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Objective: To study the effect of zinc supplementation in children under 5 years of age from low- and middle-income countries (LMICs) onanthropometry and prevalence of malnutrition.Design: Systematic review of randomized controlled trials and cluster randomized trials.Setting: Low- and middle-income countries.Participants: 63 trials with zinc supplementation, incorporating data on 27372 children. Trials conducted exclusively in specificallydiseased participants and in children with severe acute malnutrition were excluded.Intervention: Zinc supplementation, provided either as medicinal supplementation or through food fortification.Outcome Measures: (i) Anthropometry: weight, height, weight-for-height, mid-arm circumference, head circumference; (ii) Prevalenceof malnutrition.Results: There was no evidence of effect on height-for-age Z score at the end of supplementation period (25 trials; 9165 participants;MD= 0.00 Z; 95% CI -0.07, 0.07; P=0.98; moderate quality evidence) with significant heterogeneity (I² = 57%; P<0.001) related to doseand duration of zinc between trials. There was little or no effect on change in height-for-age Z score (13 trials; 8852 participants; MD= 0.11Z; 95% CI -0.00, 0.21; P=0.05), but the heterogeneity was considerable (I²=94%; P<0.001). There was no evidence of effect on length(6303 participants; MD= 1.18 cm; 95% CI -0.63, 2.99 cm, P=0.20; moderate quality evidence; considerable heterogeneity, I²=99%) but alittle positive effect on change in length (19 trials; 10783 participants; MD= 0.43 cm; 95% CI 0.16, 0.70, P=0.002; moderate qualityevidence; considerable heterogeneity, I²=93%). There was no evidence of effect on weight-for-age Z score or change in weight-for-age Zscore but a little positive effect on weight (19 trials; 8851 study participants; MD= 0.23 kg; 95% CI 0.03, 0.42; P=0.02; considerableheterogeneity, I²=91%) and change in weight (kg) (23 trials; 10143 study participants; MD= 0.11 kg; 95% CI 0.05, 0.17, P<0.001,substantial heterogeneity, I²=80%). There was no evidence of effect on weight-for-height Z score, and mid upper arm circumference at theend of supplementation period, but there was a little positive effect on change in mid-arm circumference from baseline (8 trials; 1724participants; MD = 0.09 cm; 95% CI 0.01, 0.16; P=0.03; no heterogeneity, I²=0%). Head circumference in zinc supplemented group wasmarginally higher compared to control (2966 study participants; MD= 0.39 cm; 95% CI 0.03, 0.75; P=0.03; substantial heterogeneity,I²=67%). There was no evidence of benefit in stunting (10 trials; 11838 study participants; RR= 1.0; 95% CI 0.95, 1.06; P=0.89; moderatequality evidence; no significant heterogeneity, I²=11%), wasting (7 trials; 8988 study participants; RR= 0.94; 95% CI 0.82, 1.06; P=0.31;moderate quality evidence; no significant heterogeneity, I²=13%) or underweight (7 trials; 8677 study participants; RR= 1.08; 95% CI 0.96,1.21; P=0.19; moderate quality evidence; substantial heterogeneity, I²=73%).Conclusion: Available evidence suggests that zinc supplementation probably leads to little or no improvement in anthropometric indicesand malnutrition (stunting, underweight and wasting) in children under five years of age in LMICs. Advocating zinc supplementation as apublic health measure to improve growth, therefore, appears unjustified in these settings with scarce resources.
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Objective: To evaluate the impact of water, sanitation and hygiene (WASH) interventions in children (age <18 y) on growth, non-diarrhealmorbidity and mortality in children.Design: Systematic review of randomized controlled trials, non-randomized controlled trials and controlled before-after studies.Setting: Low- and middle-income countries.Participants: 41 trials with WASH intervention, incorporating data on 113055 children.Intervention: Hygiene promotion and education (15 trials), water intervention (10 trials), sanitation improvement (7 trials), all threecomponents of WASH (4 trials), combined water and sanitation (1 trial), and sanitation and hygiene (1 trial).Outcome Measures: (i) Anthropometry: weight, height, weight-for-height, mid-arm circumference; (ii) Prevalence of malnutrition; (iii)Non-diarrheal morbidity; and (iv) mortality.Results: There may be little or no effect of hygiene intervention on most anthropometric parameters (low- to very-low quality evidence).Hygiene intervention reduced the risk of developing Acute respiratory infections by 24% (RR 0.76; 95% CI 0.59, 0.98; moderate qualityevidence), cough by 10% (RR 0.90; 95% CI 0.83, 0.97; moderate quality evidence), laboratory-confirmed influenza by 50% (RR 0.5; 95%CI 0.41, 0.62; very low quality evidence), fever by 13% (RR 0.87; 95% CI 0.74, 1.02; moderate quality evidence), and conjunctivitis by51% (RR 0.49; 95% CI 0.45, 0.55; low quality evidence). There was low quality evidence to suggest no impact of hygiene intervention onmortality (RR 0.65; 95% CI 0.25, 1.7). Improvement in water supply and quality was associated with slightly higher weight-for-age Z-score(MD 0.03; 95% CI 0, 0.06; low quality evidence), but no significant impact on other anthropometric parameters or infectious morbidity (lowto very low quality evidence). There was very low quality evidence to suggest reduction in mortality (RR 0.45; 95% CI 0.25, 0.81).Improvement in sanitation had a variable effect on the anthropometry and infectious morbidity. Combined water, sanitation and hygieneintervention improved height-for-age Z scores (MD 0.22; 95% CI 0.12, 0.32) and decreased the risk of stunting by 13% (RR 0.87; 95% CI0.81, 0.94) (very low quality of evidence). There was no evidence of significant effect of combined WASH interventions on non-diarrhealmorbidity (fever, respiratory infections, intestinal helminth infection and school absenteeism) (low- to very-low quality of evidence). AnyWASH intervention (considered together) resulted in lower risk of underweight (RR 0.81; 95% CI 0.69, 0.96), stunting (RR 0.77; 95% CI0.68, 0.86) and wasting (RR 0.12, 0.85) (low- to very-low quality of evidence).Conclusion: Available evidence suggests that there may be little or no effect of WASH interventions on the anthropometric indices inchildren from low- and middle-income countries. There is low- to very-low quality of evidence to suggest decrease in prevalence ofwasting, stunting and underweight. WASH interventions (especially hygiene intervention) were associated with lower risk of non-diarrhealmorbidity (very low to moderate quality evidence). There was very low quality evidence to suggest some decrease to no change inmortality. These potential health benefits lend support to the ongoing efforts for provision of safe and adequate water supply, sanitationand hygiene.
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Background & objectives: Abnormal endothelial function represents a preclinical marker of atherosclerosis. This study was conducted to evaluate associations between anthropometry, cardiometabolic risk factors, and early life factors and adult measures of endothelial function in a young urban Indian cohort free of clinical cardiovascular disease. Methods: Absolute changes in brachial artery diameter following cuff inflation and sublingual nitroglycerin (400 μg) were recorded to evaluate endothelium-dependent and -independent measures of endothelial function in 600 participants (362 men; 238 women) from the New Delhi Birth Cohort (2006-2009). Data on anthropometry, cardiometabolic risk factors, medical history, socio-economic position, and lifestyle habits were collected. Height and weight were recorded at birth, two and 11 yr of age. Age- and sex-adjusted linear regression models were developed to evaluate these associations. Results: The mean age of participants was 36±1 yr. Twenty two per cent men and 29 per cent women were obese (BMI > 30 kg/m2). Mean systolic blood pressure (SBP) was 131±14 and 119±13 mmHg, and diabetes prevalence was 12 and 8 per cent for men and women, respectively. Brachial artery diameter was higher for men compared with women both before (3.48±0.37 and 2.95±0.35 cm) and after hyperaemia (3.87±0.37 vs. 3.37±0.35 cm). A similar difference was seen before and after nitroglycerin. Markers of increased adiposity, smoking, SBP, and metabolic syndrome, but not early life anthropometry, were inversely associated with endothelial function after adjustment for age and sex. Interpretation & conclusions: The analysis of the current prospective data from a young urban Indian cohort showed that cardiometabolic risk factors, but not early life anthropometry, were associated with worse endothelial function.
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Background: Scaling up of evidence-based management and prevention of childhood diarrhea is a public health priority in India, and necessitates robust literature review, for advocacy and action. Objective: To identify, synthesize and summarize current evidence to guide scaling up of management of diarrhea among under-five children in India, and identify existing knowledge gaps. Methods: A set of questions pertaining to the management (prevention, treatment, and control) of childhood diarrhea was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. Results: Childhood diarrhea is a significant public health problem in India; the point (two-weeks) prevalence is 9-20%. Diarrhea accounts for 14% of the total deaths in under-five children in India. Infants aged 6-24 months are at the highest risk of diarrhea. There is a lack of robust nation-wide data on etiology; rotavirus and diarrheogenic E.coli are the most common organisms identified. The current National Guidelines are sufficient for case-management of childhood diarrhea. Exclusive breastfeeding, handwashing and point-of-use water treatment are effective strategies for prevention of all-cause diarrhea; rotavirus vaccines are efficacious to prevent rotavirus specific diarrhea. ORS and zinc are the mainstay of management during an episode of childhood diarrhea but have low coverage in India due to policy and programmatic barriers, whereas indiscriminate use of antibiotics and other drugs is common. Zinc therapy given during diarrhea can be upscaled through existing infrastructure is introducing the training component and information, education and communication activities. Conclusion: This systematic review summarizes current evidence on childhood diarrhea and provides evidence to inform child health programs in India.
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Background: The neonatal mortality rate (NMR) in India has remained virtually unchanged in the last 5 years. To achieve the Millennium Development Goal (MDG) 4 on child mortality (two thirds reduction from 1990 to 2015), it is essential to reduce NMR. A systematic review of the evidence on community-based intervention packages to reduce NMR is essential for advocacy and action to reach MDG-4. Objective: To assess the effect of community based neonatal care by community health workers (CHWs) on NMR in resource-limited settings. Design: Systematic review and meta-analysis of controlled trials. Data sources: Electronic databases and hand search of reviews, and abstracts and proceedings of conferences. Results: A total of 13 controlled trials involving about 192000 births were included in this systematic review. Community based neonatal care by CHWs was associated with reduced neonatal mortality in resource-limited settings [RR=0.73 (0.65 to 0.83); P<0.0001]. The identified studies were a heterogeneous mix with respect to the extent and quality of community based neonatal care provided and the characteristics of the CHWs delivering the intervention. There was no consistent effect of training duration of the health workers, type of intervention (home visitation versus community participatory action and learning), number of home visits done by CHWs, and provision of only preventive versus both preventive and therapeutic care. Limited data suggests that the ideal time for the first postnatal visit is the first two days of life. The interventions are highly effective when baseline NMR is above 50/1000 live births [RR=0.64(0.54 to 0.77)]. The interventions show a significant decrease in efficacy as the NMR drops below 50/1000 live births [RR=0.85 (0.73 to 0.99)], however is still substantial. NMR gains from home visitation approach are going to materialize only in the presence of high program coverage of 50% or more. Conclusion: A significant decrease in NMR is possible by providing community based neonatal care in areas with high NMR by community health workers with a modest training duration and ensuring high program coverage with home visitation on the first two days of life.
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Background: Scaling up of evidence-based management of childhood acute respiratory infection/pneumonia, is a public health priority in India, and necessitates robust literature review, for advocacy and action. Objective: To identify, synthesize and summarize current evidence to guide scaling up of management of childhood acute respiratory infection/pneumonia in India, and identify existing knowledge gaps. Methods: A set of ten questions pertaining to the management (prevention, treatment, and control) of childhood ARI/ pneumonia was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. Results: Childhood ARI/pneumonia is a significant public health problem in India, although robust epidemiological data is not available on its incidence. Mortality due to pneumonia accounts for approximately one-fourth of the total deaths in under five children, in India. Pneumonia affects children irrespective of socioeconomic status; with higher risk among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use. There is lack of robust nation-wide data on etiology; bacteria (including Pneumococcus, H. influenzae, S. aureus and Gram negative bacilli), viruses (especially RSV) and Mycoplasma, are the common organisms identified. In-vitro resistance to cotrimoxazole is high. Wheezing is commonly associated with ARI/pneumonia in children, but difficult to appreciate without auscultation. The current WHO guidelines as modified by IndiaCLEN Task force on Penumonia (2010), are sufficient for case-management of childhood pneumonia. Other important interventions to prevent mortality are oxygen therapy for those with severe or very severe pneumonia and measles vaccination for all infants. There is insufficient evidence for protective or curative effect of vitamin A; zinc supplementation could be beneficial to prevent pneumonia, although it has no therapeutic benefit. There is insufficient evidence on potential effectiveness and cost-effectiveness of Hib and Pneumococcal vaccines on reduction of ARI specific mortality. Case-finding and community-based management are effective management strategies, but have low coverage in India due to policy and programmatic barriers. There is a significant gap in the utilization of existing services, provider practices as well as family practices in seeking care. Conclusion: The systematic review summarizes current evidence on childhood ARI and pneumonia management and provides evidence to inform child health programs in India.
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India is committed to reducing childhood mortality and morbidity. This requires evidence-based policy and practice in the realm of public health. This in turn necessitates advocacy and action (among all stakeholders), focused on locally relevant issues. A collaboration to work towards this goal was forged between the Public Health Foundation of India (PHFI), United Nations International Children’s Emergency Fund (UNICEF), India; and a team of independent researchers. As a first step, a systematic review of literature on four priority areas of newborn care (community-based interventions) and child health (acute respiratory infection, diarrheal disease, anemia), was undertaken to address important issues including epidemiology, interventions for management, and operational issues of planning, implementing, and measuring actions at a programmatic level. This paper describes the development of the methodology for undertaking these systematic reviews including the process for framing of research questions, building a research team, and executing the systematic review (literature search strategy, data extraction, analysis, and reporting). The challenges associated with ensuring robust methodology, are also described.
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Context: Severe acute malnutrition (SAM) in children is a significant public health problem in India with associated increased morbidity and mortality. The current WHO recommendations on management of SAM are based on facility based treatment. Given the large number of children with SAM in India and the involved costs to the care-provider as well as the care-seeker, incorporation of alternative strategies like home based management of uncomplicated SAM is important. The present review assesses (a) the efficacy and safety of home based management of SAM using ‘therapeutic nutrition products’ or ready to use therapeutic foods (RUTF); and (b) efficacy of these products in comparison with F-100 and home-based diet. Evidence Acquisition: Electronic database (Pubmed and Cochrane Controlled Trials Register) were scanned using keywords ‘severe malnutrition’, ‘therapy’, ‘diet’, ‘ready to use foods’ and ‘RUTF’. Bibliographics of identified articles, reviews and books were scanned. The information was extracted from the identified papers and graded according to the CEBM guidelines. Results: Eighteen published papers (2 systematic reviews, 7 controlled trials, 7 observational trials and 2 consensus statements) were identified. Systematic reviews and RCTs showed RUTF to be at least as efficacious as F-100 in increasing weight (WMD=3.0 g/kg/day; 95% CI -1.70, 7.70) and more effective in comparison to home based dietary therapies. Locally made RUTFs were as effective as imported RUTFs (WMD=0.07 g/kg/d; 95% CI=-0.15, 0.29). Data from observational studies showed the energy intake with RUTF to be comparable to F-100. The pooled recovery rate, mortality and default in treatment with RUTF was 88.3%, 0.7% and 3.6%, respectively with a mean weight gain of 3.2 g/ kg/day. The two consensus statements supported the use of RUTF for home based management of uncomplicated SAM. Conclusions: The use of therapeutic nutrition products like RUTF for home based management of uncomplicated SAM appears to be safe and efficacious. However, most of the evidence on this promising strategy has emerged from observational studies conducted in emergency settings in Africa. There is need to generate more robust evidence, design similar products locally and establish their efficacy and cost-effectiveness in a ‘non-emergency’ setting, particularly in the Indian context.
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OBJECTIVE: To evaluate the effect of iron supplementation on physical performance in children (0-18 years) through systematic review of randomised controlled trials (RCTs). DATA SOURCES: Electronic databases, personal files, handsearch of reviews, bibliographies of books, abstracts and proceedings of international conferences. REVIEW METHODS: RCTs with interventions that included oral or parenteral iron supplementation, fortified formula milk, or cereals were evaluated. The physical performance outcomes studied were heart rate, treadmill endurance times, blood lactate, and oxygen consumption. RESULTS: A total of three studies were included, in all of which iron was supplemented in the form of oral medicinal iron. At 5, 6 and 7 miles per hour running speeds, the pooled weighted mean (95% Cl) difference (WMD) in the heart rate (per minute) between the iron and the placebo, following exercise was -7.3 (-19.6, 4.9; p = 0.241), -6.6 (- 19.9, 6.6; p = 0.327), and -8.0 (-19.7, 3.7; p = 0.182), respectively. After excluding the study with nonanemic subjects, the corresponding figures were -13.1 (-23.2, -3.1; p= 0.01), -14.2 (-22.3, -6.1; p = 0.001) and -12.7 (-23.5, 1.9; p = 0.021), respectively. Oxygen consumption, estimated in two studies, showed no significant difference between the treatment groups. Blood lactate levels were estimated in one study only at two different doses of iron, and were significantly lower (p < 0.05) in iron supplemented group in comparison to placebo both before (7.71 and 7.55 mg/dL versus 8.43 mg/dL) and after (14.36 and 14.35 mg/dL versus 16.48 mg/dL) exercise. Treadmill endurance time was significantly better in iron supplemented group when compared with placebo in one study. CONCLUSIONS: Iron supplementation may have a positive effect on the physical performance of children, as evaluated through the post exercise heart rate in anemic subjects, blood lactate levels and treadmill endurance time. In view of the limited data availability, this finding cannot be considered conclusive.