Micronutrient deficiencies in children

1. azad82d@gmail.com
azad.haleem@uod.ac
Dr.Azad A Haleem AL.Mezori
FRCPCH,DCH, FIBMS
Assistant Professor
University Of Duhok
College of Medicine
Pediatrics Department
Micronutrient deficiencies in
children
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2. Introduction
• Malnutrition can arise in three forms:
• hunger and undernourishment, which is defined as
dietary energy intakes below the minimum levels
necessary to achieve and maintain a healthy weight;
• obesity or overnourishment, which is defined as
dietary energy intake which exceeds requirements for
maintenance of a healthy bodyweight;
• micronutrient deficiencies, which is defined as a lack
of essential vitamins and minerals required in small
amounts by the body for proper growth and
development.

3. Micronutrients
• In contrast to macronutrients (energy, protein
and fat),
• Micronutrients are vitamins and minerals
which are consumed in small quantities, but
are nonetheless essential for physical and
mental development.
• Essential micronutrients include (but are not
limited to): iron, zinc, calcium, iodine, vitamin
A, B-vitamins, and vitamin C.

4. • Micronutrient deficiencies form an important
global health issue, with malnutrition affecting
key development outcomes including poor
physical and mental development in children,
vulnerability or exacerbation of disease, mental
retardation, blindness and general losses in
productivity and potential.
• Unlike energy-protein undernourishment, the
health impacts of micronutrient deficiency are
not always acutely visible; it is therefore
sometimes termed ‘hidden hunger’.
Micronutrients

5. Individuals most vulnerable to
micronutrient deficiency
• Although any individual can experience
micronutrient deficiency, pregnant women
and children are at greatest risk of developing
deficiencies.
• This is not only as a result of low dietary
intake, but also from higher physiological
requirements.

6. Baby Nutrition
• Breastfeeding: The Gold Standard in Infant Nutrition.
• Start Breastfeeding ASAP, within first hour of birth &
Exclusive breastfeeding till 6 months & Continue
breastfeeding 2 years and beyond.
• Complementary Feeding:
• Start complementary feeding at 6 months with continued
breast feeding to ≥2 yrs
• Provide appropriate complementary feeding:
• Timely
• Adequate
• Safe
• Properly fed

7. Importance of Early Nutrition in Brain Development During the First 1,000 Days
Physiological Development of the Brain Across the First 1,000 Days1
•1. Thompson RA and Nelson CA. Am Psychol. 2001;56(1):5–15; 2. Martorell R, et al. J Nutr. 2010;140:348–354.
WHAT IS THE ROLE OF
MICRONUTRIENTS?

8. • Oxygen, Macronutrients& Micronutrients play a crucial role in optimal brain development1
• Timing of the nutrient deficit and nutrient requirement of region of the brain at that time determine
vulnerability to nutrient deficit2
Nutrients responsible for brain development
• Protein
• Specific fats
• (long chain-
polyunsaturated fatty
acids)a
• Glucose
Macronutrients3 Micronutrients3
• Zinca
• Coppera
• Iodinea
• Irona
• Selenium
Vitamins and
cofactors3
• B Vitamins (B6, B12)
• Vitamin A
• Vitamin K
• Folatea
• Cholinea
a Nutrients that meet the principles for demonstrating a critical or sensitive period during development
1. Wullschleger S, et al. Cell. 2006;124(3):471-84.
2. Cusick SE, et al. The Journal of pediatrics. 2016;175:16-21.
3. Georgieff MK, et al. Development and psychopathology. 2015;27(2):411-423.
WHAT IS THE ROLE OF
MICRONUTRIENTS?

9. IS MICRONUTRIENT DEFICIENCY COMMON AMONG
CHILDREN?
• The World Health Organization (WHO) estimate that
more than two billion people suffer from
micronutrient deficiency globally.
• At least 50% of children aged 6 months to 5 years
suffer from one or more micronutrient deficiency
(MND)1
• 155 million children are stunted.
• 52 million children are wasted.
“Too few children are
getting the nutrition they
need to survive, grow and
develop”
UNICEF
1. CDC.
https://www.cdc.gov/immpact/micronutrients/index.
html.
2. Global nutrition report.
https://www.globalnutritionreport.org/files/2017/11/
Report_2017.pdf.

11. Reasons for high prevalence of
micronutrient deficiencies
More than 70% of pre-school children consume less than 50% of the
recommended daily allowance for vitamin A, iron, folic acid and
riboflavin
Inadequate
intake of
staple and
nutritious
food
Poor
bioavailability
of minerals
and vitamins
Frequent
intestinal
parasitic
infections
Commonly
consumed
foods have
high levels of
inhibitors of
micronutrient
absorption
Increased
consumption
of refined and
processed
foods
Reduced
dietary
diversity
Few common reasons for high prevalence2
1. National nutrition monitoring bureau. http://nnmbindia.org/NNMB%20MND%20REPORT%202004-Web.pdf.
2. The Changing Scenario of Micronutrient Deficiencies in India. http://www.nutritionfoundationofindia.org/pdfs/BulletinArticle/nfi_bull_0413_1.pdf.

13. Iron Iodine Folate Vitamin A Zinc Vitamin D
Most common MNDs
1. Bailey RL, et al. Ann Nutr Metab. 2015;66 Suppl 2:22-33.
2. WHO website. http://www.who.int/nutrition/topics/ida/en/.

14. Anemia (iron or vitamin
B12 deficiency)
• Anemia can result from a lack of iron or vitamin
B12, although iron deficiency is the most common
type.
• Globally, anemia affects more people than any
other health problem.
• Anemia has important implications for general
productivity and development, reducing the work
capacity of individuals by up to 20 percent.
• In more serious cases, anemia can lead to
exacerbation of disease and illness.

15. Anemia (iron or vitamin
B12 deficiency) in children
• The World Health Organization estimate that;
Globally, around 42% of children have
anemia , In developing countries, about
40% of preschool children are estimated to
be anemic & 20% of maternal deaths are
attributed to anemia alone.

16. Rates are high across South Asia and
Sub-Saharan Africa, with 55% and 60%
of children being anemic, respectively.
Rates are lowest in higher-income regions
of North America (9%), Europe & Central
Asia (22%), and East Asia & the Pacific
(26%).

17. Vitamin-A deficiency
• Vitamin-A deficiency (VAD) is the leading
cause of preventable blindness in children–
manifesting in a milder form as night
blindness, and progressing to permanent
blindness in stronger cases.
• VAD also serves to exacerbate serious disease
and illness, leading to increased rates of
maternal and childhood mortality.

18. Prevalence rates are typically highest across
Sub-Saharan Africa and South Asia, often
reaching up to 60-70% . in Kenya reaching 85%.
In Central Europe and Latin America was lower
than in Africa and Asia, with rates of deficiency
typically between 5-20 % of children.
For most countries, less than 1 percent of
children suffer from night blindness.
In the most extreme case- Sudan- this
rate was 8.5 percent over this period.

19. Zinc deficiency
• Zinc is an essential nutrient for growth and recovery;
deficiencies can therefore stunt growth;
• increase susceptibility to disease and infection;
• increase recovery time, or in some cases, impair recovery;
• reduce mental capacity; and
• Higher morbidity and mortality in mothers and newborns is
associated with high prevalence of zinc deficiency.
• Zinc deficiency can have a number of negative health
consequences, affecting the central nervous,
gastrointestinal, immune, epidermal, reproductive, and
skeletal systems.

20. Zinc deficiency
• Globally, zinc deficiency is very common —
particularly in lower-income countries where
diets are cereal-dominant and typically lower
in protein.
• Zinc deficiency can be prevalent in men,
women and children (as opposed to anemia,
which is much more common in women).

21. Most high-income countries, especially
across Europe, North America, Oceania
and Central Asia have incidences of zinc
deficiency below 5-10 percent of the total
population.
The prevalence of zinc deficiency across Sub-
Saharan Africa and South Asia is higher, and
variable between 15 to 50 percent. The highest
prevalence in the Democratic Republic of
Congo at 54 percent.

22. Prevention and treatment of
micronutrient deficiency
• If micronutrient requirements cannot be met
through dietary intake alone (for example if
households do not have access to or cannot
affordable the dietary diversity required to
meet micronutrient requirements) there are
three key additional strategies which can be
used to address deficiencies.
• These are supplementation, food fortification
and biofortification.

23. Prevention and treatment of
micronutrient deficiency
• Supplementation: supplementation is the delivery of
concentrated micronutrients in pill, powder or liquid form;
• Food fortification: fortification is a subset of food
processing and involves the addition of small amounts of
micronutrients to food products often commonly
consumed by the general population (such as cereals,
wheat flours and rice);
• Biofortification: the use of agronomic and plant-breeding
approaches in agriculture to increase the concentration of
particular micronutrients in staple food crops. The most
well-known example is so-called ‘golden rice‘, which is rice
grown with high concentrations of vitamin-A.

24. Iron supplementation & iron-
fortification in breast-fed infant
• Breast-feeding should be encouraged, with the addition of iron-
fortified cereals after 4-6 months of age.
• Full-term infants – Start an iron supplement at FOUR MONTHS
of age (elemental iron 1 mg/ kg daily, maximum 15 mg).
• Continue the supplement until the infant is taking sufficient
quantities of iron-rich complementary foods (eg, two or more
servings of infant cereal daily).
• Premature infants – Start an iron supplement by TWO WEEKS of
age (elemental iron 2 mg/kg daily, maximum 15 mg).
• Continue to provide iron at a dose of at least 2 mg/kg per day, via
supplements or fortified formula, through the first year of life.

25. Prevention:
• Infants who are not breast-fed should only
receive iron-fortified formula (12 mg of iron
per liter) for the first year, and thereafter
bovine milk should be limited to <20-24 oz
daily.
• For all infants (<12 months), avoid feeding
unmodified (non-formula) cow's milk or
goat's milk.

26. Vitamin-D supplementation
• Routine supplementation of all children with
vitamin D is controversial.
• supplementation in high risk groups like
breast fed infants, children on anti-epileptic
drugs and obesity.
• The American Academy of Pediatrics
recommends the use of 400 IU daily in the
first year of life .

27. Vitamin-A supplementation
• Children under the age of 5 are typically the most
vulnerable to vitamin-A deficiency.
• Many countries try to tackle this issue by
delivering vitamin-A supplements to children, in
the form of high-dose capsules several times per
year.
• The coverage rate of vitamin-A supplementation
is defined to be sufficient if a child receives at
least two high-dose capsules per year.

28. In 2014, we see that the coverage rate of
supplementation across many countries in
Sub-Saharan Africa and South Asia is very
high–in many cases greater than 90 percent.
Although some countries still have very low
rates of coverage, progress has been
considerably over the last few decades.
Since 1990, coverage rates in South Asia have
nearly doubled, and since 2000, coverage in
Sub-Saharan Africa has increased almost five-
fold.

29. Iodized salt supply
• Iodine deficiency is the leading cause of preventable brain
damage in childhood.
• Recognized as a driver in perinatal mortality, a leading
cause of mental retardation (iodine deficiency can result in
a mean IQ loss of 13.5 points in the population), and
thyroid impairments.
• Iodine deficiency results from dietary intakes low in iodine;
this typically occurs within populations with soils low in
iodine content (thereby hindering iodine concentrations in
crops).
• Iodine deficiency is therefore hard to address simply
through dietary diversification.

30. Iodized salt supply
• The global solution to addressing deficiency has
been through Universal Salt Iodization (USI)
programs.
• Salt is used as a delivery device for iodine for
several reasons: it is widely consumed and has
little seasonal variation; salt is typically
distributed from a few centralised production
centres; it has little impact on taste or texture of
foods; and it is inexpensive (USI is estimated to
cost US$ 0.02-0.05 per person per year).

31. More than 120 countries now have USI
programs, and it’s estimated that 71 percent of
households across the world have access to
iodized salt.
less than 10 percent of households in Sudan
and Mauritania consumed iodized salt.

32. • To ensure adequate micronutrient intake through
dietary intake alone (with the use of fortified,
processed foods), a diverse diet is required.
• Micronutrient-rich foods include fruit and
vegetables, meat and dairy, pulses, seafood, nuts
and seeds.
• In contrast, cereal, root and tuber commodities
tend to be energy-dense but micronutrient-poor.
Micronutrient deficiency is more
prevalent in countries with poor
dietary diversity

33. Fruits and
vegetables
Grains, roots
and tubers
Legumes and
nuts
Dairy
products
Flesh foods Eggs
Vitamin A rich
foods
7
Food
Groups
Is a proxy of micronutrient
intake
Does not ensure
adequacy
Minimum Diet Diversity

34. Age Texture Frequency
Average amount
each meal
(energy density= 0.8 to
1.0 Kcal/gm)
6-8 months
Start with thick porridge,
well mashed foods
2-3 meals per day
plus frequent
BF
Start with 2-3 table spoonfuls
9-11 months
Finely Chopped or
mashed foods, and foods
that baby can pick up
3-4 meals plus BF.
Depending on appetite
offer 1-2 snacks
½ of a 250mL cup/ bowl
12-23 months
Family foods, chopped
or mashed, only if
necessary
3-4 meals plus BF.
Depending on appetite
offer 1-2 snacks
¾ to 1 cup/bowl of 250 ML
If baby is not breastfed, give in addition: 1-2 cups of milk per day, and 1-2 extra meals per day
Tiwari S, Bharadva K, Yadav B, Malik S, Gangal P, Banapurmath C et al. Infant and Young Child Feeding Guidelines, 2016. Indian Pediatrics. 2016;53.
IYCF Guidelines,
IAP recommendations- 2016

35. Fortified Foods Provide Adequate Nutrient Intake and can combat MND
Nutrient rich food
That is varied in flavour
and texture helps
infants to avoid
malnutrition
Prepared in a safe and
hygienic manner
Develop healthy food
habits and transition to
adult foods
Fortification of complementary foods can
help fill the nutrition gaps in infant’s diet
It is vital to provide infants with
adequate nutrition and prevent
nutrition gaps during this early period
WHO. http://apps.who.int/iris/bitstream/10665/44117/1/9789241597494_eng.pdf?ua=1&ua=1.
ADDRESSING THE NUTRIENT GAP

36. Maintain body stores of nutrients more efficiently than intermittent supplements
Fortified staple foods will contain “natural” or near natural levels of micronutrients
Increase the content of vitamins in breast milk
Does not require change in existing food pattern
Feasible to fortify foods with several micronutrients
Food fortification is beneficial
WHO website. http://www.who.int/nutrition/publications/micronutrients/GFF_Part_1_en.pdf.

37. Breastmilk
Home-made
Preparations
Bridging the nutrition gap
Fortified Food:
Post 6 months, if complementary foods are not administered, there
is a resultant energy gap as well as iron deficiency

38. Key Messages