Designing Rigorous Program Evaluations to Assess the Impact on Child Growth of Integrated IYCN Programs in Burkina Faso and Ethiopia.

Objectives: The Micronutrient Initiative and academic partners have designed two program impact evaluations of Infant and Young Child Nutrition (IYCN) interventions in Ethiopia and Burkina Faso. The programs include enhanced behavioral change interventions on IYCN, improved quality of local complementary feeding, provision of Multiple Micronutrient Powders (MNPs) to children 6 to 23 months, and ensuring an integrated preventive and community-based management of moderate acute malnutrition. The objective is to critically review key elements for consideration in the design of future IYCN program evaluations. Methods: Evaluation designs were based on 1) selection of primary and secondary outcome indicators based on the Program Impact Pathways (PIP), 2) Considerations for assignment of intervention and comparison groups; 3) Considerations on designs in the context of integrated programs; 4) Ability to monitor adverse events within a program. Results: Following PIP, both impact and process indicators were identified. In Ethiopia, a matched-control cluster design and in Burkina Faso a cluster randomized matched-control design was used with repeated cross-sectional surveys. Sample size calculations took into account the selection of age-appropriate cohorts for the different impact indicators, and a population based sampling scheme. Following recent discussions around the safety of iron-containing supplements in young children without iron deficiency, the evaluations also included practical methods to assess potential adverse events in program settings. Conclusions: The complexity of measuring impact on child nutrition in an integrated programmatic context is often underestimated, leading to evaluations with inconclusive results or impacts that are difficult to attribute to program. Careful design could help avoid such pitfalls.

Post-production Losses in Iodine Concentration of Salt Hamper the Control of Iodine Deficiency Disorders: A Case Study in Northern Ethiopia.

Iodine is essential for good function of the thyroid, and its deficiency is of public-health importance in Ethiopia. Iodization of salt is an effective and sustainable strategy to prevent and control iodine deficiency in large populations. The effectiveness of salt-iodization programmes depends on the conservation of iodine concentration in salt at various stages of the supply-chain. The overall objective of the study was to assess the loss of iodine in salt from production to consumption and to estimate the proportion of adults, especially pregnant women, at risk of dietary iodine insufficiency. A cross-sectional study was conducted during February-April 2007 in northern Ethiopia. Iodine concentrations of salt samples from producers (n=41), retailers (n=7), and consumers (n=32) were determined using iodiometric titration. A risk assessment was conducted for dietary iodine insufficiency among adults, including pregnant women, using a semi-probabilistic approach. The concentration of iodine in the sampled salts decreased by 57% from the production site to the consumers. The assessment of exposure showed that adults in 63% (n=20) of the households, including 90% (n=29) with pregnant women, were at risk of insufficient iodine intake. A monitoring and evaluation system needs to be established to ensure adequate supply of iodine along the distribution chain. Special attention is needed for the retailers and consumers. At these levels, dissemination of information regarding proper storage and handling of iodized salt is necessary to address the reported loss of iodine from salt.

Avaliação do estado nutricional de ferro e anemia em crianças menores de 5 anos de creches públicas / Nutritional assessment of iron status and anemia in children under 5 years old at public daycare centers

OBJETIVO: Avaliar o estado nutricional de ferro e a prevalência de anemia em crianças menores de 5 anos de creches públicas da cidade do Recife (PE). MÉTODOS: Estudo transversal, com amostra aleatória sistemática de 162 crianças, de 6 a 59 meses. O estado nutricional de ferro foi avaliado em termos de reservas corporais (ferritina sérica), transferrinemia (ferro sérico, capacidade total de ligação do ferro e por cento de saturação da transferrina), eritropoiese (protoporfirina eritrocitária livre) e hemoglobinogênese (hemoglobina). RESULTADOS: A prevalência de anemia (hemoglobina < 11,0 g/dL) foi de 55,6 por cento (IC95 por cento 47,3-63,5), a redução dos estoques de ferro (ferritina sérica < 12,0 ng/mL) foi evidenciada em 30,8 por cento (IC95 por cento 22,9-39,3), baixa transferrinemia ( por cento de saturação da transferrina < 16) em 60,1 por cento (IC95 por cento 51,7-68,0) e eritropoiese deficiente (protoporfirina eritrocitária livre > 40 æmol/mol heme) em 69,6 por cento (IC95 por cento 61,0-77,1) das crianças. Os parâmetros de ferro não apresentaram correlação com o gênero (p > 0,05). No entanto, crianças < 24 meses apresentaram concentrações mais baixas de hemoglobina (p < 0,00) e níveis mais elevados de protoporfirina eritrocitária livre (p < 0,000) e de capacidade total de ligação do ferro (p < 0,001), quando comparadas às crianças > 24 meses. A significante correlação observada entre reserva, transferrinemia e eritropoiese representa achado compatível com o esperado ciclo de vida do ferro no organismo. CONCLUSÕES: A deficiência de ferro e a anemia parecem ser um importante problema de saúde pública entre as crianças menores de 5 anos de creches públicas do Recife. Logo, ações efetivas direcionadas à prevenção e ao controle dessa deficiência são fortemente recomendadas nesse contexto ecológico.

OBJECTIVE: To assess nutritional iron status and anemia prevalence in children less than 5 years old at public daycare centers in the city of Recife, PE, Brazil. METHODS: A cross-sectional study, with a systematic random sampling of 162 children aged 6 to 59 months. Nutritional iron status was assessed in terms of body iron reserves (serum ferritin), transferrinemia (serum iron, total iron binding capacity, and transferrin saturation percent), erythropoiesis (free erythrocyte protoporphyrin) and hemoglobin production (hemoglobin). RESULTS: The prevalence of anemia (hemoglobin < 11.0 g/dL) was 55.6 percent (95 percentCI 47.3-63.5), evidence was found of depleted iron stocks (serum ferritin < 12.0 ng/mL) in 30.8 percent (95 percentCI 22.9-39.3), low transferrinemia levels (transferrin saturation percent < 16) in 60.1 percent (95 percentCI 51.7-68.0) and deficient erythropoiesis (free erythrocyte protoporphyrin > 40 æmol/mol heme) in 69.6 percent (95 percentCI 61.0-77.1) of the children. Iron parameters were not correlated with sex (p > 0.05). However, children < 24 months exhibited lower hemoglobin concentrations (p < 0.00) and higher levels of free erythrocyte protoporphyrin (p < 0.000) and total iron binding capacity (p < 0.001) when compared with children > 24 months. The significant correlation observed between reserves, transferrinemia and erythropoiesis is a finding that is compatible with the expected lifecycle of iron in the body. CONCLUSIONS: Iron deficiency and anemia appear to be an important public health problem among children less than 5 years old at public daycare centers in Recife. Therefore, effective actions aimed at the prevention and control of this deficiency are strongly recommended in this ecological context.

Perceptions of growth monitoring and promotion among an international panel of district medical officers.

The growth chart has been proposed as an educational tool to make the child's growth visible to both health workers and caregivers and to enhance communication between them. In the case of growth faltering, this would trigger timely corrective measures. Although the relevance of growth monitoring and promotion (GMP) has often been questioned in the literature, opinions of District Medical Officers responsible for local implementation of GMP are unknown. The aim of this qualitative research was to explore the perceptions and difficulties of an international panel of District Medical Officers regarding GMP. As an exploratory study, in-depth interviews of an international panel of District Medical Officers (n=19) were conducted. Data were coded using the QSR Nudist 5.0 software. A discrepancy between intended purposes and practice of GMP was detected at two levels. First, lack of participation of care-givers was reported. Second, the District Medical Officers expressed a restrictive interpretation of the concept of growth monitoring. The communication with parents was never reported as a means or a result of GMP, neither as an evaluation criterion of programme efficiency. The growth chart was mainly considered a tool intended to be used by health services for the purpose of diagnosis. This two-fold discrepancy between the intention of international policy-planners and practice of local programme implementers could be a crucial factor affecting the performance of GMP. More emphasis should be put on social communication and involvement of caregivers.

Feeding practices and factors contributing to wasting, stunting, and iron-deficiency anaemia among 3-23-month old children in Kilosa district, rural Tanzania.

Infants in Tanzania are particularly vulnerable to under-nutrition during transition from breastmilk (as the only source of nourishment) to solid foods. A cross-sectional study was undertaken in Kilosa district in Tanzania to determine the feeding practices and the extent of wasting, stunting, and iron-deficiency anaemia. The study was done in two stages: in the first stage, a 24-hour dietary assessment was conducted to identify the type of complementary foods given and the eating habits according to age for 378 children aged 3-23 months. In the second stage, a progressive recruitment of 309 infants aged six months was made to measure weight, length, haemoglobin (Hb) concentration, zinc protoporphyrin concentration, and malaria parasitaemia. Birth-weight, the potential contributing factor to under-nutrition and iron-deficiency anaemia, was obtained from the children's clinic cards. The 24-hour dietary assessment revealed that children consumed mainly a thin porridge prepared from maize flour as complementary food. Carbohydrates contributed most energy (on average 69%), followed by fats (18.6%) and protein (on average 12.1%). The complementary food co-vered only 15%, 20%, and 27% of the recommended iron intake for children aged 6-8, 9-11 and 12-23 months respectively. The mean Hb concentration was 9.3 +/- 1.9 g/dL, 68% of the infants were moderately anaemic (7 < or =11 g/dL), and about 11% were severely anaemic with Hb below 7 g/dL, while 21% were non-anaemic Hb (> or =11 g/dL). Equally, the mean zinc protoporphyrin concentration was 10.0 +/- 6.2 microg/g Hb, and 76% of the infants were iron-deficient (>5 microg/g Hb). The prevalence of stunting was 35%, while wasting was only 1.3%. Low birth-weight and low body mass index of mothers were the strong predictors of stunting, whereas low birth-weight and iron-deficiency were the strong predictors of anaemia. The prevalence of malaria parasitaemia was high, affecting 50% of the infants. Having malaria was the only independent predictor associated with stunting, anaemia, and iron-deficiency. There is an urgent need to improve tradi-tional complementary foods in the studied community in terms of energy density, amount of fat in the diet, and bioavailability of macro and micronutrients.

Hipovitaminose A em pré - escolares de creches públicas do Recife: indicadores bioquímico e dietético / Vitamin A deficiency among preschool children attending public day care centres of Recife: biochemical and dietetic indicators

OBJETIVO: Estimar a prevalência de hipovitaminose A em pré-escolares de creches públicas da cidade do Recife, Estado de Pernambuco, Brasil. MÉTODOS: Estudo de corte transversal, envolvendo 311 crianças menores de cinco anos, de ambos os sexos, aleatoriamente selecionadas, e avaliadas pelos indicadores bioquímico (retinol sérico), dietético (inquérito de consumo alimentar) e antropométrico (peso/idade, altura/idade e peso/altura). RESULTADOS: A prevalência de níveis de retinol sérico baixos (<0,70æmol/L) foi de 7,0 por cento, caracterizando a deficiência de vitamina A como problema de saúde pública do tipo leve, segundo critérios da Organização Mundial de Saúde. Cerca de 78,0 por cento das crianças apresentaram adequação do consumo de vitamina A, considerando-se as cifras recomendadas pela Dietary Reference Intakes, 2001. A distribuição dos níveis séricos de retinol e do consumo alimentar de vitamina A foi homogênea, segundo o sexo. No entanto, crianças na faixa etária de 12 a 48 meses mostraram menor consumo de alimentos fonte de vitamina A em relação às crianças das demais faixas etárias (p<0,05). A prevalência de baixo peso foi de 7,5 por cento, de retardo do crescimento linear de 8,1 por cento e de desnutrição aguda de 1,8 por cento. A hipovitaminose A não mostrou correlação com a desnutrição energético-protéica (p>0,05). O consumo dietético de vitamina A mostrou sensibilidade reduzida (43,0 por cento) e baixíssimo valor preditivo positivo (6,8 por cento) no diagnóstico da hiporretinolemia. CONCLUSÃO: A identificação de grupos populacionais vulneráveis, bem como a seleção de indicadores fidedignos do estado nutricional de vitamina A, são elementos essenciais para o diagnóstico e o planejamento de ações visando à prevenção e ao controle dessa carência nutricional específica.

Bringing together viewpoints of mothers and health workers to enhance monitoring and promotion of growth and development of children: a case study from the Republic of Congo.

In 1996, the Government of the Republic of Congo launched a pilot project to improve the child growth and development component of primary healthcare. The present study was carried out (i) to explore perceptions and practices of mothers and health workers regarding child growth, health, and development, and (ii) to design culturally-appropriate tools to enhance their monitoring and promotion. The study was carried out in two randomly-selected health centres in Brazzaville. Qualitative data collected included 16 focus-group discussions with 174 mothers, two focus-group discussions with 18 health workers, and 20 individual interviews with paediatricians or psychologists. The health workers reported that the main indicator of child growth was weight, while the mothers used broader concepts for evaluating growth and development of their toddlers. A strategy encompassing anthropometrics, developmental milestones, and acquisition of social skills was elaborated to enhance communication between health workers and mothers. A new growth chart was designed, and a new calendar of systematic visits, including key tasks and messages, was established. However, these new tools derived from the formative research still need to be carefully tested.

Parameters of evaluation of zinc nutritional status: comparison between zinc hair rates and serum alkaline phosphatase in prescholars of the Municipality of João Pessoa, Paraíba

Objetivos: avaliar o estado nutricional de zinco em crianças de dois a cinco de idade, institucionalizadas em creches do município de João Pessoa, Paraíba. Métodos: utilizou-se uma amostra aleatória sistemática, constituída de 377 crianças. O status nutricional de zinco foi avaliado pelos seguintes parâmetros: concentrações do mineral no cabelo e níveis de atividade enzimática da fosfatase alcalina sérica. Resultados: a prevalência das concentrações inadequadas de zinco no cabelo foi de 61,9 por cento predominando a deficiência na sua forma grave, 38,5 por cento. A prevalência das concentrações inadequadas de níveis de atividade enzimática da fosfatase alcalina sérica foi de 40,1 por cento. As concentrações de zinco no cabelo mostraram correlação com a fosfatase alcalina sérica (r = 0,01; p = 0,882). A distribuição do zinco no cabelo segundo sexo e idade foi homogênea; comportamento idêntico foi observado com a fosfatase alcalina.