Effectiveness of weekly vitamin A (10,000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia.

OBJECTIVE: High prevalences of vitamin A deficiency and anaemia among adolescents warrant interventions. This study evaluated the effectiveness of school-based supplementation to reduce anaemia and improve vitamin A status. DESIGN: School-based, grade-randomized, intervention. SUBJECTS AND SETTING: In all, 1757 girls and 1859 boys, aged 12-15 y, in 24 Junior High Schools. INTERVENTIONS: Weekly supplementation for 14 weeks with 60 mg iron and 250 microg folate (Fe group; n=978), 10 000 IU vitamin A (VA group; n=970) or both (VAFe group; n=1042) to subjects in 15 schools, compared to subjects in nine other schools not receiving supplements (control; n=626). RESULTS: The baseline anaemia prevalence (Hb <120 g/l) in girls was 20% (prepubertal) and 26% (pubertal), and in boys 24% (pre-pubertal) and 11% (pubertal). Serum retinol concentrations were low (<1.05 micromol/l) in 41% of boys and 45% of girls. The interventions did not increase haemoglobin concentrations. Serum retinol concentration of boys, but not girls, in the VA group increased (0.33 vs 0.07 micromol/l in controls; P<0.01). The risk factors for low serum retinol concentration were lower baseline serum retinol concentration (OR 0.02-0.03) with, for girls, nightblindness at baseline (OR 5.88), and for boys, not receiving vitamin A (OR control: 1.00; VA: 0.37; Fe: 0.77; VAFe: 0.34) and maternal illiteracy (OR mother never attended school 1.00, mother received any formal education 0.17-0.33). CONCLUSIONS: Supplementation with vitamin A increased serum retinol concentration of boys. Iron supplementation did not change Hb. This appeared to be due to poor compliance, and partly related to side effects.

Pattern of linear growth velocities of infants from birth to 12 months in Madura, Indonesia.

The paper analyses growth velocity data of infants aged 0-11 months from Madura, Indonesia, with the aim of identifying the time of onset of linear growth retardation. Velocities were calculated as average velocities from mid-point intervals, so that they can serve as comparative information for further studies. Secondly, the relation between weight and length velocities is tested. Thirdly, growth velocities are related to birthweight, length at birth and ponderal index (PI = weight/height3 x 100 in g/cm3. The anthropometric information of infants is taken from two large longitudinal studies, East Java Pregnancy Studies Phase I and Phase II (EJPS I and II). These were conducted from August 1981 to December 1985 and January 1987 to December 1989, respectively, in two villages in Madura, Indonesia. The results support the following hypotheses: linear growth in the first year in Madurese infants shows two periods of deceleration. The early phase starts in the first month and is related to intra-uterine growth. It lasts up to about 4-6 months. Children with normal birthweight but with a low PI grow slowest in length after birth. The second period is towards the second half of the first year, when differences in linear velocity decrease with the references and velocity distribution change. Differences in weight velocity increase during this period. Factors outside the intricate fetal mother-child relationship could start to play a role.

Morbidity and growth performance of infants in Madura, Indonesia.

Between January 1987 and July 1988, all children born in two villages on the island of Madura, Indonesia were visited weekly by a field worker trained to interview mothers on disease symptoms. The maximum recall period was 1 week. All infants were measured (weight and height) at monthly intervals. Information on growth and morbidity is analysed for infants from birth until the age of 11 months. Morbidity, defined as acute respiratory tract infection (ARI), diarrhoea, fever and other diseases, is analysed over 4-week periods and related to growth performance. In total, there are 1373 4-week reporting periods with morbidity information from birth to the age of 12 months. Of all the diseases recorded (1021), 47% were ARI, 13% diarrhoea, 14% fever and 26% other diseases. The average (SD) duration of diarrhoea was 7 (11) days, ARI 14 (9) days, fever 6 (4) days and 16 (10) days for other diseases. The most striking results in this analysis are: (i) the lack of a relationship between morbidity and growth (either linear or weight) during the 1st 6 months of life; (ii) the existence of a relationship between illness and weight increment for which only ARI showed significant influence for infants of 6 months and more; (iii) the lack of a relationship between morbidity and linear growth performance at all ages; and (iv) the fact that no cumulative effect of disease on growth performance was found to explain the observations.

PIP: To collect data on infant morbidity and growth, all children born in an 18-month period in 1987-88 in two villages on the island of Madura, Indonesia, were visited weekly by a field worker. Infants were weighed and measured monthly. In total, 1373 4-week reporting periods covering birth through 12 months were available for analysis. Disease was present in 51% of these periods, and 22% of infants had more than one illness episode in a 4-week period. Of the 1021 disease episodes recorded, the most prevalent were acute respiratory infection (47%), fever (14%), and diarrhea (13%). The average durations of these three diseases were 14 +or- 9 days, 6 +or- 4 days, and 7 +or- 11 days, respectively. Extrapolation of these findings suggests the average infant in Mandura will have 4 episodes of acute respiratory infection, 1-2 episodes of diarrhea and fever, and 2-3 episodes of other diseases in the first year of life. There was no association between morbidity and growth in the first 6 months of life. However, between 6 and 11 months of age, acute respiratory infection (but not diarrhea) was significantly associated with incremental weight loss. Height was not affected by morbidity at any age. There was no cumulative effect of disease on growth performance. These findings suggest that if infants are breast fed, well cared for, and provided access to curative care in the first year of life, as the infants in Mandura were, intercurrent illness has no midterm adverse effect on growth.

Energy supplementation during pregnancy and postnatal growth.

The effect of improving maternal nutrition during pregnancy on growth of the child has not been assessed, since previous studies supplemented the diets of children as well as mothers. In a controlled randomised trial in Madura, East Java, pregnant women received a high (HE) or low (LE) energy supplement that provided 1950 kJ (465 kcal) or 218 kJ (52 kcal), respectively, in the last trimester of pregnancy. The effect of this intervention on the children's growth was assessed longitudinally for the first 5 years of life. Only the children of mothers who had complied for at least 90 days were included. Infants entered the study at birth and their growth was measured at 4-week intervals until 12 months old; thereafter they were measured every 3 months. Growth curves were calculated from a mathematical model, based on the best fit of actual measurements and the age-related growth velocity. Up to the age of 24 months, HE children were significantly heavier than LE children (p less than 0.05). HE children were also taller throughout the first 5 years (p less than 0.005 from 15 to 48 months, p less than 0.05 at both 3-12 and 60 months). Weight-for-height by age was similar in both groups, but stunting (height-for-age) was less prevalent in HE children. In a community characterised by chronic energy deficiency among women of reproductive age, energy supplementation of women for the last 90 days of pregnancy was effective in the promotion of postnatal growth and reduction in malnutrition of preschool children.

PIP: In 1982-84, health workers randomly assigned 542 women in the last trimester of pregnancy who lived in 3 villages in East Java, Indonesia to either the low energy (LE) or high energy (HE) supplement group (52 kcal vs. 465 kcal). They followed the children for 5 years to determine the association between prenatal nutrition and postnatal growth. No difference in infant and child mortality (mean=116 and 32, respectively) existed between the HE and LE children. The supplement had no effect on growth of children whose mothers took it for 45 days. HE children weighed more and were taller than those of LE children during the entire 5 years. The weight differences were significant only until 24 months (p.05), but height differences were significant during the entire 60 months (p.005 from 15-48 months; p.05 from 3-12 and 60 months). Weight differences peaked at 9 months (463 gm). Height differences rose with age (0.9 cm at 3 months and 1.7 cm at 60 months). Growth rates were always more rapid in HE children, and differences in height gain were only significant at 2-3 months (p.01) and in weight gain from 1-6 months (p.05). Thus improved growth was realized early in life. 38% of the HE children had a satisfactory nutritional status based on height for age at 12 months compared with 16% for LE children (p.01). These corresponding figures for weight for age were 28% and 14%. At 24 months, however, the weights were similar for both groups. 23% of HE children at 24 months had a satisfactory height compared with only 8% of LE children. After 24 months, the differences no longer existed for either weight or height. No significant differences existed for weight for height thus showing that both groups of children were stunted. Prevalence of stunting was lower among HE children, however. These results indicated that high energy supplementation during the 3rd trimester boosted postnatal growth and reduced malnutrition in 1-60 month old children.

Reproduction and maternal nutrition in Madura, Indonesia.

The prevalence and severity of chronic energy deficiency (CED) among women of reproductive age as well as its consequences on the newborn and the mother were assessed in a longitudinal study. More than 40% of the mothers had a Body Mass Index (BMI) less than 18.5 before pregnancy, a level below which CED is considered to exist. Weight gain during pregnancy was low, on average 6.6 kg. Taking the difference between 4 week postpartum weight and pre-pregnant weight as net weight gain during pregnancy, mothers with a BMI less than 18.5 before pregnancy gained weight while those with a higher BMI lost weight. This observation suggests that the partitioning of energy to the fetus and the mother depends on the energy reserves of the mother before pregnancy. The functional significance of BMI as an indicator of CED is illustrated by its relation with birth weight. Similarly, 4 week postpartum, weight and BMI were predictive for the weight changes in the mother in the first 12 months after delivery. The groups with the lowest values gained weight, while the heaviest mothers lost weight. In view of the negative effects of CED among women of reproductive age on the infant and the mother, maternal undernutrition should receive the same attention as malnutrition among preschool children.

PIP: Between late 1982 and late 1985 and early 1987 and late 1989, health workers collected anthropometric and caloric intake data on 1032 women living in a rural village on the island of Madura, East Java, Indonesia, to determine the prevalence and severity of chronic energy deficiency and the effect reproduction had on their nutritional status. These women had 2013 single births. 41.3% of all women suffered from chronic energy deficiency, defined as a body mass index (BMI) less than 18.5. Further, 2.6% of all women had severe chronic energy deficiency. This indicated that these women had suffered malnutrition during childhood. 31.6% of the women weighed less than 41 kg before pregnancy. 80% of these women had chronic energy deficiency. Caloric intake during pregnancy averaged 1550 kcal/day. Pregnancy women ate a mean of 42 g of protein/day. Their physical activity level was low. Mean total weight gained during pregnancy was a low 6.6 kg. Pregnant women used fat reserves during pregnancy, as indicated by lower upper aim circumferences and skinfold thicknesses (in 75% of cases) at the end of pregnancy compared to the first trimester. Women who weighted the least before pregnancy (35-45 kg) gained weight (0.9-2.8 kg) during pregnancy, while those weighing at least 45 kg before pregnancy lost weight (0.3-0.6 kg). There was a very significant positive trend in mean birth weight with prepregnant weight and BMI. For example, the mean birth weight for infants of mothers whose BMI was less than 16 was 2740 g, and 3044 g for =or 18.5 BMI. Thus, the tiniest women built up fat reserves during pregnancy at the expense of fetal growth. Postpartum women consumed just 200 kcal more during lactation than they did during pregnancy. Women who weighed less than 35 kg and had a low BMI at 4 weeks postpartum gained weight over the 12 months postpartum while those who weighed the most lost weight. These findings stress the need to put as much emphasis on maternal undernutrition as there is on malnutrition among preschoolers.

Low birth weight babies under village conditions: feeding pattern, growth and motor development.

Feeding, growth and motor development of low birth weight babies (LBW) were assessed among infants born from September 1982 through December 1984 in 3 villages in Madura. Mean birth weight of Madurese infants ranged from 2850-2950 g and the incidence of LBW from 9.5-12.2%. A larger percentage of the very small LBW babies (birth weight 2.0-2.2 kg) received breastmilk as the sole food in the first 6 months. Yet, force-feeding was also practiced for LBW babies. Infants remained in their growth channel according to birth weight, however, relative to the NCHS centiles at birth, LBW infants grew better in the first 6 months than normal birth weight (NBW) infants. Growth deteriorated conspicuously in the second half of infancy, irrespective of birth weight. There was no difference in motor development between LBW and NBW infants. Once they had survived, LBW infants appeared to do as well as NBW under village conditions.

PIP: Researchers followed at least 561 single births born between September 1982-December 1984 in 3 villages in Madura, Indonesia from birth to 12 months to assess infant feeding, growth, and motor development of full term, low birth weight (LBW) infants. Mean birth weight varied from 2850-2950 g and the incidence of LBW from 9.5-12.2%. No special interventions were employed with the LBW infants. Only about 15% of the infants were exclusively breast fed in the 1st 12 months, but not all of the 15% were the same infants. Most infants who returned to exclusive breast feeding refused other food. Some infants received their 1st supplementary food by the end of the 1st week. Apparently this did not adversely affect the infants health, however. Mothers of infants 2300 g tended to exclusively breast feed more and longer than all other mothers. All infants stayed in their growth category by birth weight cohort. In fact, LBW infants grew better than normal birth weight (NBW) infants according to the NCHS centiles at birth during the 1st 6 months. The fact that the LBW infants were wasted may have explained the catch up in growth with NBW infants during the 1st 6 months. During 6-12 months, however, the weight and length of both LBW and NBW infants faltered. The deflection from the reference level at birth was greater for NBW infants, however. Further the motor development of both NBW and LBW infants progressed at basically the same rate. In conclusion, surviving LBW infants grew quite well and their motor skills developed satisfactorily under village conditions in rural Madura, Indonesia.

Patterns of variability in the nutrient intake of nutritionally vulnerable pregnant women.

Intra/inter-individual variance ratios for energy, protein, fat and retinol-equivalent intake during the third trimester of pregnancy were calculated. Data were collected on 743 pregnant women from rural Indonesia between 1982 and 1984. Food intake of these women was directly weighed for three consecutive days per month during months 6-9 of pregnancy, yielding 7139 observations for analysis. Ratios were calculated separately for a single month of pregnancy and for the last trimester of pregnancy. The intra/inter-individual variance ratio for kilocalorie and protein intake was less than 1.0 for a single month; it was greater than 1.0 for the trimester. This suggests that women varied their intake of kilocalories and protein more over the course of their pregnancy than they did during one month of their pregnancy. Both the monthly and trimester variance ratios for fat and retinol-equivalent intake were greater than 1.0. Our findings suggest that usual mean intake during the third trimester of pregnancy can be measured with relative precision with two replicates per individual. However, more measurements are needed for regression analyses: measurement error greatly attenuated the coefficients, even though data were collected by the direct weighing method. Thus the number of measurements per individual needed in a study of nutrition and pregnancy depends on the nutrient, the period of 'usual intake' that is of interest, as well as the analytical strategy.

Nutritional transition during infancy in East Java, Indonesia: 1. A longitudinal study of feeding pattern, breast milk intake and the consumption of additional foods.

Infant feeding pattern was studied longitudinally from birth to 52 weeks among all infants born in the period September 1982-December 1984 in three villages in Madura, East Java (n = 687). Genuine demand breast-feeding was practised but it is the custom to force-feed infants from as early as the third day after birth until about 16 weeks. In a sub-sample the intake of breast milk and additional foods were measured, longitudinally in 76 infants and cross-sectionally in 77 infants. Breast milk intake ranged from 745 g per 24 h in the first month to 640 g per 24 h in the 12th month. Force-feeding did not have a negative influence on breast milk intake. The main constraint in infant feeding is the low intake of additional foods, which remained at 180 kcal and 3 g protein per day from the age of 16 weeks onwards.

Nutritional transition during infancy in East Java, Indonesia: 2. A longitudinal study of growth in relation to the intake of breast milk and additional foods.

Weight and length of infants, born in two villages in Madura, East Java were measured longitudinally from birth to 12 months (n = 391). In a sub-sample (n = 76) the intake of breast milk and additional foods during 48 h were also measured. The shape of the weight curve of Madurese infants is comparable to that of healthy, exclusively breast-fed infants in the UK and US during the first 6 months of life, in spite of the custom to force-feed from as early as the first week. The use of a more 'appropriate' growth curve of exclusively breast-fed, healthy infants instead of the NCHS reference failed to define more accurately the age at which growth faltering starts. It is recommended to use weight increments as an indicator of the onset of growth faltering. Breast milk intake correlated significantly with attained weight. However, it explains only a small percentage of the variation in weight, viz. 12-24 per cent. There was no correlation between energy or protein intake from breast milk and additional foods and weight gain.

PIP: Weight and length of infants, born in 2 villages in Madura, East Java, were measured longitudinally from birth-12 months (n=391). In a subsample (n=76), the intake of breastmilk and additional foods during a 48 period were also measured. The shape of the weight curve of Madurese infants is comparable to that of healthy, exclusively breastfed infants in the United Kingdom and the US during the 1st 6 months of life, in spite of the custom of force feeding from as early as the 1st week of life. The use of a more appropriate growth curve of exclusively breastfed, healthy infants instead of the NCHS reference failed to define more accurately the age at which growth faltering starts. It is recommended that weight increments be used as an indicator of the onset of growth faltering. Breastmilk intake correlated significantly with attained weight. However, it explains only a small % of the variation in weight, approximately 12-24%. There was no correlation between energy or protein intake from breastmilk and additional foods and weight gain.

When does growth faltering start?

Three indicators were used to assess the onset of growth faltering: (a) average weight - and length - for - age as percentage of the NCHS references or (b) the Cambridge references based on breastfed infants and (c) incremental growth over 4 weeks in which "faltering" was defined as a weight increment less than minus 2 standard deviations, calculated by Waterlow from USA and British data or no gain in length. The population covered were singleton infants born in two villages in Madura in September 1982 through December 1984 (N = 391). Weight and length were measured at 4 week intervals. The first two indicators did not properly identify the age period at which growth became unacceptable according to weight or length increments. This was mainly due to the large variation and the skewed distribution of weight and length of Madurese infants. Arbitrarily a magnitude of 20% weight falterers was used as a cut-off point for the onset of growth faltering. Among Madurese infants it would be at or before 3-4 months. It is recommended to analyse weight increments from data, generated by growth monitoring at POSYANDUS for mapping of the age period at risk throughout Indonesia.

Energy supplementation in the last trimester of pregnancy in East Java, Indonesia: effect on maternal anthropometry.

The effect of prenatal energy supplementation on maternal anthropometry was assessed in a controlled, randomized trial in Madura, East Java. At 26-28 wk of gestation women were either given 465 kcal/d (HE group) or 52 kcal/d (LE group). Two hundred seventy-six women were enrolled in the HE group and 266 women, in the LE group. Supplement intake was variable. Testing of effect by treatment and compliance was thus done by subcategories (HE 1-3 and LE 1-3, corresponding to less than 45, 45-89, and greater than or equal to 90 packets of supplement consumed). Analysis of variance did not show significant differences among the six subcategories in third-trimester weight gain, sum of skinfold thicknesses, 4-wk postpartum weight, or body mass index. In this population energy supplementation for the short duration of the last 90-110 d of pregnancy was not sufficient to improve maternal nutrition as judged by anthropometry.

The effects on weight and attendance of a supplementary feeding programme operating in two under-5 clinics in Lesotho.

The routinely collected weight data of 2202 pre-school children who visited two under-5 clinics in Lesotho between 1978 and 1983 were used to calculate growth curves and to assess the effects of supplementary feeding. Up to the age of 5 months growth curves were above the NCHS reference. Growth started to decrease at the age of 3 months and stabilized at 11-13 months at the 10th percentile of the reference. The decrease of growth might have been due to environmental factors such as under-nutrition and disease. If this was the case, supplementary feeding might have had a positive impact on weight, but such an effect was not observed in this study. Supplementary feeding had, however, a positive effect on attendance rates and hence contributed to higher coverage of other under-5 clinic activities, such as immunization, health and nutrition education, and growth monitoring. Whether this positive effect warrants its extra cost remains open to question.

Energy supplementation in the last trimester of pregnancy in East Java, Indonesia: effect on breast-milk output.

Breast-milk output was measured in women who during the last trimester of pregnancy consumed a high- or low-energy supplement (53 and 55 women, respectively). Infant and mother pairs were enrolled at 2 or 6 wk postpartum. Test weighings were done four times at 8-wk intervals. Mean breast-milk output ranged from 682 to 744 g/d in the age period of 2 wk to 7 mo. There was no difference in milk output between the two experimental groups. In all cohorts, breast-feeding frequency influenced milk output positively. Only at age 18-22 wk did the mothers' prepregnancy or 4-wk postpartum body mass index play an additional role. The results confirm that breast-milk output of mildly undernourished women is comparable with that of well-nourished women. Short-term energy supplementation during pregnancy did not increase breast-milk output, probably because the sample studied was not at nutritional risk.

Infant mortality in Madura, Indonesia. Implications for action.

Infant mortality by age at death and birth weight was assessed in a prospective, population-based study in Madura, East Java. Even after elimination of neonatal tetanus by vaccination during pregnancy as a major cause of death, the infant mortality rate was high, viz. 121 per 1000 live births. The majority of live born infants died in the first 6 months of life. Birth weight was the best practical indicator of survival. The implications for Primary Health Care are discussed.

Birthweight distribution in a healthy urban population in Surabaya-Indonesia.

The birthweight distribution was assessed in an apparently healthy urban population in Surabaya, Indonesia. A total of 924 pregnant women of a middle income group were enrolled at 20-24 weeks of gestation of which 543 women delivered in the university hospital. In the latter group mean birthweight of liveborn singletons was 3047 g for males and 2900 g for females. The percentages of low birthweight by sex were 7.9% and 13.8% respectively. These values were lower than those reported for more affluent women in Indonesia and comparable with those of rural Madurese women studied in the same time period.

Energy supplementation in the last trimester of pregnancy in East Java: I. Effect on birthweight.

The effect of two levels of energy supplementation in the last trimester of pregnancy on birthweight was tested in a controlled randomized trial in three villages in Madura, East Java. The high and low energy supplements provided 1.95 MJ (465 kcal) and 218 kJ (52 kcal) per day respectively. In the baseline period the home diet provided on average 6.28 MJ (1500 kcal) (SD 2.1 MJ (499 kcal] and 41 g (SD 13 g) of protein. The mean birthweight was 2835 g and the rate of low birthweight 12.2%. In the experimental period the home diet was better. The average intake ranged from 6.45 to 7.19 MJ (1541-1717 kcal) and 41.4-44.2 g per day, depending on the degree of compliance. Mean birthweight increased by 100 g and the rate of low birthweight dropped to 9.5%. There was no difference between the high and low energy supplemented group as a whole, probably due to the masking effect of the better home diet in the experimental period. It is likely that a positive effect of energy supplementation on birthweight was restricted to the group of pregnant women with the lowest home dietary intake and/or a low prepregnant weight. In this community targeting of supplementation to lean seasons and/or to women with a low prepregnant weight may be cost-effective.