Nutrisearch

The success of child survival programmes and the expansion of basic education coverage have resulted in a greater number of children reaching school age a with a higher proportion actually attending primary school¹ . However, there is increasing evidence, with resulting international concern, that the high level of nutritional deprivation combined with the heavy burden of disease in this age group has negative consequences for a child's long term overall development. This has prompted an increased focus on the diverse needs of the school-age child.

Malnutrition refers to disorders resulting from an inadequate diet or from failure to absorb or assimilate dietary elements.

Stunting (low height-for-age) is a physical indicator of chronic or long term malnutrition and is often linked to poor mental development. Stunting is a cumulative process of poor growth that primarily occurs before the age of three years and is not easily reversed. This infers that these first years of life provide a window of opportunity for effective nutritional programming. Underweight (low weight-for-age) is an indicator of both chronic and acute undernutrition. Wasting (low weight-for-height) is an indicator of acute under nutrition. Few representative data are available on the levels of malnutrition in school-age children; however, the avail-able data on school-age children follow the regional pattern of the more extensive representative data from surveys of preschool children.

PRESCHOOL CHILDREN: The prevalence of stunting, underweight and wasting varies by region and sub-region throughout low income countries b . The Africa region has the highest estimated prevalence of stunting (20.2-48.1%)c and has the lowest rate of improvement. In East Africa sub-region, rates of stunting are increasing. The prevalence of stunting in Asia (32.8-43.7%)d is also high, particularly in South Central Asia, although rates of stunting continue to improve throughout this region. In Latin America and the Caribbean, the prevalence of stunting is significantly lower (9.3-24%) e than the other two regions and is improving, except in the Central America sub-region.

SCHOOL CHILDREN: Stunting is widely believed to occur mainly in early childhood (mostly by three years of age), and through a cumulative process. Children stunted at school-age are likely to have been exposed to poor nutrition since early childhood and that the degree of stunting tends to increase throughout the school-age years. However, children can exhibit catch-up growth if their environment improves². This suggests that interventions in school-age children can supplement efforts in the preschool years to reduce levels of stunting and related effects on children's health and education. Underweight among school-age children, like stunting, can reflect a broad range of insults such as prenatal undernutrition, deficiencies of macro- and micronutrients, infection and, possibly, inadequate attention by caregivers. Wasting, which reflects acute malnutrition, is not as common as either stunting or underweight in school-age children. Nevertheless, wasting rates can change rapidly in situations of acute food crisis, with school-age children, adolescents in particular, becoming severely malnourished in such situations. Recent studies on school-age children have shed new information on stunting, wasting and underweight for this age group:

Important questions are raised from these studies that reflect the need for more information on the patterns and determinants of growth in this age group. First, it is important to identify whether the height deficits accrued during the primary school years are made up through longer pubertal growth and at what stage boys and girls stop growing in height. Second, the functional implications of linear growth retardation in school-age children needs to be more clearly under-stood. Third, the question as to what extent school-age stunting is preventable through school-based interventions needs to be addressed .

The studies of the effect of undernutrition on cognitive ability although not entirely conclusive, indicate that chronic undernutrition is associated with lower achievement levels in school children(13)

These findings' indicate that stunted and non-stunted children can benefit similarly from education(14).

Nutritional anaemia, particularly deficiencies of iron, iodine, and vitamin A are major problems for school-age children in low income countries. It has been shown that such deficiencies can negatively impact on growth, increase susceptibility to infection and also impair the mental development and learning ability of school children.

Iron Deficiency And Anaemia: Iron deficiency (ID) is the most common nutritional disorder in the world and is estimated to affect more than 2b peopleof whom 1.2b suffer from iron deficiency anaemia (IDA)(26)k . Insufficient intake of iron rich foods is the major cause of ID. It can also be caused by parasitic infections (particularly hookworm and malaria) and deficiencies of other nutrients.

There is little evidence to suggest any recent decrease in the prevalence of anaemia . It is estimated that 53% or 210m school-age children suffer from IDA(16,17) . The highest prevalence is reported in Asia (58.4%) fol-lowed by Africa (49.8%)(18).

Recent studies and surveys have tried to capture the prevalence of IDA in school children:

The main focus of IDA reduction programmes has been young children and women of reproductive age. Recent studies have emphasized the high prevalence of iron deficiency and anaemia in school-age children. This has resulted in an increased programmatic response for this age. However, there is conflicting evidence concerning the beneficial effect of iron supplementation on growth in children. Some studies have shown that daily supplementation improves growth and appetite, while others have not found any beneficial growth response:

In recent years, a number of studies have suggested that weekly iron supplementation is as effective as daily supplementation in raising haemoglobin levels, however, there is a still a need to further assess the effectiveness of weekly supplements under programme conditions to ensure that compliance is achieved(26-30).

Iodine deficiency affects estimated 1.6b people worldwide and estimated 60m school-age children. The consequences of iodine deficiency include severe mental retardation, goitre (a condition involving the enlargement of the thyroid gland and a disruption of normal thyroid production), hypothyroidism, abortion, stillbirths and low birthweight and mild forms of motor and cognitive deficits.

Recent studies i n school-age children have found very high levels of goitre and iodine deficiency. School-age children are often the target population of IDD assessments because of their physiological vulnerability and their accessibility.

Iodine deficiency is the leading cause of preventable intellectual impairment worldwide. A number of studies comparing children living in iodine-deficient areas with those living in iodine sufficient areas have found that the iodine deficient children have poorer levels of cognitive development and school achievement(35).

Universal iodization of salt is seen as the permanent and sustainable solution to the global IDD problem. Iodization of salt is the preferred approach for supplementation in iodine deficient populations. It is now mandatory for manufactured salt to be iodized in most countries, however, this does not guarantee the elimination or reduction of IDD. In many countries a persistence of goitre in school children is being observed despite near universal iodized salt consumption. In areas where iodized salt is not available and where the prompt correction of IDD is urgent, iodized oil can be administered to school children inexpensively and simply, maintaining iodine levels for a period of twelve months.

Mild or sub-clinical VAD n causes impaired immune function, increased severity of some infections and an increased risk of mortality from infectious diseases and is widely recognized as an important cause of blindness in children. It is estimated that 85m school-age children are at increased risk of acute respiratory and other infections because they are deficient in vitamin A(39). VAD also affects iron metabolism so that with any iron supplements taken, subsequent improvement in iron status may be limited when vitamin A status is low.

School-age children have not been considered an 'at-risk' group for VAD in the past. Little is known about the occurrence or effects of VAD in this age group. However, the small number of recent studies con-ducted, suggest that VAD is a public health problem in school-age children.

Food-based approaches, including fortification, are the preferred long term strategy to prevent VAD. However, for the short term, providing vitamin A supplements, multiple micronutrient supplements or vitamin A fortified foods to school-age children may be effective strategies to prevent VAD in this population.

Single micronutrient deficiencies seldom occur in isolation, but instead, interact and tend to cluster. For example, iron deficiency and VAD often coexist in the same populations (see below). Providing vitamin A supplementation can both improve vitamin A status, as well as, iron metabolism in deficient populations.

Further, vitamin A food fortification programmes produce similar results. School-age children, like most populations in low income countries, suffer from multiple micronutrient deficiencies. Data are not available on the extent ofthe problem in school-age children. However, inference can be made from data on pre-school children; 13 to 27% of pre-school school children are estimated to have two or more micronutrient deficiencies suggesting that 100m pre-school children are affected(16) .

Given the frequent overlap and clustering of micronutrient deficiencies, multiple micronutrient supplementation or fortified foods may be a cost-effective strategy to address nutrient deficiencies in school-age children, in addition to synergistic effects between certain micronutrients.

Overweight p and obesity is becoming increasingly prevalent in low income countries where improvements in socioeconomic conditions and rapid urbanization are causing a 'nutrition transition'. A rapid shift in the composition of diet (higher fat and lower carbohydrate), reduced activity patterns and a subsequent shift in body composition characterize this transition. Countries undergoing a 'nutrition transition' have high levels of stunting, which is believed to be a risk factor for obesity. This may be explained by the relationship of stunting to undernutrition. Evidence from animal and human studies suggests that with malnutrition in utero and in early life, endocrine development may be affected, resulting in hormonal alterations and a predisposition to metabolic disorders and obesity(47-49). It is suggested that the increased risk of obesity among stunted children will lead to considerable problems with obesity in children in low income countries over the coming decades(50,51).

Although there is a growing body of data on obesity and overweight in this age group, few data are available on the true extent of overweight among school-age children in low income countries. Nationally representative data are lacking and few countries have repeated surveys, thus trend data are limited. Furthermore, there are methodological concerns, the use and interpretation of weight-for-height indices based on children from the US has been questioned in populations with significant levels of stunting(52).

School Feeding/Food for Education Stakeholders Meeting, October 2000

Lessons related to the rationale for school feeding programmes:

Nutritional benefits: There is little evidence to suggest that school feeding programs have a positive impact on nutrition for participating children. In some instances, parents may provide less food at home, and the school meal simply replaces a home meal rather than adding food to the child's diet.
Impact on education and the link between hunger and learning: Much evidence suggests that children who are hungry or chronically malnourished are less able to learn, regardless of the setting. But the converse - that children in school feeding and food for education programmes are better able to learn - only holds true when the food is accompanied by other inputs related to school quality.
Impact on attendance: The evidence strongly suggests that school feeding programmes can increase attendance rates, especially for girls. School feeding or take-home rations serve as incentives for enrolling children in school and encouraging daily attendance. This is likely a short term solution, however, because if there is no change in the quality of schooling (or increase in intrinsic demand for education) attendance will likely drop once the food incentive is removed.

Programmatic lessons learned:

Relationship to education reform: School feeding must take place within the context of broad, national school reform programmes. These reforms should focus on other essential inputs to education and learning such as teacher development, curriculum reform, and student assessment.
Burden on governments and education ministries: National ministries of education should not be encouraged to 'take on' school feeding at the expense of the other educational inputs, as it is difficult politically to refuse food aid.
Working through communities: Getting the community involved from the beginning, and giving them owner-ship of school feeding programmes greatly increases the chances for the programme's success and sustainability.
Complementary inputs: To overcome the reliance on outside food sources such as school feeding programmes, it is necessary to focus on complementary health and nutrition inputs to accompany the school feeding, such as: nutrition and health education, micronutrient supplementation and deworming.
Targeting: There is evidence that providing national coverage is not cost effective for national school feeding programmes. Targeting the most underserved, food insecure areas, with relatively low rates of school attendance (where the reason for lack of attendance is related to lack of income and not lack of a facility ) seems to make the most sense. Regional coverage is often necessary to avoid children transferring to schools as a result of the school feeding. Within the selected regions, girls can be specifically targeted with take-home rations. Areas particularly hard hit by HIV/AIDS could also be targeted.
Testing innovations: There should be room to design food-for-education programmes as true pilots, with the flexibility to test new methods of food delivery. USAID/Haiti, for example, has been experimenting with nutrient- rich snack biscuits made from surplus grains, which reduce the need for cooking and other preparations at the school and also provide micronutrients.

Source: USAID (2000) School Feeding/Food for Education Stakeholder's Meeting. October 3, 2000.

In 1995, an estimated 17.6m children in the low in-come countries were overweight(53). The overall prevalence of overweight in the pre-school population is low, at 3.3%(53) . Available data suggest that the problem of obesity begins in preschool children, becoming more evident among school-age children(52).

There is increasing evidence of the negative consequences for children suffering from short term hunger, particularly in children who are not fed before going to school. Children who are hungry are more likely to have difficulty concentrating and performing complex tasks, even if otherwise well nourished. In recent years there has been some doubt about the value of stand-alone school feeding programmes in terms of their impact on either nutrition of education. However, the value when implemented in the right context should not be underestimated. In 2000, a School Feeding/Food for Education stake-holders meeting brought together top practitioners and experts from USAID, USDA, the World Bank, UNICEF and other organizations who either administer or implement SNPs(56) , who reviewed the current situation. Some of the main conclusions of this meeting are found on the Box.

Recent studies show the impact of what alleviating short term hunger can have on children's education:

The poor, particularly children in low income countries, carry the greatest burden of morbidity and mortality. Much of this burden results from hazards within their homes or their immediate environment(61) . For children in low income countries, many of the health problems of childhood are associated with lack of clean water and poor sanitation.

The total number of diarrhoeal episodes may be as high as 4000m(62) . Most of the diarrhoeal disease burden occurs in children in developing countries, with under-fivesat greatest risk(63) . Approximately 90% of the diarrhoeal disease burden is related to environmental factors of poor sanitation and lack of access to clean water and safe food(64).

A recent review of 144 different interventions demonstrated the impact on morbidity of general water, sanitation and hygiene interventions:

Since inadequate access to clean water, lack of adequate sanitation facilities and poor hygienic practices are high risk transmission factors for diarrhoeal diseases, there has been increased emphasis on hygiene promotion programmes as a means of changing behaviour and reducing the incidence of diarrhoeal diseases. As a short term measure, selective fly control during the 'fly season' might be useful in some circumstances(66) .

School Sanitation And Hygiene Hygiene promotion in schools is a primary intervention because of the potential high risk of disease transmission if facilities are either non-existent, in a poor state of repair or incorrectly used. In addition, studies show that school-age children can provide effective links with their peers (child to child) and the wider community in communicating important hygiene messages as well as promoting improved sanitation(67) .

Hygiene promotion is now seen as an intrinsic element of any water and sanitation initiative and, in the con-text of school health, is now a central focus for school sanitation and hygiene programme(67) .

Helminth Infections In The School-Age Child: It is estimated that over 35% (320m) of school-age children are infected with roundworm; 25% (233m) with whipworm and 26% (239m) with hook-worm. As the intensity of infection is the central determinant of the severity of morbidity, it is the school-age child who is most at risk; for girls and boys aged 5-14 years in low income countries, intestinal worms alone account for an estimated 12 and 11% respectively of the total disease burden of this age group, making this the single largest contributor to the disease burden of this group(70) .

The most significant infection causing blood loss is hookworm infection. This may be caused by blood lose at the site of feeding; exacerbation of bleeding by the secretion of an anticoagulant; interference of up-take of iron in the duodenum; impaired appetite (with moderate to heavy infections).

The school-age child, but also pregnant women and preschool children, are most at risk from hookworm-attributable anaemia. Attributable fraction analyzes indicate:

Improved sanitation and hygiene provides the long term solution to controlling helminth infection. However, evidence showing the negative impact of helminth infections and the recent development of inexpensive drugs has led to an increase in mass control programmes(72) .

Drug Treatment for Helminth Infections

The WHO recommends mass treatment of children in schools where the prevalence of infections is 50% or greater. Reinfection often occurs after 4-6 months, suggesting that school children need to be regularly treated in highly endemic areas. In areas where hookworm infections are endemic (prevalence >20-30%) and where anaemia is prevalent, WHO also recommends hookworm control strategies to improve the health and nutritional status of girls and women. Dosage: 1 dose of 400 mg albendazole 1 dose of praziquantel at 40mg/kg body wieght A recent assessment of the use of praziquantel and albendazole/mebendazole for women of child bearing age, and for pregnant and lactating women, concluded that these drugs may be used for such women, and that these women should not be excluded from treatment programmes.

The expected benefical effects of de-worming include improved growth, appetitie, fitness, cognitive performance and iron stores. Recent information also suggests that deworming can contribute to the reduction of VAD. The precise mechanisms by which these improvements occur, however, are unclear(73)r.

Recent research shows that school based deworming programmes can reach out to those not enrolled in school and be effective.

Malaria is probably the world's most important parasitic infectious disease, occurring in tropical and sub-tropical countries.

Globally the malaria situation is serious and worsening with mortality ranging between 1.5-2.7m and morbidity 300-500m annually. Although malaria affects 40% of the world's population, 90% of the burden is in Africa (south of the Sahara).

Most studies to date have focused primarily upon pre-school children estimating that over 75% of all-age malaria mortality is experienced by this age group(77) . In contrast there are few empirical studies on mortality in school-aged children. However, recent preliminary estimates suggest mortality among school-aged children is between 5-14% lower than among younger children. This implies that malaria may still account for 10-20% of all-cause deaths among school-age children(63).

School children who have not acquired exposure-driven immunity may be at particularly high risk of severe and fatal consequences when exposed to the disease in unstable transmission areas. However, these risks are balanced by the low, and often very seasonal, exposure to the parasite. Pregnant schoolgirls are also a particular high-risk group(78) .

Malaria can cause iron deficiency and anaemia. However, the effect of malaria on iron metabolism and anaemia is not fully understood, particularly in endemic areas where large numbers of school-age children are affected but are asymptomatic.

The priority age group for malaria control is younger than school-age children978) . However, WHO and the World Bank are working with the Roll Back Malaria Partner-ship to identify an effective, operational response to the issue of malaria control in school-age children. Skills based health education through schools can help promote a community wide understanding of malaria with particular emphasis on the need for community based control measures such as the use of impregnated bed nets. Schools can serve as a focus for synchronized impregnation of bed nets and distribution(79).

Approximately 40m people throughout the world are now living with HIV/AIDS (with 70% of these people living in sub-Saharan Africa), including almost 3m children under the age of 15. The impact and repercusions of this global epidemic in every sphere of people's lives is now becoming apparent(80).

Throughout the world, HIV infection prevalence is lowest in the 5 to 14 year old age group, and AIDS mortality does not have its primary effect on school-age children. The majority of children dying of AIDS are young children who have contracted the disease from mother-child transmission. An estimated 3.8m children have been infected with HIV since the epidemic began, and more than two-thirds have died. UNAIDS estimates that in 2001, 800,000 children under the age of 15 became newly infected with HIV, and that 580,000 children under the age of 15 died of AIDS, the vast majority of them in Sub-Saharan Africa(81). During this time, approximately 2.4m adults (aged 15 to 49) died of AIDS.

Girls and young women are highly vulnerable to contracting HIV/AIDS for social, cultural, economic, and even physiological reasons (81,82).

Children on the Brink 2002, outlines five key strategies for supporting orphans and other children affected by HIV/AIDS:

For school-age children, especially vulnerable children, finding strategies to keep them in school, or to reach them in out of school situations, is one of the key lines in defence against HIV/AIDS, especially for girls. By remaining in education, girls may have the opportunity to reduce the social and economic vulnerability that exposes them to the higher risk of contracting HIV.

In many countries, school-based reproductive health and HIV/AIDS education is often used as part of a wider strategy of community and national HIV/AIDS prevention programmes, and may be most effective in this context, especially when a skills-based approach is utilized.

Skills-based health education, including HIV/AIDS prevention, aims to help children develop the knowledge, attitudes, values, and skills- including interpersonal skills, critical and creative thinking, decision-making, and self awareness -needed to make sound health-related and social decisions. According to major reviews covering 23 studies in the United States(83) ; 53 studies in Europe, the United States, and elsewhere(84) ; and 37 studies in other countries, including in Asia and Latin America(85):

Improving the health and learning of school children through school-based nutrition and health programmes is not a new concept. However, many early programmes have been characterized as being heavily focused on disease prevention, being uncoordinated, lacking integration and poorly evaluated and disseminated. Most importantly, the traditional school nutrition and health pro-grammes have been based in the better off schools and in urban centres. This situation appears to be rapidly improving as new policies and partnerships are being formulated which help ensure that programmes are socially progressive and specifically target the poor, girls and the most disadvantaged children.

This change in perspective is timely as countries and agencies seek to achieve Education for All (EFA) by 2015, and address the Millennium Development Goals (MDG) of Universal Basic Education and Gender Equality in Education Access. If every girl and boy is to be able to complete a basic education of good quality, then school nutrition and health programmes are essential to ensure that the poorest children, who suffer the most malnutrition and ill health, are also able to attend school.

In order to operationalize an effective response, education sectors need to develop an infrastructure and policy context for improving the nutrition and health of school children. A major step forward was taken when a framework to Focus Resources on Effective School Health (FRESH) was developed by UNESCO, WHO, UNICEF, Education International and the World Bank and launched at the World Education Forum in Dakar in April 2000. Partners also include WFP, The Partnership for Child Development, and Save the Children US.

Key Messages

The main nutritional problems facing the school-age child include stunting, underweight, anaemia and iodine deficiency and, on the basis of information from recent surveys, vitamin A deficiency.
In countries experiencing the 'nutrition transition', overweight and obesity are increasing problems in the school-age child.
The main health problems facing school-age children are malaria, helminth infections, diarrhoeal diseases, respiratory infections and the direct and indirect effects of HIV/AIDS.
Much of the disease burden derives from the poor environmental conditions in which children live including exposure to biological, chemical and physical hazards in the environment and a lack of resources essential for human health.

The FRESH framework provides the context for effective implementation of access to health and nutrition services within school health programmes. School based health and nutrition services, such as food for education, micronutrient supplementation and deworming, are most effective when they are supported by other strategies. These strategies include policies to provide a non-discriminatory safe and secure environment, provision of safe water and sanitation, effective referral to external health service providers and links with the community. The FRESH frame-work provides this context by positioning access to health and nutrition services among four core components that should be made available together for all schools:

The 54 th World Health Assembly's resolution set a global target of scaling up intervention to regularly treat 75% of school-age children (398m) at risk by 2010. To achieve this goal, WHO has taken the lead in developing a broad partnership that promotes the in-corporation of deworming of school-age children into existing institutions and programmes, for both the education and health sectors(87). The Partnership for Parasite Control (PPC) was launched in 2001, with the aim of mobilizing resources and promoting new synergy among public and private efforts for the control of soil-transmitted helminths and schistosomiasis at the global and national levels. Working with the World Food Programme (WFP), the Canadian International Development Agency and the World Bank, WHO in 2001 trained representatives of the ministries of health and education of 21 countries, and deworming programmes have already begun in 19 of the 41 endemic countries in Africa.

Much remains to be done. But countries and agencies are now working actively to ensure that poor nutrition and ill health no longer hold children back from what may be their only opportunity to receive an education.

Editor's note:
The article is an abridged version. For full article please refer to SCN News. ACC/SCN No.25 Dec. 2002.
Website: http//www.unsytem.org/scn/

Prepared for the SCN Working Group on Nutrition of School-Age Children by Lesley Drake, Celia Maier, Matthew Jukes and Anthi Patrikios, Partnership for Child Development ;Don Bundy, World Bank;Alison Gardner and Carmel Dolan, Nutrition Works For details Contact: Lesley Drake, Partnership for Child Development lesley.drake@ic.ac.uk

Smoking during pregnancy can not only predispose to low birth weights but also obesity in offspring ! This observational study was conducted on over 8000 school children aged between 5 and 7 years from Germany. The researchers noted that 660 mothers smoked during pregnancy, while 1500 smoked before, but not during pregnancy. The odds ratio for obesity among children of mothers who smoked throughout pregnancy was 1.92, and among those who smoked before and after but not throughout pregnancy offspring was 1.74. While low birth weights are a likely consequence of smoking related placental vasoconstriction in the last trimester, metabolic imprinting in the fetus due to the influence of smoking early in pregnancy on dopamine and serotonin neurotransmitter systems could be responsible for obesity in childhood, the researchers conclude.( European J Pediatrics 2002; 161: 445-448)

Though zinc supplements reduce the severity of acute diarrhea, they do not have a similar effect when given during the course of bronchopneumonia. In this trial from India, eighty five children admitted with bronchopneumonia as a complication of measles were randomized to receive either zinc supplements or a placebo. All children were given oral dose of 100,000 units of vitamin A. The researchers noted that the time taken for clinical improvement was similar in both the zinc supplemented and control groups. While long term zinc supplements have a positive influence on the immune system, the effect may not be evident in the short term, they suggest. Zinc supplements have no role as adjunct in treatment of bronchopneumonia complicating measles, the report concludes.( Amer J Clin Nutr 2002; 76: 604-607)

More on zinc! Zinc supplements, used as an adjunct, have no beneficial effect in the management of falciparum malaria. In this randomized study, over 1000 children under 5 years of age with falciparum malaria received either oral zinc or a placebo along with anti-malarials. The time taken for becoming afebrile, clearance of parasitemia and post treatment hemoglobin levels were similar in both the groups. The researchers concluded that zinc supplements are not beneficial as supplements in treatment of acute malaria.( Amer J Clin Nutr 2002; 76: 805-812)

The Barker's hypothesis has been challenged! A meta-analysis has questioned the link between low birth weights and hypertension in later life. Over 100 studies on this association were analyzed. The researchers note that link between hypertension and low birth weight was weakest in the larger studies. After adjusting for current weight, the blood pressure was only 0.4 mm Hg lesser for every one kg increase in birth weight. The researchers conclude that there is no link between birth weight and blood pressure later in life and that such associations could be due to inappropriate adjustment for the current weight and for confounding factors.(Lancet 2002; 360: 659-665)

According to studies conducted in Sweden and Honduras, boys have a higher risk of iron deficiency anemia during infancy. Over 250 breast fed infants were randomized to receive either iron supplements or a placebo from 4 - 9 months of age. The study recorded lower hemoglobin, MCV and ferritin levels in boys and also reported a ten times higher risk of iron deficiency at 9 nine months of age as compared to girls. While the reason for the sex differences were not conclusively proved, the researchers suggested that both genetic and acquired factors could be responsible.(Pediatrics 2002; 110: 545-552)

Delayed initiation of weaning could be responsible for the high incidence of stunting among Indian children. These conclusions were based on an analysis of records of over 6000 children between 2 and 4 years from the NFHS 1992-1993 data. The researchers noted over 50% of the children under 4 years of age were stunted, while weaning was delayed beyond six months in nearly 50% of the children. They also noted that the incidence of stunting was lowest among children weaned at 3 months of age and increased thereafter with age. The odds ratio of stunting among children weaned after 6 months was 1.88 as compared to children weaned early. They also reported that over 60% of children weaned after 6 months of age were stunted. They noted that only a marginal improvement has been noted in the recent NCHS data and recommended appropriate initiation of weaning. (Int J Epidemiol 2002; 31: 855-863)

Maternal weight gain in the first trimester has the maximum influence on birth weight. These conclusions were based on an analysis of records of 379 mother-infant pairs. The researchers noted that a weight gain of one kilogram in the first trimester translated into a 31 grams gain in birth weight. A similar effect was however, not noted regarding weight gain in the third trimester, they note. The Ponderal index was also similarly affected, they note. These findings reiterate the importance of adequate nutrition in the first trimester, the report concludes. (Amer J Clin Nutr, 2002; 76 : 205-209)

The benefits of oral iron supplements in treating breath holding spells have been confirmed by this evidence based analysis. The report analyzed six published papers including 3 original articles and noted that iron deficiency anemia was common among children with breath holding spells. They also noted that for an effective response, an eight week course of oral iron (5-6 mg/kg/day) would be appropriate. The researchers conclude that iron therapy is beneficial and that breath holding spells associated with iron deficiency anemia respond best to iron supplements as compared to those without iron deficiency.( Arch Dis Childh 2002;87:77-78)

C. Vidyashankar,
Pediatrician,
Military Hospital, Namkum,
Ranchi - 834010, Jharkhand,
email: vidyashankar@vsnl.com