers must be trained to adapt family foods, give frequent meals, and continue to breast feed. Action is needed when growth begins to falter to prevent the need for later treatment. In Dhaka, the total cost to rehabilitate one child is US$29 for home-based care, US$59 for day care, and US$156 for in-patient care.     

Dealing with diarrhoea

Children with severe dehydration, persistent diarrhea with dehydration, or bloody diarrhea with no signs of improvement must be hospitalized. In-patient care for a child with severe dehydration includes rapid intravenous (IV) fluid therapy. Children who can still drink should be given oral rehydration salts (ORS) solution while the health worker sets up the IV drip. Children with difficulty drinking should be given ORS as soon as the IV fluid therapy restores their ability to drink (within 3-4 hours for babies, or 1-2 hours for older children), since ORS amends mineral deficiencies more effectively than the IV fluids. The IV drip should be re-administered if the child still exhibits dehydration after 3 hours for older children or 6 hours for babies. If improvement is noted, health workers should encourage the mother to administer ORS and to breast feed frequently. Hospital personnel should observe the child for at least 6 hours before discharge. This allows them to be sure that mothers can maintain the child's fluid balance. Children with diarrhea for more than 14 days face malnutrition or death. Any child with persistent diarrhea who exhibits moderate or severe malnutrition and signs of dehydration and is less than 4 months old needs to be admitted to a hospital. Management of persistent diarrhea involves fluid replacement, appropriate diet, and treatment of associated infections, if needed. ORS is usually effective for persistent diarrhea, although in a few cases poor absorption of glucose may necessitate initial rehydration with IV therapy. Breast feeding is encouraged for infants. Older infants and young children should eat 6 times a day as soon as they are able to eat. Recommended diets for these children are a low lactose diet (milk, yogurt, or curds; cooked rice; oil; sugar/glucose) and a low starch and no lactose diet (eggs, chicken, or fish; cooked rice; oil; sugar/glucose). Children with serious infections may require nasogastric feeding at first. Shigella bacteria tend to be responsible for dysentery. Children with this bloody diarrhea should be treated with an antibiotic. If their condition does not improve and they are malnourished, less than 1 year old, were initially dehydrated, or have recently had measles, they need to be hospitalized. Drugs to reduce frequency of stools should never be given in cases of bloody diarrhea. Older babies and children should be given an extra meal and supplementary vitamins and minerals each day for two weeks.     

Effect of age, malnutrition and renutrition on free secretory component and IgA in secretions

The development of free secretory component (FSC) was studied in the tears of normal infants, children and adults. The level of FSC in tears was higher in older adults than in children. Free secretory component was also measured in the tears of normal, moderately and severely malnourished Colombian children. Children suffering from kwashiorkor, combined protein-calorie malnutrition or marasmus were studied before and after renutrition. No change was detected in the concentration of FSC in tears of moderately malnourished (Grade I and II) children. There was a significant difference between normal and severely malnourished children which improved with renutrition. The levels of tear IgA were decreased in the moderately malnourished children. These results indicate that reduction in secretory IgA levels in moderate malnutrition may not be explained by a lack of available free secretory component in tears, but that severe malnutrition may impair the S-IgA system by significantly reducing the availability of free secretory component.     

Local cultural animal food contributes high levels of nutrients for Arctic Canadian Indigenous adults and children

Food systems of Canadian Arctic Indigenous Peoples contain many species of traditional animal and plant food, but the extent of use today is limited because purchased food displaces much of the traditional species from the diet. Frequency and 24-h dietary interviews of Arctic adults and children were used to investigate these trends. The most frequently consumed Arctic foods were derived from animals and fish. In adults these foods contributed 6-40% of daily energy of adults. Children ate much less, 0.4-15% of energy, and >40% of their total energy was contributed by "sweet" and "fat" food sources. Nevertheless, for adults and children, even a single portion of local animal or fish food resulted in increased (P < 0.05) levels of energy, protein, vitamin D, vitamin E, riboflavin, vitamin B-6, iron, zinc, copper, magnesium, manganese, phosphorus, and potassium; although children had similar results for these nutrients, they did not reach significance for energy, vitamin D, or manganese. Because market foods are the major source of energy in the Arctic, traditional animal-source foods are extremely important to ensure high dietary quality of both adults and children.     

Discriminant function of complement C3, serum albumin and anthropometric measurements in identifying malnutrition

A prospective study was conducted on 32 malnourished and 12 healthy pre-school children to study the role of certain variables, viz., supine length, weight-for-supine length, complement C3, weight-for-head circumference, serum albumin, weight and mid-arm circumference, in detecting the presence of malnutrition and to grade the severity of malnutrition. Out of 32 malnourished children 14 cases were re-investigated after 15 days of nutritional rehabilitation to find out the significant discriminator(s) of pre and post-treatment condition. Step-down discriminant analysis showed that supine length, weight-for-supine length and complement C3 were efficient discriminators in detecting cases of malnutrition. To transform the variables, viz., supine length, weight-for-supine length and complement C3 (each expressed as a percentage of standard-for-age) into score form, respective simplified weights, for multiplication, were found to be 0.9, 0.4 and 0.1. A dividing score (Z) of 123.1, with a bordering range () of 119.6 to 126.7 for 90% probability limits, separated malnourished from healthy children. For classifying children with respect to severity of malnutrition, weight-for-supine length and serum albumin concentration were found to be significant discriminators. Malnourished children with oedema (N=11) had higher weight-for-supine length ratio and lower serum albumin concentration as compared to non-oedematous malnourished children (N=21). While oedematous and non-oedematous malnourished children were almost equally stunted, higher weight for supine length ratio was attributed to accumulation of oedema fluid, in the former group. A subsample of 14 malnourished children who had received a 15-day nutritional therapy could be differentiated from their earlier condition (before treatment) by a significant rise in complement C3 and serum albumin levels.     

Micronutrient Malnutrition, Infection, and Immunity: An Overview

Micronutrient deficiencies and infectious diseases often coexist and exhibit complex interactions leading to the vicious cycle of malnutrition and infections among underprivileged populations of the developing countries, particularly in preschool children. Several micronutrients such as vitamin A, beta-carotene, folic acid, vitamin B_12, vitamin C, riboflavin, iron, zinc, and selenium, have immunomodulating functions and thus influence the susceptibility of a host to infectious diseases and the course and outcome of such diseases. Certain of these micronutrients also possess antioxidant functions that not only regulate immune homeostasis of the host, but also alter the genome of the microbes, particularly in viruses, resulting in grave consequences like resurgence of old infectious diseases or the emergence of new infections. These micronutrient infection and immune function interactions and their clinical and public health relevance in developing countries are briefly reviewed in this article.     

Use of simple clinical signs to predict pneumonia in young Gambian children: the influence of malnutrition.

The current WHO recommendations for the case management of acute respiratory infections (ARI) in children aged 2 months to 5 years in developing countries use fast breathing (respiratory rate of > or = 50 per minute in children under 12 months and > or = 40 in children aged 12 months to 5 years) and lower chest wall indrawing to determine which child is likely to have pneumonia and should therefore receive antibiotics. We have evaluated these and other physical signs in 487 malnourished children and 255 well nourished children who presented with a cough or breathing difficulty. Pneumonia, defined as definite radiological pneumonia or probable radiological pneumonia associated with crackles on auscultation, was present in 145 (30%) of the malnourished children and 68 (26%) of the well nourished children. The respiratory rate predicted pneumonia equally well in the two groups, but to achieve an appropriate sensitivity and specificity the respiratory rate cut-off required in malnourished children was approximately 5 breaths per minute less than that in well nourished children. Intercostal indrawing was more common and lower chest wall indrawing was less common in the malnourished children, with or without pneumonia. These results suggest that fast breathing, as defined at present by WHO, and lower chest wall indrawing are not sufficiently sensistive as predictors of pneumonia in malnourished children. As the latter are a high-risk group, we should like to recommend that children with malnutrition who present with a cough, fast breathing or difficult breathing should be treated with antibiotics.     

Appropriate food policies and investments could reduce child malnutrition by 43% in 2020

This report describes past trends in global child malnutrition and assesses future prospects for reducing child malnutrition. Most developing countries have significantly reduced the proportion of malnourished children during the past three decades. However, because of population growth, the absolute number of malnourished children has fallen much less sharply. Moreover, the number of malnourished children has increased in Sub-Saharan Africa. A global food supply-and-demand model is used to project child malnutrition to 2020 under alternative assumptions on policies and investments that influence food security outcomes in education, clean water, agricultural research, irrigation and rural infrastructure. The baseline "best-estimate" projection shows that the number of malnourished children will continue to decline slowly but that child malnutrition will continue to increase in Sub-Saharan Africa. The optimistic scenario shows that better policy and more rapid economic and agricultural growth can lead to substantial food security improvements, but the pessimistic scenario shows that significantly worse outcomes are also possible with relatively small declines in policy and investment efforts relative to the baseline. A concerted effort to eliminate childhood malnutrition would require policy reform and significant increases in public investment to produce long-term gains in income growth, agricultural productivity and social indicators.