The document summarizes evidence for interventions to improve maternal and child nutrition. It finds that scaling up access to 10 core nutrition interventions in 34 high-burden countries could reduce deaths in children under 5 by 15% (1 million lives saved) and stunting by 20.3%. Key interventions include management of acute malnutrition, breastfeeding promotion, and micronutrient supplementation. Achieving 90% coverage of the interventions would cost an additional $9.6 billion annually but could significantly reduce undernutrition and mortality. Continued investments in direct nutrition interventions and delivery strategies that engage vulnerable communities are needed.
This document outlines strategies and interventions to tackle stunting in children under 2 years old. It recommends preventive and early interventions at the community level through empowerment and improved healthcare services. The key is to assure sustainability through ongoing quality improvement processes. It describes screening children under 2 to identify nutritional needs and providing evidence-based interventions. Interventions discussed include delayed cord clamping, early breastfeeding, dietary diversity, facility-based management of severe and moderate acute malnutrition, community-based management, identifying at-risk children, fortified supplements, deworming, zinc therapy, multivitamin supplements, and vitamin A supplementation. Metrics include decreasing malnutrition and assuring regular quality improvement team meetings.
1) A team of international nutrition experts reviewed evidence and estimated the impact and cost of scaling up 10 proven nutrition interventions to reach 90% of at-risk populations. This could save 900,000 lives in high-burden countries and reduce stunting in children by 33 million.
2) The total additional annual cost of achieving 90% coverage with these interventions is estimated to be $9.6 billion.
3) While nutrition-specific interventions can reduce stunting by 20%, nutrition-sensitive programs that address the underlying causes of undernutrition, like food security and women's empowerment, are also needed. These programs have potential to deliver nutrition interventions at large scale.
Food gardens have the potential to help address malnutrition in children aged 0-5 years in South Africa. While food gardens may improve access to micronutrients like vitamin A, it is unclear if they can provide sufficient nutrition on their own. For food gardens to be effective, they must be paired with nutrition education programs and focus on growing nutrient-dense crops. Larger, more structured programs in schools and early childhood centers may have better outcomes than small household gardens alone.
Maternal and child undernutrition is a serious problem in Bangladesh, with nearly half of children under five stunted and 14% suffering from wasting. Micronutrient deficiencies like iron deficiency anemia and iodine deficiency are also widespread. Inadequate childcare practices like low rates of exclusive breastfeeding and late introduction of complementary foods contribute to undernutrition. While the government and NGOs have implemented some nutrition interventions, coverage remains low and interventions have faced challenges. The government has now established the National Nutrition Service to mainstream nutrition services and implement a multi-sectoral response to reduce malnutrition in Bangladesh.
This document presents pathways between SBCC delivery strategies and improved maternal, infant, and young child nutrition practices. It introduces a conceptual framework that shows how SBCC can target different populations to address behavioral determinants and improve nutrition practices and status. The framework includes evidence-based high-impact nutrition practices in five areas: dietary practices during pregnancy/lactation, breastfeeding, complementary feeding, anemia prevention/control, and WASH. It then outlines key determinants of behavior change and SBCC delivery strategies like community mobilization, BCC, and advocacy. The document provides citations supporting the prioritized nutrition practices and refers readers to additional evidence on effective SBCC approaches on the SPRING website.
Nutrition sensitive sp programs and nutrition alderman may 2014essp2
This document discusses how nutrition-sensitive social protection programs can help accelerate progress in improving maternal and child nutrition. It defines nutrition-sensitive interventions as programs that address the underlying determinants of nutrition by incorporating specific nutrition goals and actions. While targeted household transfers have shown modest impacts on nutrition, the document argues they could be enhanced by prioritizing nutritionally vulnerable groups, improving program design, and using social protection programs as a platform to deliver nutrition-specific interventions.
This document from the American Academy of Pediatrics outlines their policy statement on breastfeeding and the use of human milk. The key points are:
1) Extensive research has demonstrated significant health benefits for infants and mothers from breastfeeding, including reduced risk of infectious diseases, sudden infant death syndrome, diabetes, obesity, and improved cognitive development.
2) The policy statement provides recommendations for pediatricians and healthcare professionals to promote, protect, and support breastfeeding through individual practice, hospitals, medical schools, and communities.
3) Certain infectious diseases like HIV may preclude breastfeeding in some situations, but exclusive breastfeeding for the first 6 months does not increase HIV transmission risk according to some studies in developing countries.
This document proposes solutions to reduce malnutrition globally. It states that malnutrition affects billions and contributes to millions of child deaths daily from lack of essential nutrients. It recommends providing affordable vitamin/mineral supplements to vulnerable people and encouraging communities to improve food production/consumption. The proposed solutions aim to integrate health services, ensure quality care, alleviate cost barriers, and receive funding from eliminating user fees and establishing cash transfer systems. However, challenges include lack of political will due to funding issues, lack of awareness, and orthodox societies.
This document outlines strategies and interventions to tackle stunting in children under 2 years old. It recommends preventive and early interventions at the community level through empowerment and improved healthcare services. The key is to assure sustainability through ongoing quality improvement processes. It describes screening children under 2 to identify nutritional needs and providing evidence-based interventions. Interventions discussed include delayed cord clamping, early breastfeeding, dietary diversity, facility-based management of severe and moderate acute malnutrition, community-based management, identifying at-risk children, fortified supplements, deworming, zinc therapy, multivitamin supplements, and vitamin A supplementation. Metrics include decreasing malnutrition and assuring regular quality improvement team meetings.
1) A team of international nutrition experts reviewed evidence and estimated the impact and cost of scaling up 10 proven nutrition interventions to reach 90% of at-risk populations. This could save 900,000 lives in high-burden countries and reduce stunting in children by 33 million.
2) The total additional annual cost of achieving 90% coverage with these interventions is estimated to be $9.6 billion.
3) While nutrition-specific interventions can reduce stunting by 20%, nutrition-sensitive programs that address the underlying causes of undernutrition, like food security and women's empowerment, are also needed. These programs have potential to deliver nutrition interventions at large scale.
Food gardens have the potential to help address malnutrition in children aged 0-5 years in South Africa. While food gardens may improve access to micronutrients like vitamin A, it is unclear if they can provide sufficient nutrition on their own. For food gardens to be effective, they must be paired with nutrition education programs and focus on growing nutrient-dense crops. Larger, more structured programs in schools and early childhood centers may have better outcomes than small household gardens alone.
Maternal and child undernutrition is a serious problem in Bangladesh, with nearly half of children under five stunted and 14% suffering from wasting. Micronutrient deficiencies like iron deficiency anemia and iodine deficiency are also widespread. Inadequate childcare practices like low rates of exclusive breastfeeding and late introduction of complementary foods contribute to undernutrition. While the government and NGOs have implemented some nutrition interventions, coverage remains low and interventions have faced challenges. The government has now established the National Nutrition Service to mainstream nutrition services and implement a multi-sectoral response to reduce malnutrition in Bangladesh.
This document presents pathways between SBCC delivery strategies and improved maternal, infant, and young child nutrition practices. It introduces a conceptual framework that shows how SBCC can target different populations to address behavioral determinants and improve nutrition practices and status. The framework includes evidence-based high-impact nutrition practices in five areas: dietary practices during pregnancy/lactation, breastfeeding, complementary feeding, anemia prevention/control, and WASH. It then outlines key determinants of behavior change and SBCC delivery strategies like community mobilization, BCC, and advocacy. The document provides citations supporting the prioritized nutrition practices and refers readers to additional evidence on effective SBCC approaches on the SPRING website.
Nutrition sensitive sp programs and nutrition alderman may 2014essp2
This document discusses how nutrition-sensitive social protection programs can help accelerate progress in improving maternal and child nutrition. It defines nutrition-sensitive interventions as programs that address the underlying determinants of nutrition by incorporating specific nutrition goals and actions. While targeted household transfers have shown modest impacts on nutrition, the document argues they could be enhanced by prioritizing nutritionally vulnerable groups, improving program design, and using social protection programs as a platform to deliver nutrition-specific interventions.
This document from the American Academy of Pediatrics outlines their policy statement on breastfeeding and the use of human milk. The key points are:
1) Extensive research has demonstrated significant health benefits for infants and mothers from breastfeeding, including reduced risk of infectious diseases, sudden infant death syndrome, diabetes, obesity, and improved cognitive development.
2) The policy statement provides recommendations for pediatricians and healthcare professionals to promote, protect, and support breastfeeding through individual practice, hospitals, medical schools, and communities.
3) Certain infectious diseases like HIV may preclude breastfeeding in some situations, but exclusive breastfeeding for the first 6 months does not increase HIV transmission risk according to some studies in developing countries.
This document proposes solutions to reduce malnutrition globally. It states that malnutrition affects billions and contributes to millions of child deaths daily from lack of essential nutrients. It recommends providing affordable vitamin/mineral supplements to vulnerable people and encouraging communities to improve food production/consumption. The proposed solutions aim to integrate health services, ensure quality care, alleviate cost barriers, and receive funding from eliminating user fees and establishing cash transfer systems. However, challenges include lack of political will due to funding issues, lack of awareness, and orthodox societies.
This document reviews factors that influence mothers in the WIC program to choose formula feeding over breastfeeding for their infants. Several studies examined found that parents who formula feed generally have less knowledge of the health benefits of breastfeeding and a less positive attitude towards it. A cohort study found that breastfed infants enrolled in WIC programs saved over $400 in expenses in their first 6 months compared to formula fed infants. A review also showed that education and support services are effective at increasing the duration of breastfeeding. The document suggests WIC programs develop policies to better promote and educate mothers on breastfeeding.
Livestock-Climate Change CRSP Annual Meeting 2011: Integrating Human Nutritio...Colorado State University
Tips for integrating human nutrition into research on the interaction between livestock/agricultural production and climate change; overview of the Global Livestock CRSP's ENAM project in Ghana. Presentation given by G. Marquis (McGill University) at the Livestock-Climate Change CRSP Annual Meeting, Golden, CO, April 26-27, 2011.
Sustainable Undernutrition Reduction in Ethiopia (SURE): Evaluation studies essp2
The SURE program is a government-led multisectoral intervention in Ethiopia that aims to reduce undernutrition through a package of interventions like joint household visits, cooking demonstrations, and media campaigns. Evaluation studies of SURE used a quasi-experimental design and found that children's dietary diversity is positively associated with reduced stunting, and that household production of fruits and vegetables was linked to increased child dietary diversity and reduced stunting. However, the studies also found variability in the delivery of nutrition messages across households and limited awareness of nutrition guidelines among local officials.
This document discusses reducing the global rate of low birth weight by 30% by 2025. It provides background on low birth weight, noting that 15-20% of births worldwide have low birth weight. Interventions discussed include improving maternal nutrition, treating conditions like preeclampsia, and increasing access to quality healthcare. Cost-effective community interventions are also presented, such as nutrition programs, smoking cessation support, and improved antenatal care. The document emphasizes the need for a comprehensive, evidence-based global strategy to address the multifactorial causes of low birth weight.
Gynecological and Nutritional Risk Factors for Female Infertilityijtsrd
Backgrounds Besides aging, there are a number of modifiable lifestyle risk factors, such as smoking, elevated consumption of caffeine and alcohol, stress, chronic exposure to environmental pollutants, hormonal imbalance and other nutritional habits exert a negative impact on a women's fertility. The aim of present work was to study the gynecological and nutritional risk factors implicated in developing female infertility. Methodology This cross sectional study comprised of 109 women with infertility either primary or secondary . Data were collected using a questionnaire and in face to face interviews. The questionnaire include questions about risk factors, food intake history by 24 hours recall and modified FFQ beside data on anthropometric. Data was presented as either mean ± SD or frequencies and percentages according to the natural of data. Chi square test was used at a 0.05. Results Of the total samples 109 women with infertility aged between 17 40 years old shown that the peak age at 18 25 years old. The gynecological risk factors shown no significant differences. However, the obtained biochemical result revealed that abnormal high levels of estrogen, TSH, T4, LH, and testosterone, and abnormal low levels of FSH, and T3. The nutritional risk factors have been determined include low levels of serum vitamin D, and serum ferritin. In addition, women with infertility shown to have heavier body weight, overall BMI was 31.5 kg m2 by which the majorities of women found significant obesity P 0.05 , have high risk of waist circumferences and also WHR P 0.05 . The result of present work found that food intake and food pattern of women have low energy intake and their dietary habits shown lack fruits and fish intake with increased junk food consumption P 0.05 . Conclusion The gynecological risk factors can be modified. The correct balance of energy, vitamin D and iron in the daily diet provides essential benefit for an optimal female reproductive health and reduces the risk of infertility. In this context, the association of certain risk factor to develop of infertility could be ameliorate by increase intake of balance diet or triggers can be eliminated. Souad El-mani | Reima Mansour | Ali Ateia Elmabsout "Gynecological and Nutritional Risk Factors for Female Infertility" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-6 , October 2021, URL: https://www.ijtsrd.com/papers/ijtsrd47507.pdf Paper URL : https://www.ijtsrd.com/medicine/other/47507/gynecological-and-nutritional-risk-factors-for-female-infertility/souad-elmani
Abstracts of studies that were presented at IFPRI-POSHAN's event on "Strengthening Actions for Nutrition in India: Insights from the National Family Health Survey" (4 Sept 2018, IIC, New Delhi) where multiple researchers from organizations such as International Food Policy Research Institute (IFPRI), Brookings India, International Institute for Population Sciences (IIPS), Society for Applied Studies (SAS), Population Council and more, shared insights from their ongoing/completed analyses of NFHS data on maternal and child nutrition.
Community Based Approaches to Managing Severe Acute Malnutritionssuserb3b109
The document summarizes a presentation given at a workshop on community-based approaches to managing severe malnutrition. The presentation provided background on Community Therapeutic Care (CTC), including its strategy, principles, and description. CTC aims to maximize coverage, access, and timeliness of treatment. It emphasizes sectoral integration and capacity building. A CTC program includes a supplementary feeding program, stabilization phase for children with complications, and outpatient therapeutic program providing specialized food and medical protocols. The presentation compared CTC to traditional therapeutic feeding centers and outlined the evolution of a CTC program over time.
The document discusses ways to tackle malnutrition in India through a proposed micro-nutrient nutrition program. It notes that over 30% of India's population suffers from calorie-protein and micronutrient deficiencies. The program would provide multiple vitamin and mineral supplements to pregnant and lactating women and children aged 6-59 months. It outlines the composition of supplements designed to provide daily recommended nutrient intake. The program aims to address malnutrition across generations in a coordinated manner through supplements, fortified foods, and public awareness campaigns.
Aene project a medium city public students obesity studyCIRINEU COSTA
Identifying undernutrition and obesity on students and propose public policies of health are urgent issues. This paper presents a study with weight and stature from students collected by physical education teachers (PEF) in schools of a city near São Paulo. The PEF collected the data and they were inserted in a program especially developed for each school Department (AENE Project). The datas were analyzed by software and evaluation done based on a World Health Organization (WHO_2007) table, that develops health programs worldwide. The results evaluations were used to raise the students and family, teachers and responsibles for treatment search (when required).
This document discusses malnutrition in Belize and evidence-based interventions. It provides statistics showing that 22% of children in Belize are stunted. The first 1000 days of life are critical for development and damage from malnutrition during this period is largely irreversible. Recommendations to tackle chronic malnutrition in children under two include preventive and early interventions, community empowerment, improving quality of health services, and ensuring sustainability through quality improvement. The Belize health system considers these strategies to address the country's chronic malnutrition problem.
LITERATURE SELECTION2LITERATURE SELECTION6Lite.docxSHIVA101531
LITERATURE SELECTION 2
LITERATURE SELECTION 6
Literature Selection
Augustina Ferguson
Grand Canyon University: NRS-441V
August 30, 2015
Running head: LITERATURE SELECTION 1
Literature Selection
#1
Nwaru, B. I., & Hemminki, E (2011). Infant Care practice in rural China and their relation to prenatal care utilization.Global Public Health, 6(1), 1- 14.doi:10.1080/17441691003667307.
How does each article describe the nature of the problem, issue, or deficit you have identified?
Studies describing postpartum childcare practices and the influence of prenatal care on infant care outcomes in rural China are scarce. Inadequate care was positively associated with never breastfeeding, early introduction of milk formula and cereal/porridge, and early start of work after delivery.
Does each article provide statistical information to demonstrate the gravity of the issue, problem, or deficit?
Yes! Data were available from a Knowledge, Attitude and Perception cross-sectional survey collected from 2001 to 2003, after a prenatal care intervention in Anhui County, China, with a response rate of 97%.
What are example(s) of morbidity, mortality, and rate of incidence or rate of occurrence in the general population?
None Identified
Does each article support your proposed change?
Yes, it does
#2
Udgiri, R., K. J., S., & Sorganvi, V. (2015). Breast Feeding Practices among Postnatal Mothers-a Hospital based Study. Journal of Advanced Scientific Research, 6(1), 10-13. Grand Canyon University Library. (2015). Research & Resource LopeSearch. Retrieved from http://library.gcu.edu/
How does each article describe the nature of the problem, issue, or deficit you have identified?
It assesses the knowledge and practices of mothers about breastfeeding Practices Cross- sectional study was carried out for a period of one month.
Does each article provide statistical information to demonstrate the gravity of the issue, problem, or deficit?
A total of 162 postnatal mothers admitted in postnatal ward constitute the sample size. The data was collected using semi-structured questionnaires. Data was analyzed by using SPSS 16th version. The study shows that 21(12.9%) of the babies were feed with prelacteal feeds like honey and sugar water.
What are example(s) of morbidity, mortality, and rate of incidence or rate of occurrence in the general population?
None was identified.
Does each article support your proposed change?
Yes.
# 3
Geçkil, E., Şahin, T., & Tunçdemir, A. (2012). The Effect of * The Following and Supporting Breast-feeding Programme*, That Is Applied by Family Health Staff, on The Mother's Effective Breastfeeding Behaviors in The First Six Months of The Post-Birth Period. (English)
How does each article describe the nature of the problem, issue, or deficit you have identified?
This study investigates the effect of the education and observation of supporting breast-feeding programme that is applied by family health staff on the mothers of the post birt ...
4. day 2 session 1 nutrition sensitive programs and policiesPOSHAN
Presentation made at a two-day workshop "Stepping up to India’s Nutrition Challenge: The Critical Role of Policy Makers" for district administrators from India’s Aspirational Districts, on 6-7 Aug 2018, at Mussoorie.
Why Do Women Stop Breastfeeding Findings From The Pregnancy RiskBiblioteca Virtual
This study examined breastfeeding behaviors using data from the Pregnancy Risk Assessment and Monitoring System (PRAMS) from 2000-2001. The authors found that 32% of women did not initiate breastfeeding, 4% stopped within the first week, 13% stopped within the first month, and 51% continued for over 4 weeks. Younger women and those with limited socioeconomic resources were more likely to stop breastfeeding early. Common reasons for stopping included sore nipples, perceived inadequate milk supply, and difficulties with breastfeeding. Women's predelivery intentions impacted their likelihood of initiating and continuing breastfeeding.
JAMA Network: Pregnant women may not be getting recommended nutrientsΔρ. Γιώργος K. Κασάπης
This study analyzed dietary intake data from 1003 pregnant women in the United States to evaluate nutrient adequacy and excess based on Dietary Reference Intake guidelines. The results showed that 10% or more of pregnant women had intakes below recommendations for several key vitamins and minerals from foods alone, even with dietary supplement use. Nearly all pregnant women exceeded sodium recommendations, and many were at risk of excessive intakes of folic acid and iron based on total usual intake from foods and supplements. The findings suggest improved dietary guidance is needed to help pregnant women meet but not exceed nutrient recommendations.
Breastfeeding in low-resource settings: Nota a “small matter”
The evidence is clear – breastfeeding has positive health effects both for mother and child. In an editorial published in PLOS Medicine Professor Lars Åke Persson summarises some of the most striking reasons for babies to be breast-fed within the first hour, exclusively within the first six months and continued during the second year of life. Health benefits include lower morbidity and mortality rates, as well as better neuro-cognitive functions. For mothers who breastfeed reduced risk of cancer is cited. Why then is breastfeeding not the social norm around the world? Professor Persson explains that an enabling environment, at societal level, within the health system, at the workplace and in families, is necessary for more babies to be breastfed.
World Breastfeeding Week is an annual celebration marked from 1-7 August that highlights this essential practice. This year it is built around the theme of Breastfeeding Support for Mothers. More mothers breastfeed when they receive support, counselling and education in health centres and in their communities
This study investigated the level of nutrition knowledge among 400 pregnant Australian women across eight domains related to the Australian Guide to Healthy Eating (AGHE) recommendations for pregnancy. The results showed that over half of the women were unfamiliar with the AGHE recommendations. Detailed analysis revealed misconceptions in areas like standard serving sizes, nutrient contents of foods, fat density, and importance of key nutrients. Demographic factors like education level, income, age, stage of pregnancy, language, and nutrition qualifications significantly affected women's nutrition knowledge scores based on regression analysis. The study highlights poor nutrition knowledge among Australian pregnant women and the need for improved support and education.
Association Between Bio-fortification and Child Nutrition Among Smallholder H...Premier Publishers
This study examined the relationship between biofortification and child stunting in Uganda using panel data from 6 districts over 3 years. A panel logistic regression was estimated to study the association between child stunting and household production of biofortified crops. The results confirmed a strong association between production of biofortified varieties and reduced child stunting. Other factors associated with lower stunting included male gender, older child age, higher birth weight, greater dietary diversity, more education of caregiver, better antenatal care, smaller household size, and better access to water and livestock. The findings provide empirical support for Uganda's policies promoting biofortified crops to address malnutrition.
Food fortification involves adding nutrients to foods that naturally lack them. For pregnant women in developing countries, food fortification can help address common nutrient deficiencies and improve pregnancy outcomes. Micronutrient deficiencies are widespread in these populations, putting pregnant women at risk. While food fortification has been shown to effectively reduce deficiencies, evaluations of programs need stronger methodologies to fully assess impact on health. Improving program design, implementation, and using standardized evaluation methods can generate higher quality evidence of food fortification's effects.
Issues Identify at least seven issues you see in the case1..docxbagotjesusa
Issues: Identify at least seven issues you see in the case
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What is the Key issue you see in the case: __________________________
What facts pertain to the case: Identify at least three important facts that pertain to the case
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What assumptions do you plan to make in your analysis: None is an acceptable answer
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What people and organizations may have an impact on the case: There should be at least five.
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You are writing the case from the perspective of which person or organization:______________
What tools of Analysis would you use in this case: You only need to identify them and explain what information each will give you that you feel is important.
Based upon the above information – provide three alternatives
Alternative 1 is the Status Quo or to do nothing different that the current situation.
Identify at least three arguments in favor and three against this approach
Pros
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Cons
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Alternative 2 ____________________________________________________
Identify at least three arguments in favor and three against this approach
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Cons
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Alternative 3 ______________________________________________
Identify at least three arguments in favor and three against this approach
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Given the information above select your recommended alternative and explain why you feel it is the best alternative: This should take three to five paragraphs and be based upon the information presented in your case.
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Issues and disagreements between management and employees lead.docxbagotjesusa
Issues and disagreements between management and employees lead to formation of labor unions. Over the decades, the role of labor unions has been interpreted in various ways by employees across the globe.
What are some of the reasons employees join labor unions?
Did you ever belong to a labor union? If you did, do you think union membership benefited you?
If you've never belonged to a union, do you think it would have benefited you in your current or past employment? Why or why not?
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This document reviews factors that influence mothers in the WIC program to choose formula feeding over breastfeeding for their infants. Several studies examined found that parents who formula feed generally have less knowledge of the health benefits of breastfeeding and a less positive attitude towards it. A cohort study found that breastfed infants enrolled in WIC programs saved over $400 in expenses in their first 6 months compared to formula fed infants. A review also showed that education and support services are effective at increasing the duration of breastfeeding. The document suggests WIC programs develop policies to better promote and educate mothers on breastfeeding.
Livestock-Climate Change CRSP Annual Meeting 2011: Integrating Human Nutritio...Colorado State University
Tips for integrating human nutrition into research on the interaction between livestock/agricultural production and climate change; overview of the Global Livestock CRSP's ENAM project in Ghana. Presentation given by G. Marquis (McGill University) at the Livestock-Climate Change CRSP Annual Meeting, Golden, CO, April 26-27, 2011.
Sustainable Undernutrition Reduction in Ethiopia (SURE): Evaluation studies essp2
The SURE program is a government-led multisectoral intervention in Ethiopia that aims to reduce undernutrition through a package of interventions like joint household visits, cooking demonstrations, and media campaigns. Evaluation studies of SURE used a quasi-experimental design and found that children's dietary diversity is positively associated with reduced stunting, and that household production of fruits and vegetables was linked to increased child dietary diversity and reduced stunting. However, the studies also found variability in the delivery of nutrition messages across households and limited awareness of nutrition guidelines among local officials.
This document discusses reducing the global rate of low birth weight by 30% by 2025. It provides background on low birth weight, noting that 15-20% of births worldwide have low birth weight. Interventions discussed include improving maternal nutrition, treating conditions like preeclampsia, and increasing access to quality healthcare. Cost-effective community interventions are also presented, such as nutrition programs, smoking cessation support, and improved antenatal care. The document emphasizes the need for a comprehensive, evidence-based global strategy to address the multifactorial causes of low birth weight.
Gynecological and Nutritional Risk Factors for Female Infertilityijtsrd
Backgrounds Besides aging, there are a number of modifiable lifestyle risk factors, such as smoking, elevated consumption of caffeine and alcohol, stress, chronic exposure to environmental pollutants, hormonal imbalance and other nutritional habits exert a negative impact on a women's fertility. The aim of present work was to study the gynecological and nutritional risk factors implicated in developing female infertility. Methodology This cross sectional study comprised of 109 women with infertility either primary or secondary . Data were collected using a questionnaire and in face to face interviews. The questionnaire include questions about risk factors, food intake history by 24 hours recall and modified FFQ beside data on anthropometric. Data was presented as either mean ± SD or frequencies and percentages according to the natural of data. Chi square test was used at a 0.05. Results Of the total samples 109 women with infertility aged between 17 40 years old shown that the peak age at 18 25 years old. The gynecological risk factors shown no significant differences. However, the obtained biochemical result revealed that abnormal high levels of estrogen, TSH, T4, LH, and testosterone, and abnormal low levels of FSH, and T3. The nutritional risk factors have been determined include low levels of serum vitamin D, and serum ferritin. In addition, women with infertility shown to have heavier body weight, overall BMI was 31.5 kg m2 by which the majorities of women found significant obesity P 0.05 , have high risk of waist circumferences and also WHR P 0.05 . The result of present work found that food intake and food pattern of women have low energy intake and their dietary habits shown lack fruits and fish intake with increased junk food consumption P 0.05 . Conclusion The gynecological risk factors can be modified. The correct balance of energy, vitamin D and iron in the daily diet provides essential benefit for an optimal female reproductive health and reduces the risk of infertility. In this context, the association of certain risk factor to develop of infertility could be ameliorate by increase intake of balance diet or triggers can be eliminated. Souad El-mani | Reima Mansour | Ali Ateia Elmabsout "Gynecological and Nutritional Risk Factors for Female Infertility" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-6 , October 2021, URL: https://www.ijtsrd.com/papers/ijtsrd47507.pdf Paper URL : https://www.ijtsrd.com/medicine/other/47507/gynecological-and-nutritional-risk-factors-for-female-infertility/souad-elmani
Abstracts of studies that were presented at IFPRI-POSHAN's event on "Strengthening Actions for Nutrition in India: Insights from the National Family Health Survey" (4 Sept 2018, IIC, New Delhi) where multiple researchers from organizations such as International Food Policy Research Institute (IFPRI), Brookings India, International Institute for Population Sciences (IIPS), Society for Applied Studies (SAS), Population Council and more, shared insights from their ongoing/completed analyses of NFHS data on maternal and child nutrition.
Community Based Approaches to Managing Severe Acute Malnutritionssuserb3b109
The document summarizes a presentation given at a workshop on community-based approaches to managing severe malnutrition. The presentation provided background on Community Therapeutic Care (CTC), including its strategy, principles, and description. CTC aims to maximize coverage, access, and timeliness of treatment. It emphasizes sectoral integration and capacity building. A CTC program includes a supplementary feeding program, stabilization phase for children with complications, and outpatient therapeutic program providing specialized food and medical protocols. The presentation compared CTC to traditional therapeutic feeding centers and outlined the evolution of a CTC program over time.
The document discusses ways to tackle malnutrition in India through a proposed micro-nutrient nutrition program. It notes that over 30% of India's population suffers from calorie-protein and micronutrient deficiencies. The program would provide multiple vitamin and mineral supplements to pregnant and lactating women and children aged 6-59 months. It outlines the composition of supplements designed to provide daily recommended nutrient intake. The program aims to address malnutrition across generations in a coordinated manner through supplements, fortified foods, and public awareness campaigns.
Aene project a medium city public students obesity studyCIRINEU COSTA
Identifying undernutrition and obesity on students and propose public policies of health are urgent issues. This paper presents a study with weight and stature from students collected by physical education teachers (PEF) in schools of a city near São Paulo. The PEF collected the data and they were inserted in a program especially developed for each school Department (AENE Project). The datas were analyzed by software and evaluation done based on a World Health Organization (WHO_2007) table, that develops health programs worldwide. The results evaluations were used to raise the students and family, teachers and responsibles for treatment search (when required).
This document discusses malnutrition in Belize and evidence-based interventions. It provides statistics showing that 22% of children in Belize are stunted. The first 1000 days of life are critical for development and damage from malnutrition during this period is largely irreversible. Recommendations to tackle chronic malnutrition in children under two include preventive and early interventions, community empowerment, improving quality of health services, and ensuring sustainability through quality improvement. The Belize health system considers these strategies to address the country's chronic malnutrition problem.
LITERATURE SELECTION2LITERATURE SELECTION6Lite.docxSHIVA101531
LITERATURE SELECTION 2
LITERATURE SELECTION 6
Literature Selection
Augustina Ferguson
Grand Canyon University: NRS-441V
August 30, 2015
Running head: LITERATURE SELECTION 1
Literature Selection
#1
Nwaru, B. I., & Hemminki, E (2011). Infant Care practice in rural China and their relation to prenatal care utilization.Global Public Health, 6(1), 1- 14.doi:10.1080/17441691003667307.
How does each article describe the nature of the problem, issue, or deficit you have identified?
Studies describing postpartum childcare practices and the influence of prenatal care on infant care outcomes in rural China are scarce. Inadequate care was positively associated with never breastfeeding, early introduction of milk formula and cereal/porridge, and early start of work after delivery.
Does each article provide statistical information to demonstrate the gravity of the issue, problem, or deficit?
Yes! Data were available from a Knowledge, Attitude and Perception cross-sectional survey collected from 2001 to 2003, after a prenatal care intervention in Anhui County, China, with a response rate of 97%.
What are example(s) of morbidity, mortality, and rate of incidence or rate of occurrence in the general population?
None Identified
Does each article support your proposed change?
Yes, it does
#2
Udgiri, R., K. J., S., & Sorganvi, V. (2015). Breast Feeding Practices among Postnatal Mothers-a Hospital based Study. Journal of Advanced Scientific Research, 6(1), 10-13. Grand Canyon University Library. (2015). Research & Resource LopeSearch. Retrieved from http://library.gcu.edu/
How does each article describe the nature of the problem, issue, or deficit you have identified?
It assesses the knowledge and practices of mothers about breastfeeding Practices Cross- sectional study was carried out for a period of one month.
Does each article provide statistical information to demonstrate the gravity of the issue, problem, or deficit?
A total of 162 postnatal mothers admitted in postnatal ward constitute the sample size. The data was collected using semi-structured questionnaires. Data was analyzed by using SPSS 16th version. The study shows that 21(12.9%) of the babies were feed with prelacteal feeds like honey and sugar water.
What are example(s) of morbidity, mortality, and rate of incidence or rate of occurrence in the general population?
None was identified.
Does each article support your proposed change?
Yes.
# 3
Geçkil, E., Şahin, T., & Tunçdemir, A. (2012). The Effect of * The Following and Supporting Breast-feeding Programme*, That Is Applied by Family Health Staff, on The Mother's Effective Breastfeeding Behaviors in The First Six Months of The Post-Birth Period. (English)
How does each article describe the nature of the problem, issue, or deficit you have identified?
This study investigates the effect of the education and observation of supporting breast-feeding programme that is applied by family health staff on the mothers of the post birt ...
4. day 2 session 1 nutrition sensitive programs and policiesPOSHAN
Presentation made at a two-day workshop "Stepping up to India’s Nutrition Challenge: The Critical Role of Policy Makers" for district administrators from India’s Aspirational Districts, on 6-7 Aug 2018, at Mussoorie.
Why Do Women Stop Breastfeeding Findings From The Pregnancy RiskBiblioteca Virtual
This study examined breastfeeding behaviors using data from the Pregnancy Risk Assessment and Monitoring System (PRAMS) from 2000-2001. The authors found that 32% of women did not initiate breastfeeding, 4% stopped within the first week, 13% stopped within the first month, and 51% continued for over 4 weeks. Younger women and those with limited socioeconomic resources were more likely to stop breastfeeding early. Common reasons for stopping included sore nipples, perceived inadequate milk supply, and difficulties with breastfeeding. Women's predelivery intentions impacted their likelihood of initiating and continuing breastfeeding.
JAMA Network: Pregnant women may not be getting recommended nutrientsΔρ. Γιώργος K. Κασάπης
This study analyzed dietary intake data from 1003 pregnant women in the United States to evaluate nutrient adequacy and excess based on Dietary Reference Intake guidelines. The results showed that 10% or more of pregnant women had intakes below recommendations for several key vitamins and minerals from foods alone, even with dietary supplement use. Nearly all pregnant women exceeded sodium recommendations, and many were at risk of excessive intakes of folic acid and iron based on total usual intake from foods and supplements. The findings suggest improved dietary guidance is needed to help pregnant women meet but not exceed nutrient recommendations.
Breastfeeding in low-resource settings: Nota a “small matter”
The evidence is clear – breastfeeding has positive health effects both for mother and child. In an editorial published in PLOS Medicine Professor Lars Åke Persson summarises some of the most striking reasons for babies to be breast-fed within the first hour, exclusively within the first six months and continued during the second year of life. Health benefits include lower morbidity and mortality rates, as well as better neuro-cognitive functions. For mothers who breastfeed reduced risk of cancer is cited. Why then is breastfeeding not the social norm around the world? Professor Persson explains that an enabling environment, at societal level, within the health system, at the workplace and in families, is necessary for more babies to be breastfed.
World Breastfeeding Week is an annual celebration marked from 1-7 August that highlights this essential practice. This year it is built around the theme of Breastfeeding Support for Mothers. More mothers breastfeed when they receive support, counselling and education in health centres and in their communities
This study investigated the level of nutrition knowledge among 400 pregnant Australian women across eight domains related to the Australian Guide to Healthy Eating (AGHE) recommendations for pregnancy. The results showed that over half of the women were unfamiliar with the AGHE recommendations. Detailed analysis revealed misconceptions in areas like standard serving sizes, nutrient contents of foods, fat density, and importance of key nutrients. Demographic factors like education level, income, age, stage of pregnancy, language, and nutrition qualifications significantly affected women's nutrition knowledge scores based on regression analysis. The study highlights poor nutrition knowledge among Australian pregnant women and the need for improved support and education.
Association Between Bio-fortification and Child Nutrition Among Smallholder H...Premier Publishers
This study examined the relationship between biofortification and child stunting in Uganda using panel data from 6 districts over 3 years. A panel logistic regression was estimated to study the association between child stunting and household production of biofortified crops. The results confirmed a strong association between production of biofortified varieties and reduced child stunting. Other factors associated with lower stunting included male gender, older child age, higher birth weight, greater dietary diversity, more education of caregiver, better antenatal care, smaller household size, and better access to water and livestock. The findings provide empirical support for Uganda's policies promoting biofortified crops to address malnutrition.
Food fortification involves adding nutrients to foods that naturally lack them. For pregnant women in developing countries, food fortification can help address common nutrient deficiencies and improve pregnancy outcomes. Micronutrient deficiencies are widespread in these populations, putting pregnant women at risk. While food fortification has been shown to effectively reduce deficiencies, evaluations of programs need stronger methodologies to fully assess impact on health. Improving program design, implementation, and using standardized evaluation methods can generate higher quality evidence of food fortification's effects.
Similar to Series452 www.thelancet.com Vol 382 August 3, 2013.docx (20)
Issues Identify at least seven issues you see in the case1..docxbagotjesusa
Issues: Identify at least seven issues you see in the case
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
What is the Key issue you see in the case: __________________________
What facts pertain to the case: Identify at least three important facts that pertain to the case
1.
2.
3.
4.
5.
What assumptions do you plan to make in your analysis: None is an acceptable answer
1.
2.
3
What people and organizations may have an impact on the case: There should be at least five.
1.
2.
3.
4.
5.
6.
7.
8.
9.
You are writing the case from the perspective of which person or organization:______________
What tools of Analysis would you use in this case: You only need to identify them and explain what information each will give you that you feel is important.
Based upon the above information – provide three alternatives
Alternative 1 is the Status Quo or to do nothing different that the current situation.
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Alternative 2 ____________________________________________________
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Alternative 3 ______________________________________________
Identify at least three arguments in favor and three against this approach
Pros
1.
2.
3.
4.
5.
Cons
1.
2.
3.
4.
5.
Given the information above select your recommended alternative and explain why you feel it is the best alternative: This should take three to five paragraphs and be based upon the information presented in your case.
.
Issues and disagreements between management and employees lead.docxbagotjesusa
Issues and disagreements between management and employees lead to formation of labor unions. Over the decades, the role of labor unions has been interpreted in various ways by employees across the globe.
What are some of the reasons employees join labor unions?
Did you ever belong to a labor union? If you did, do you think union membership benefited you?
If you've never belonged to a union, do you think it would have benefited you in your current or past employment? Why or why not?
.
ISSA Journal September 2008Article Title Article Author.docxbagotjesusa
ISSA Journal | September 2008Article Title | Article Author
1�1�
ISSA The Global Voice of Information Security
Extending the McCumber Cube
to Model Network Defense
By Sean M. Price – ISSA member Northern Virginia, USA chapter
This article proposes an extension to the McCumber
Cube information security model to determine the best
countermeasures to achieve a desired security goal.
Confidentiality, integrity, and availability are the se-curity services of a system. In other words they are the security goals of system defense, intangible at-
tributes� providing assurances for the information protected.
Each service is realized when the appropriate countermea-
sures for a given information state are in place. But, it is not
enough to select countermeasures ad hoc. Countermeasures
should be selected to defend a system and its information
against specific types of attacks. When attacks against partic-
ular information states are considered, the necessary coun-
termeasures can be selected to achieve the desired security
service or goal. This article proposes an extension to the Mc-
Cumber Cube information security model as a way for the
security practitioner to consider the best countermeasures to
achieve the desired security goal.
Security models
Models are useful tools to help understand complex topics. A
well-developed model can often be represented graphically,
allowing a deeper understanding of the relationships of the
components that make the whole. A formal security model
is broadly applicable and rigorously developed using formal
methods.2 In contrast, an informal model is considered lack-
ing one or both of these qualities. There are a variety of in-
formal models in the information security world which are
regularly used by security practitioners to understand basic
information and concepts.
� Security goals often lack explicit definitions and are difficult to quantify. They are
usually based on policies with broad interpretations and tend to be qualitative. It is
true that security goals emerge from the confluence of information states and coun-
termeasures which have measurable attributes. But, the subjective nature of security
goals combined with informal modeling characterizes their attributes as intangible.
2 P. T. Devanbu and S. Stubblebine, “Software Engineering for Security: A Roadmap,”
Proceedings of the Conference on The Future of Software Engineering (2000), 227-239.
One such informal model is the generally accepted risk as-
sessment framework. This model is used to assess risk by
estimating asset values, vulnerabilities, threats with their
likelihood of exploiting a vulnerability, and losses. Figure �
illustrates this model. Note that this commonly used model
requires a substantial amount of estimating on the part of
the risk assessment participants. This is problematic when
reliable estimates cannot be obtained. Another problem with
this model is that it does not guide th.
ISOL 536Security Architecture and DesignThreat Modeling.docxbagotjesusa
ISOL 536
Security Architecture and Design
Threat Modeling
Session 6a
“Processing Threats”
Agenda
• When to find threats
• Playing chess
• How to approach software
• Tracking threats and assumptions
• Customer/vendor
• The API threat model
• Reading: Chapter 7
When to Find Threats
• Start at the beginning of your project
– Create a model of what you’re building
– Do a first pass for threats
• Dig deep as you work through features
– Think about how threats apply to your mitigations
• Check your design & model matches as you
get close to shipping
Attackers Respond to Your Defenses
Playing Chess
• The ideal attacker will follow the road you
defend
– Ideal attackers are like spherical cows — they’re a
useful model for some things
• Real attackers will go around your defenses
• Your defenses need to be broad and deep
“Orders of Mitigation”
Order Threat Mitigation
1st Window smashing Reinforced glass
2nd Window smashing Alarm
3rd Cut alarm wire Heartbeat signal
4th Fake heartbeat Cryptographic signal integrity
By Example:
• Thus window smashing is a first order threat, cutting
alarm wire, a third-order threat
• Easy to get stuck arguing about orders
• Are both stronger glass & alarms 1st order
mitigations? (Who cares?!)
• Focus on the concept of interplay between
mitigations & further attacks
How to Approach Software
• Depth first
– The most fun and “instinctual”
– Keep following threats to see where they go
– Can be useful skill development, promoting “flow”
• Breadth first
– The most conservative use of time
• Best when time is limited
– Most likely to result in good coverage
Tracking Threats and Assumptions
• There are an infinite number of ways to
structure this
• Use the one that works reliably for you
• (Hope doesn’t work reliably)
Example Threat Tracking Tables
Diagram Element Threat Type Threat Bug ID
Data flow #4, web
server to business
logic
Tampering Add orders without
payment checks
4553 “Need
integrity controls on
channel”
Info disclosure Payment
instruments sent in
clear
4554 “need crypto”
#PCI
Threat Type Diagram Element(s) Threat Bug ID
Tampering Web browser Attacker modifies
our JavaScript order
checking
4556 “Add order-
checking logic to
server”
Data flow #2 from
browser to server
Failure to
authenticate
4557 “Add enforce
HTTPS everywhere”
Both are fine, help you iterate over diagrams in different ways
Example Assumption Tracking
Assumption Impact if it’s
wrong
Who to talk
to
Who’s
following up
Follow-up
by date
Bug #
It’s ok to
ignore
denial of
service
within the
data center
Availability
will be
below spec
Alice Bob April 15 4555
• Impact is sometimes so obvious it’s not worth filling out
• Who to talk to is not always obvious, it’s ok to start out blank
• Tracking assumptions in bugs helps you not lose track
• Treat the assumption as a bug – you need to resolve it
The Customer/Vendor Boundary
• There is always.
ISOL 533 Project Part 1OverviewWrite paper in sections.docxbagotjesusa
ISOL 533 Project Part 1
Overview
Write paper in sections
Understand the company
Find similar situations
Research and apply possible solutions
Research and find other issues
Health network inc
You are an Information Technology (IT) intern
Health Network Inc.
Headquartered in Minneapolis, Minnesota
Two other locations
Portland Oregon
Arlington Virginia
Over 600 employees
$500 million USD annual revenue
Data centers
Each location is near a data center
Managed by a third-party vendor
Production centers located at the data centers
Health network’s Three products
HNetExchange
Handles secure electronic medical messages between
Large customers such as hospitals and
Small customers such as clinics
HNetPay
Web Portal to support secure payments
Accepts various payment methods
HNetConnect
Allows customers to find Doctors
Contains profiles of doctors, clinics and patients
Health networks IT network
Three corporate data centers
Over 1000 data severs
650 corporate laptops
Other mobile devices
Management request
Current risk assessment outdated
Your assignment is to create a new one
Additional threats may be found during re-evaluation
No budget has been set on the project
Threats identified
Loss of company data due to hardware being removed from production systems
Loss of company information on lost or stolen company-owned assets, such as mobile devices and laptops
Loss of customers due to production outages caused by various events, such as natural disasters, change management, unstable software, and so on
Internet threats due to company products being accessible on the Internet
Insider threats
Changes in regulatory landscape that may impact operations
Part 1 project assignment
Conduct a risk assessment based on the information from this presentation
Write a 5-page paper properly APA formatted
Your paper should include
The Scope of the risk assessment i.e. assets, people, processes, and technologies
Tools used to conduct the risk assessment
Risk assessment findings
Business Impact Analysis
.
Is the United States of America a democracyDetailed Outline.docxbagotjesusa
Is the United States of America a democracy?
Detailed Outline:
-Introduction (2-3 Paragraphs):
Define and discuss the criteria for democracy.
What does a country need to be democratic?
-Thesis Statement (1 Paragraph):
Clearly state whether or not you think America is a democracy. Briefly preview the three pieces of evidence you are going to use. Your thesis statement is your argument. It must be clear and strongly stated so I know what you are arguing.
-Supporting Evidence 1 (1-3 Paragraphs)
Using Freedom House’s 2021 (2020 if 21 is not available)analysis of the U.S., support your argument regarding democracy in the U.S analysis of the U.S., support your argument regarding democracy in the U.S.
Supporting Evidence 2 (1-3 Paragraphs)
Choose a news article and explain the event covered in the article and how it
supports your argument.
Supporting Evidence 3 (1-3 Paragraphs)
Choose another news article
-Conclusion (1-2 Paragraphs)
Summarize your supporting evidence and how it supports your overall argument. This should include a brief discussion about how the other argument could be right
Citations: You will need outside sources for this paper. All sources must be properly cited. This means that the sources need to be parenthetically cited in the text of the paper and need to be included in a bibliography page. You are not allowed to use any user edit web sites (Wikipedia, Yahoo Answers, Ask.com, etc.) or social media as sources
4-5 papers
.
Islamic Profession of Faith (There is no God but God and Muhammad is.docxbagotjesusa
Islamic Profession of Faith (There is no God but God and Muhammad is his prophet.)
1. [contextualize] How are they a reflection of the time and culture which produced them?
2. [evaluate] What were the implications of these beliefs and values during the Middle Ages?
3. [compare] How do the beliefs and values of these cultures compare to your own?
.
IS-365 Writing Rubric Last updated January 15, 2018 .docxbagotjesusa
IS-365 Writing Rubric
Last updated: January 15, 2018
Student:
Score (out of 50):
General Comments:
Other comments are embedded in the document.
Criterion <- Higher - Quality - Lower ->
Persuasiveness The reader is
compelled by solid
critical reasoning,
appropriate usage of
sources, and
consideration of
alternative
viewpoints.
The document is
logical and coherent
enough that the
reader can accept its
points and
conclusions
Gaps in logic and
uncritical review of
sources cause the
reader to have some
doubts about the
points made by the
document, or
whether they’re
relevant to the
question asked.
The reader is unsure
of what the document
is trying to
communicate, or is
wholly unconvinced
by its arguments
Not
applicable
Evidence and support Exceptional use of
authoritative and
relevant sources,
properly cited,
providing strong
support of the
document’s points
Sufficient relevant
and authoritative
sources give
confidence that the
document is based
on adequate
research
Sources are
insufficient in
number, not
authoritative, not
relevant, or
improperly cited
No sources are used,
undermining the
document’s
foundations
Not
applicable
Writing Word choices, flow
of logic, and
sentence and
paragraph structure
engage the reader,
making for a
pleasurable
experience
Writing is clear and
adequately fulfills
the document’s
purpose
Some issues with
word choice and
sentence and
paragraph structure
interfere with the
conveyance of the
document’s ideas
Frequent questionable
choices in writing
make it difficult to
read and understand
Not
applicable
Language Essentially free of
language errors
Minor errors in
grammar,
punctuation, or
spelling
Noticeable language
errors that detract
from the readability
of the document
Significant language
errors that call the
credibility of the
document into
question
Not
applicable
Formatting (heading
styles, fonts, margins,
white space, tables
and graphics)
Professional and
consistent formatting
that enhances
readability.
Appropriate use of
tables and graphics.
Generally acceptable
formatting choices.
Some missed
opportunities for
displaying data via
tables or graphics.
Inconsistent or
questionable
formatting choices
that detract from the
document’s
readability
Critical formatting
issues that make the
document
unprofessional-
looking
Not
applicable
Page 1
Page 1
Page 2
(Name deleted)
IS-365
Art Fifer
2/17/2017
Technical Documents for Varying Audiences
In this paper, I’ll be exploring the differences in presenting technical communications to audiences of varying knowledge. The topic of these two general summaries will be the manner in which computers connect to each other, including summaries of several communication protocols, how information traverses the network, and how it arrives at its destination and is read by th.
ISAS 600 – Database Project Phase III RubricAs the final ste.docxbagotjesusa
ISAS 600 – Database Project Phase III Rubric
As the final step to your proposed database, you submitted your Project Plan. This document should communicate how you intend to complete the project. Include timelines and resources required.
Area
Does not meet expectations
Meets expectations
Exceeds expectations
A. Analysis - how will you determine the needs of the database
Did not identify appropriate plan for analysis phase
Identified appropriate plan for analysis phase
Identified appropriate plan for analysis phase and included additional content
Design - what process will you use to design the database (tables, forms, queries, reports)
Did not sufficiently identify detail on the appropriate process for design phase
Identified appropriate process for design phase
Identified appropriate process for design phase and included additional detail
Prototype/End user feedback - Will you show users a prototype before building the system?
Did not sufficiently identify method for feedback and prototypes during building of the system
Identified method for feedback and prototypes during building of the system
Identified method for feedback and prototypes during building of the system and provided additional detail
Coding - what process will you use to build the database?
Did not sufficiently identify appropriate process for coding the database
Identified appropriate process for coding the database
Identified appropriate process for coding the database and provided additional detail.
Testing - How will you test it?
to build the database?
Did not sufficiently identify appropriate process for testing the database
Identified appropriate process for testing the database
Identified appropriate process for testing the database and provided additional detail.
User Acceptance - describe the final step of determining if you met the user's needs?
Did not sufficiently identify an appropriate process for User Acceptance phase - How to determine if the database meets user’s needs.
Identified appropriate process for User Acceptance phase - How to determine if the database meets user’s needs.
Identified appropriate process for User Acceptance phase - How to determine if the database meets user’s needs. Answer provided additional detail
Training - what is the plan for training end users?
Did not identify appropriate detail for training plan
Identified appropriate detail for training plan
Identified appropriate detail for a training plan and provided additional detail.
Project close out - what steps will you take to finalize the project?
Did not sufficiently identify appropriate steps for closing out the project
Identified appropriate steps for closing out the project
Identified appropriate steps for closing out the project and provided additional detail.
Entity Relationship Diagram1
ERD:
Normalization:
1NF:
For the 1st NF we will have to check the tables’ attributes, like there must not be any multivalued attribute, if there is any multivalued at.
Is teenage pregnancy a social problem How does this topic reflect.docxbagotjesusa
Is teenage pregnancy a social problem? How does this topic reflect the social construction of problems? How does social location impact if you view this as a social problem?
Explain why media representation of social problems is an important issue using the example of teenage pregnancy. What is an example of a problematic representation? Does this vary across race, ethnicity, religion, socioeconomic status and gender?
.
Is Texas so conservative- (at least for the time being)- as many pun.docxbagotjesusa
Is Texas so conservative- (at least for the time being)- as many pundits and observers claim? Or is that just an opinion not supported by analysis and facts? Not only does Texas vote Republican in many elections but has done so for many years. It is also the birthplace of the so-called Tea Party movement and of Ron Paul's campaigns for president. Texas also appears to espouse conservative approaches to government and to issues. You will need to define in a concrete and operational way what conservative means as conservative is more than voting behavior or party affiliation.
Texas is the 2nd largest state in population compared to California and.like California made up of many differing migrant and immigrant groups. Texas like California was also part of Northern Mexico. but Texas is very, very different from California in voting behavior and positions on social issues. Why? Texas and California are good comparisons or are they? Provide explanations of the differences and similarities in this ideological context
Texas was once "Democratic" but even that was not really the case in terms of either past or current Democratic ideals and goals but a historic reaction to the consequences of the civil war and the fact that Texas was on the losing side in that war and of the attempt to defend agrarian interests in the form of slavery.. Being Democratic from post civil war to the middle of the 20th century in part meant for decades being in favor of inequality for minorities and defenders in spirit, if not in fact, of slavery.net
So Texas was never "Democratic" and never a more liberal interpretation of reality but a reflection of conservative thought and a particular view of individualistic man.
Is Texas conservative and why? ( you will need a social, cultural, historical and economic analysis here
with supporting evidence)?
? Need much more than opinions here.
.
Irreplaceable Personal Objects and Cultural IdentityThink of .docxbagotjesusa
Irreplaceable: Personal Objects and Cultural Identity
Think of a
personal object
that is
irreplaceable
to you.
Please answer the following:
1. Describe the item and tell a brief story, memory, or ritual related to the item.
2. How does this possession influence your identity?
3. How does this item represent your cultural identity?
4. How is your selection of this item influenced by your identity and culture?
Instructions:
please answer all 4 questions accordingly. Each answer should have the question re-typed following the answer. A minimum of 500 words in all excluding the re-typed questions. No reference is needed.
.
IRB is an important step in research. State the required components .docxbagotjesusa
IRB is an important step in research. State the required components one should look for in a project to determine if IRB submission is needed. Discuss an example of a research study found in one of your literature review articles that needed IRB approval. Specifically, describe why IRB approval was needed in this instance.
.
irem.org/jpm | jpm® | 47
AND
REWARD
RISK
>>
BY KRISTIN GUNDERSON HUNT
THE FIGHT TO FILL VACANT COMMERCIAL REAL ESTATE SPACE IN RECENT YEARS
HAS FORCED REAL ESTATE OWNERS AND MANAGERS TO CONSIDER NEW USES
FOR THEIR PROPERTIES—EVEN IF THEY REQUIRE TAKING ADDITIONAL RISKS.
especially vacancies,” said Janice
Ochenkowski, managing director
for Jones Lang LaSalle and the com-
mercial real estate firm’s director of
global risk management in Chicago.
“But property owners and manag-
ers have been very creative in how
to use their existing facilities.”
Traditional retail stores have been
transformed into everything from
medical office space and churches
to fitness centers and breweries. In
addition, special events and pop-
up stores are more commonplace;
traditional office spaces have been
converted to daycare centers; in-
dustrial warehouses are being used
as practice facilities for youth base-
ball teams; and the list goes on.
“From a risk management per-
spective, these new uses can bring
new challenges,” Ochenkowski said.
“However, it is the primary goal
of the risk manager to support the
business, which means we need to
be more creative in the way we deal
with these risks.”
DOESN’T MEAN YOU HAVE TO WALK AWAY.”–JANICE OCHENKOWSKI, JONES
LANG LASAL
LE
DO THE ASSESSMENT HONESTLY. JUST BECAUSE THERE IS A HI
GHER RISK
“DON’T BE AFRAID TO THINK ABOUT WHAT THE RISKS ARE.
the tough economy has resulted in a lot of challenges—“
DUE DILIGENCE
The risks associated with new-use tenants are as varied as the tenants them-
selves.
First and foremost, certain tenants could present additional life safety
risks, said Jeffrey Shearman, a Pittsburgh-based senior risk engineering con-
sultant and real estate industry practice leader for commercial insurance
provider, Zurich.
For example, restaurant tenants create increased exposure to fire; church
and/or educational institutions might spur egress concerns because they en-
courage large gatherings in spaces formerly used for different occupancy;
and hazardous waste can be a risk with some medical tenants.
“You have to recognize that certain types of work are going to create cer-
tain types of hazards,” Shearman said.
Beyond life safety risks, certain tenants might be more susceptible than
previous tenants to codes and regulations imposed by state or federal laws,
such as licensing regulations for daycares or American Disabilities Act re-
quirements for medical tenants, said Pat Pollan, CPM, principal at Pollan
Hausman Real Estate Services in Houston.
New-use tenant risks don’t stop there: financial risks also exist. Replac-
ing a unique tenant with a similar occupant after the lease expires can be
difficult—a particular concern if a lot of money was spent customizing the
space for an alternative use.
“It’s not just the risk of liability, it’s the risk of the tenant going out of busi-
ness and losing any money you put into the tenant, or its space, .
IoT References:
https://www.techrepublic.com/article/how-to-secure-your-iot-devices-from-botnets-and-other-threats/
https://www.peerbits.com/blog/biggest-iot-security-challenges.html
https://www.bankinfosecurity.asia/securing-iot-devices-challenges-a-11138
https://www.sumologic.com/blog/iot-security/
https://news.ihsmarkit.com/press-release/number-connected-iot-devices-will-surge-125-billion-2030-ihs-markit-says
https://cdn.ihs.com/www/pdf/IoT_ebook.pdf
https://go.armis.com/hubfs/Buyers%E2%80%99%20Guide%20to%20IoT%20Security%20-Final.pdf
https://www.techrepublic.com/article/smart-farming-how-iot-robotics-and-ai-are-tackling-one-of-the-biggest-problems-of-the-century/
Video Resources:What is the Internet of Things (IoT) and how can we secure it?
https://www.youtube.com/watch?v=H_X6IP1-NDc
What is the problem with IoT security? - Gary explains
https://www.youtube.com/watch?v=D3yrk4TaIQQ
Classmate 1
The Rise of the Republican Party
The Republican Party was formed due to a split in the Whig Party. The anti-slavery
“Conscience Whigs” split from the pro-slavery “Cotton Whigs”. Some anti-slavery Whigs joined
the American “Know-Nothing” Party, while the remainder joined with independent Democrats
and Free-Soilers to form a new party, the Republicans. The initial members stood for one
principle: the exclusion of slavery from the western territories (Shi, p. 462). Knowing the
Republicans ideology, we will look at how the events leading up to the Kansas-Nebraska Act led
to greater political division that eventually caused the formation of the Republican Party and it’s
rise to the presidency in 1860.
In the 1850’s, America was becoming increasingly divided between those for and against
slavery. The Compromise of 1850 had temporarily appeased both sides by admitting California
as a free state, allowing no slavery restrictions in New Mexico and Utah, paying Texas,
abolishing slave trade but no slavery in the District of Columbia, establishing the Fugitive Slave
Act, and denying congress authority to interfere with interstate slave trade (Shi, p. 457). This
Fugitive Slave Act was highly contested, although very few slaves were returned to the south
under this Act. In fact, it ended up uniting anti-slavery people, more than aiding the South. It was
during this time that Uncle Tom’s Cabin was written, selling more than a million copies
worldwide and detailing the harsh brutality of slavery (Shi, p. 460-461).
In the mid-1850’s, the Kansas-Nebraska Act was passed. The main reason for it was to the
settle the vast territory west of Missouri and Iowa, and to create a transcontinental railroad to
capitalize on Asian markets and goods. New territories brought up questions of whether slavery
would be allowed, with many supporting “popular sovereignty” where voters chose whether they
would have slavery or not. The issue here was that the 1820 Missouri Compromise had said there
would be no new slaver.
In two paragraphs, respond to the prompt below. Journal entries .docxbagotjesusa
In two paragraphs, respond to the prompt below. Journal entries must contain proper grammar, spelling and capitalization.
Consider the communication pattern within your family of origin. How does your family's conversation orientation (how open your family is to discuss a range of topics) and conformity orientation (how strongly your family reinforces the uniformity of attitudes, values and beliefs) affect your interactions with your partner? If you don't think there is any effect, explain your reasoning.
.
Investigative Statement AnalysisInitial statement given by Ted K.docxbagotjesusa
Investigative Statement Analysis
Initial statement given by Ted Kennedy in reference to the accident that occurred on July 18, 1969 in Chappaquiddick, Massachusetts.
Date:
October 30, 2007
Analyst Comments:
Narrative Balance: The Prologue begins with sentence #1 and ends with sentence #3. The Central Issue begins with sentence #4 and ends with sentence #9. The Epilogue begins with sentence #10 and ends with sentence #14. Thus the breakdown is:
Prologue = 3 sentences
Central Issue = 6 sentences
Epilogue = 5 sentences
The narrative is somewhat unbalanced due to the short Prologue and thus can be considered to be possibly deceptive on its face. It is not unbalanced enough to say this conclusively.
Mean Length of Unit:
The narrative has 14 sentences and 237 words, thus giving a MLU of 16.9 rounded to 17. Thus any sentences 23 words or longer and any sentences 11 words or less can be considered deceptive on their face.
Structure of Analysis:
The actual sentences from the narrative are in bold italicized type. After each sentence are the number of words in the sentence, whether or not it is deceptive on its face, and the analyst’s comments. All of these will be in normal type.
1.
On July 18th, 1969, at approximately 11:15 P.M. in Chappaquiddick, Martha’s Vineyard, Massachusetts, I was driving my car on Main Street on my way to get the ferry back to Edgartown.
30 words – Deceptive on its face. There is no mention of the passenger in this sentence. All of the pronouns are singular. It is “my car” “on my way”, etc. When the passenger is mentioned later, it is almost an afterthought. The deception in this sentence may be the last part of the sentence where he relates why he was driving the car. He very well may have been driving for some reason other than to get the ferry. This would be an area to be further explored in an interview.
2.
I was unfamiliar with the road and turned right onto Dike Road, instead of bearing hard left on Main Street.
20 words. “I was unfamiliar with the road” is an explanatory phrase telling us why he ended up on Dike Road. The phrase “instead of bearing hard left on Main Street” is a strange way of phrasing. Most people would say something like “instead of staying on Main Street.”
3.
After proceeding for approximately one-half mile on Dike Road I descended a hill and came upon a narrow bridge.
20 words. There is nothing particularly deceptive about this sentence. The phrasing of the sentence is very formal. The phrasing is almost like a police type report or a legal/lawyer way of phrasing. It also appears that the phrase “came upon a narrow bridge” is almost a passive way of phrasing that indicates he was taken by surprise and had no control over what he was doing.
4.
The car went off the side of the bridge.
9 words – This sentence is deceptive on its face. This is the very first sentence of the Central Issue. It is interesting to note that four of the six s.
Investigating Happiness at College SNAPSHOT T.docxbagotjesusa
Investigating Happiness at College
SNAPSHOT:
TOPIC Either a specific group related to college or a factor within
college life that possibly affects a specified group of college
students or students in general.
PITCH Present your topic and your research question to the class—
shark tank! Sound too scary? How about guppy tank ?).
Tentative due date: 2/5 & 2/7
ESSAY 1 The prospectus and the annotated bibliography.
Tentative due date: 2/21
ESSAY 2 Change in your topic or conducting your own study
Tentative due date: 3/16
ESSAY 3 Argument about a specific controversy within your topic
Tentative due date: 4/6
ESSAY 4 Answers and argues your refined research question about the
importance of your topic.
Tentative due date: 4/24
♥ Rough drafts with reflections about what is working and not working and
WHY will be required for the prospectus and essays 2 and 3. The work
on the rough draft and the reflections will count toward your essay grade.
♥ Final reflections submitted the class period after you submit your final
draft for essays 2-4 will also count as part of your essay grade.
♥ You will upload your drafts on Moodle. You will be asked to identify the
portions of the sources you used and submit hard copies of your sources
in a folder or files of your sources online.
Investigating Happiness at College:
Some questions that will help you form your own research
questions:
● Is happiness a necessity or a perk in college life?
● What do the expectations of happiness and the pursuit of
happiness reveal about a specific college group, college
students in general, or another college-related group?
● Considering both on-campus factors and off-campus factors
(at least at first), what most influences your group’s
happiness (or unhappiness)?
● Is there one major factor (on campus or off campus) you
would want to investigate that affects students’ happiness?
● How do the expectations about happiness that society has in
general or a certain specific segment of society (for
instance, parents) has, relate to college or college students?
● How much do preconceived notions and expectations about
college life affect student happiness?
● Hard work is hard to enjoy. So how do students balance that
hard work with the .
Investigate Development Case Death with Dignity Physician-Assiste.docxbagotjesusa
Investigate Development Case: Death with Dignity / Physician-Assisted Suicide
MAKE A DECISION: Is Ben's decision making being affected by his depression?
Yes
No
Why? Give reasons for why you chose the way you did. Consider the following factors in your reasons:
The effects of depression on decision making
Other stresses in Ben's life contributing to his state of mind
Ben's current quality of life
The family's values and beliefs
Your own values and beliefs
Please see attachment
.
A Free 200-Page eBook ~ Brain and Mind Exercise.pptxOH TEIK BIN
(A Free eBook comprising 3 Sets of Presentation of a selection of Puzzles, Brain Teasers and Thinking Problems to exercise both the mind and the Right and Left Brain. To help keep the mind and brain fit and healthy. Good for both the young and old alike.
Answers are given for all the puzzles and problems.)
With Metta,
Bro. Oh Teik Bin 🙏🤓🤔🥰
How to Manage Reception Report in Odoo 17Celine George
A business may deal with both sales and purchases occasionally. They buy things from vendors and then sell them to their customers. Such dealings can be confusing at times. Because multiple clients may inquire about the same product at the same time, after purchasing those products, customers must be assigned to them. Odoo has a tool called Reception Report that can be used to complete this assignment. By enabling this, a reception report comes automatically after confirming a receipt, from which we can assign products to orders.
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
Gender and Mental Health - Counselling and Family Therapy Applications and In...PsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
How to Download & Install Module From the Odoo App Store in Odoo 17Celine George
Custom modules offer the flexibility to extend Odoo's capabilities, address unique requirements, and optimize workflows to align seamlessly with your organization's processes. By leveraging custom modules, businesses can unlock greater efficiency, productivity, and innovation, empowering them to stay competitive in today's dynamic market landscape. In this tutorial, we'll guide you step by step on how to easily download and install modules from the Odoo App Store.
Series452 www.thelancet.com Vol 382 August 3, 2013.docx
1. Series
452 www.thelancet.com Vol 382 August 3, 2013
Maternal and Child Nutrition 2
Evidence-based interventions for improvement of maternal
and child nutrition: what can be done and at what cost?
Zulfi qar A Bhutta, Jai K Das, Arjumand Rizvi, Michelle F Gaff
ey, Neff Walker, Susan Horton, Patrick Webb, Anna Lartey,
Robert E Black,
The Lancet Nutrition Interventions Review Group, and the
Maternal and Child Nutrition Study Group
Maternal undernutrition contributes to 800 000 neonatal deaths
annually through small for gestational age births;
stunting, wasting, and micronutrient defi ciencies are estimated
to underlie nearly 3·1 million child deaths annually.
Progress has been made with many interventions implemented at
scale and the evidence for eff ectiveness of nutrition
interventions and delivery strategies has grown since The
Lancet Series on Maternal and Child Undernutrition in
2008. We did a comprehensive update of interventions to
address undernutrition and micronutrient defi ciencies in
women and children and used standard methods to assess
emerging new evidence for delivery platforms. We
modelled the eff ect on lives saved and cost of these
interventions in the 34 countries that have 90% of the world’s
children with stunted growth. We also examined the eff ect of
various delivery platforms and delivery options using
community health workers to engage poor populations and
promote behaviour change, access and uptake of
2. interventions. Our analysis suggests the current total of deaths
in children younger than 5 years can be reduced by
15% if populations can access ten evidence-based nutrition
interventions at 90% coverage. Additionally, access to and
uptake of iodised salt can alleviate iodine defi ciency and
improve health outcomes. Accelerated gains are possible and
about a fi fth of the existing burden of stunting can be averted
using these approaches, if access is improved in this
way. The estimated total additional annual cost involved for
scaling up access to these ten direct nutrition interventions
in the 34 focus countries is Int$9·6 billion per year. Continued
investments in nutrition-specifi c interventions to avert
maternal and child undernutrition and micronutrient defi
ciencies through community engagement and delivery
strategies that can reach poor segments of the population at
greatest risk can make a great diff erence. If this improved
access is linked to nutrition-sensitive approaches—ie, women’s
empowerment, agriculture, food systems, education,
employment, social protection, and safety nets—they can
greatly accelerate progress in countries with the highest
burden of maternal and child undernutrition and mortality.
Introduction
Stunting prevalence has been decreasing slowly and
165 million children were stunted in 2011.1 Under-
nutrition, consisting of fetal growth restriction, stunt-
ing, wasting, and defi ciencies of vitamin A and zinc,
along with sub optimum breastfeeding, underlies nearly
3·1 million deaths of children younger than 5 years
annually world wide, representing about 45% of all
deaths in this group.2 Maternal and child obesity
have also increased in many low-income and middle-
income countries.3
In a comprehensive review of nutrition interven-
tions, we previously assessed 43 nutrition-related inter-
3. ventions in detail and reported estimates of effi cacy and
eff ect for 11 core interventions.4 Much progress has been
made since with many interventions implemented at
scale, assessments of promising new interventions, and
new delivery strategies. We used standard methods to do
a comprehensive review of potential nutrition-specifi c
inter ventions to address undernutrition and micro-
nutrient defi ciencies in women and children. We
modelled the potential eff ect of delivery of these inter-
ventions on lives saved in the 34 countries with 90% of
the global burden of stunted children, and estimated the
eff ect of various delivery platforms that could enhance
equitable scaling up of nutrition-specifi c interventions.
Selection of interventions for review
We selected several nutrition-specifi c interventions
across the lifecycle for assessment of evidence of benefi t
(fi gure 1); these interventions included those aff ect-
ing adolescents, women of reproductive age, pregnant
women, newborn babies, infants, and children. We also
reviewed the evidence for delivery platforms for nutri-
tion interventions and other emerging interventions of
interest for nutrition of women and children.
We identifi ed and relied on the most recent reviews
with good quality methods for all interventions and
updated the evidence by incorporating newer studies,
when available. For other identifi ed interventions, when
we did not fi nd any relevant review, we did a de-novo
review using the methodology described in panel 1.5
Additionally, we consulted the electronic library on
nutrition actions (eLENA) for existing evidence used by
WHO for development of guidelines and policies for
action (appendix p 2).
Interventions to address adolescent health
4. and nutrition
There is growing interest in adolescent health as an
entry point to improve the health of women and chil-
dren, especially because an estimated 10 million girls
younger than 18 years are married each year.6 A range of
Lancet 2013; 382: 452–77
Published Online
June 6, 2013
http://dx.doi.org/10.1016/
S0140-6736(13)60996-4
This online publication has
been corrected. The corrected
version fi rst appeared at
thelancet.com on June 20, 2013
See Comment page 371
This is the second in a Series of
four papers about maternal and
child nutrition
Aga Khan University, Karachi,
Pakistan (Prof Z A Bhutta PhD,
J K Das MBA, A Rizvi MSc);
Hospital for Sick Children,
Toronto, ON, Canada
(M F Gaff ey MSc); Johns
5. Hopkins University, Bloomberg
School of Public Health,
Baltimore, MD, USA
(N Walker PhD,
Prof R E Black PhD); University
of Waterloo, Waterloo, ON,
Canada (Prof S Horton PhD);
Tufts University, Medford, MA,
USA (Prof P Webb PhD); and
University of Ghana, Accra,
Ghana (Prof A Lartey PhD)
Correspondence to:
Prof Zulfi qar A Bhutta, Center of
Excellence in Women and Child
Health, The Aga Khan University,
Karachi 74800, Pakistan
zulfi [email protected]
See Online for appendix
http://crossmark.dyndns.org/dialog/?doi=10.1016/S0140-
6736(13)60996-4&domain=pdf
Series
www.thelancet.com Vol 382 August 3, 2013 453
inter ventions exist in relation to adolescent health and
6. nutrition, which could also aff ect the period before fi rst
pregnancy or between pregnancies. Evi dence supporting
reproductive health and family planning interventions
in this age group suggests that it might be possible to
reduce unwanted pregnancies and optimise age at fi rst
pregnancy. These aims might be important to reduce
the risk of small-for-gestational age (SGA) births in
populations in which a substantial proportion of births
occur in adolescents. Opportunities might also exist to
address micronutrient defi ciencies and emerging issues
of overweight and obesity in adoles cents through com-
munity and school-based edu cation platforms. Although
evidence from robust random ised controlled trials is
scarce, we identifi ed a range of inter ventions in the adol-
es cent period aff ecting maternal, newborn, and child
health and nutrition outcomes (panel 27–18).
Interventions in women of reproductive age and
during pregnancy
Folic acid supplementation
Neural tube defects can be eff ectively prevented with
peri conceptional folic acid supplementation. A review19
of fi ve trials of periconceptional folic acid supplemen-
tation suggested a 72% reduction in risk of develop ment
of neural tube defects and a 68% reduction in risk of
recur rence compared with either no intervention,
placebo, or micro nutrient intake without folic acid
(table 119–26). A review20 of folic acid supplementation
during preg nancy showed that folic acid supple men-
tation improved mean birthweight, with a 79% reduction
in the incidence of megaloblastic anaemia (table 119–26).
Further more no evi dence of adverse eff ects was noted
from folic acid supple mentation in pro gramme settings.
Despite strong evidence of benefi t, reaching women of
Key messages
7. • Globally, 165 million children are stunted; undernutrition
underlies 3·1 million deaths in children younger than 5 years.
• A clear need exists to introduce promising evidence-based
interventions in the preconception period and in adolescents
in countries with a high burden of undernutrition and young
age at fi rst pregnancies; however, targeting and reaching a
suffi cient number of those in need will be challenging.
• Promising interventions exist to improve maternal nutrition
and reduce fetal growth restriction and small-for-gestational-
age (SGA) births in appropriate settings in developing
countries, if scaled up before and during pregnancy. These
interventions include balanced energy protein, calcium, and
multiple micronutrient supplementation and preventive
strategies for malaria in pregnancy.
• Replacement of iron-folate with multiple micronutrient
supplements in pregnancy might have additional benefi ts for
reduction of SGA in at-risk populations, although further
evidence from eff ectiveness assessments might be needed to
guide a universal policy change.
• Strategies to promote breastfeeding in community and facility
settings have shown promising benefi ts on enhancing
exclusive breastfeeding rates; however, evidence for long-term
benefi ts on nutritional and developmental outcomes is scarce.
• Evidence for the eff ectiveness of complementary feeding
strategies is insuffi cient, with much the same benefi ts
noted from dietary diversifi cation and education and food
supplementation in food secure populations and slightly
greater eff ects in food insecure populations. Further
eff ectiveness trials are needed in food insecure populations
with standardised foods (pre-fortifi ed or non-fortifi ed),
8. duration of intervention, outcome defi nition, and cost
eff ectiveness.
• Treatment strategies for severe acute malnutrition with
recommended packages of care and ready-to-use
therapeutic foods are well established, but further evidence
is needed for prevention and management strategies for
moderate acute malnutrition in population settings,
especially in infants younger than 6 months.
• Data for the eff ect of various nutritional interventions on
neurodevelopmental outcomes are scarce; future studies
should focus on these aspects with consistency in
measurement and reporting of outcomes.
• Conditional cash transfers and related safety nets can address
the removal of fi nancial barriers and promotion of access of
families to health care and appropriate foods and nutritional
commodities. Assessments of the feasibility and eff ects of
such approaches are urgently needed to address maternal
and child nutrition in well supported health systems.
• Innovative delivery strategies, especially community-based
delivery platforms, are promising for scaling up coverage
of nutrition interventions and have the potential to reach
poor populations through demand creation and household
service delivery.
• Nearly 15% of deaths of children younger than 5 years can
be reduced (ie, 1 million lives saved), if the ten core
nutrition interventions we identifi ed are scaled up.
• The maximum eff ect on lives saved is noted with
management of acute malnutrition (435 000
[range 285 000–482 000] lives saved); 221 000
9. (135 000–293 000) lives would be saved with delivery of an
infant and young child nutrition package, including
breastfeeding promotion and promotion of complementary
feeding; micronutrient supplementation could save
145 000 (30 000–216 000) lives.
• These interventions, if scaled up to 90% coverage, could
reduce stunting by 20·3% (33·5 million fewer stunted
children) and can reduce prevalence of severe wasting
by 61·4%.
• The additional cost of achieving 90% coverage of these
proposed interventions would be Int$9·6 billion per year.
Series
454 www.thelancet.com Vol 382 August 3, 2013
reproduc tive age in the peri conceptual period to provide
folic acid supple ments through existing delivery plat-
forms remains a logistical challenge. Fortifi cation of
cereals and other foods might be a feasible way to reach
the population in need.
Iron or iron and folic acid supplementation
A review21 of iron supplementation in non-pregnant
women of reproductive age showed that intermittent
iron supplementation (alone or with any other vitamins
and minerals) reduced the risk of anaemia by 27%
(table 119–26). A Cochrane review22 of daily iron supple-
mentation to women during pregnancy reported a 70%
reduction in anaemia at term, a 67% reduction in iron
defi ciency anaemia (IDA), and 19% reduction in the
incidence of low birthweight. Another review27 further
10. suggests that the eff ects were much the same in women
receiving inter mittent iron supplementation, or daily
iron, or iron and folic acid supplementation. Although
some evidence suggests that side-eff ects are fewer with
intermittent iron therapy in non-anaemic populations,
WHO recommends daily iron supplementation during
pregnancy as part of the standard of care in populations
at risk of iron defi ciency.28
Maternal multiple micronutrient supplementation
Multiple-micronutrient defi ciencies often coexist in low-
income and-middle-income countries (LMICs) and can
be exacerbated in pregnancy with potentially adverse
maternal outcomes. A Cochrane review23 of multiple
micro nutrient supplementation in pregnant women
Preconception care: family
planning, delayed age at first
pregnancy, prolonging of
inter-pregnancy interval,
abortion care, psychosocial care
• Folic acid supplementation
• Multiple micronutrient
supplementation
• Calcium supplementation
• Balanced energy protein
supplementation
• Iron or iron plus folate
• Iodine supplementation
• Tobacco cessation
• Delayed cord clamping
• Early initiation of breast
11. feeding
• Vitamin K administration
• Neonatal vitamin A
supplementation
• Kangaroo mother care
• Exclusive breast feeding
• Complementary feeding
• Vitamin A supplementation
(6–59 months)
• Preventive zinc
supplementation
• Multiple micronutrient
supplementations
• Iron supplementation
WRA and pregnancy Neonates Infants and children
• Malaria prevention in
women
• Maternal deworming
• Obesity prevention
Disease prevention and
treatment
Management of SAM
Management of MAM
• Therapeutic zinc for
12. diarrhoea
• WASH
• Feeding in diarrhoea
• Malaria prevention
in children
• Deworming in children
• Obesity prevention
Disease prevention and
treatment
Increased work
capacity
and productivity
Economic
development
Decreased maternal
and childhood
morbidity and
mortality
Improved cognition,
growth, and
neurodevelopmental
outcomes
Delivery platforms: Community delivery platforms, integrated
management of childhood illnesses, child health days, school-
based
delivery platforms, financial platforms, fortification strategies,
nutrition in emergencies
Adolescent
13. Bold=Interventions modelled
Italics=Other interventions reviewed
Figure 1: Conceptual framework
WRA=women of reproductive age. WASH=water, sanitation,
and hygiene. SAM=severe acute malnutrition. MAM=moderate
AM.
Panel 1: Methods, search strategy, and selection criteria
As per the Child Health Epidemiology Reference Group
(CHERG) systematic review
guidelines,5 we searched PubMed, Cochrane libraries,
electronic library on evidence on
nutrition actions (eLENA), and WHO regional databases and
included publications in every
language available in these databases. We used Medical Subject
Heading Terms (MeSH) and
keyword search strategies with various combinations of relevant
terms. We made every
eff ort to gather unpublished data when reports were available
for full abstraction. Inclusion
and exclusion criteria were established for each area of review,
and studies meeting these
criteria were double data extracted and categorised according to
outcome. Evidence was
then summarised by outcome and study design, including study
quality, generalisability, and
summary outcome measures. We did meta-analyses for each
outcome containing more
than one study, using either the Mantel-Haenszel or the Der
Simonian-Laird pooled relative
risks (RR, with 95% CIs), when there was unexplained
heterogeneity of eff ect. Heterogeneity
was assessed by visual inspection of forest plots and by the χ2 p
14. value (p<0·10). The binary
measure for individual studies and pooled statistics was
reported as the RR between the
experimental and control groups with 95% CIs. For the outcome
of interest for each
intervention, we applied the CHERG Rules for Evidence
Review5 to generate a fi nal estimate.
Series
www.thelancet.com Vol 382 August 3, 2013 455
assessed 23 trials and reported an 11–13% reduction in
low birthweight and SGA births, whereas eff ects on
anaemia and IDA were much the same when compared
with iron and folic acid supplements (table 1). Despite
earlier concerns about potential excess neonatal mortal-
ity with multiple micro nutrient use,29 present analyses
suggest no adverse eff ects on maternal mortality, still-
births, perinatal, and neonatal mortality with insuffi cient
data for neuro developmental outcomes. Although scarce,
there are interesting data for benefi ts of maternal
multiple micro nutrient supple mentation on growth in
early childhood.30 Preliminary data from a large trial31
comparing multiple micronutrient with iron-folate
supplementation in preg nancy in Bangladesh show a
signifi cant reduction in pre term births with no adverse
eff ects. Inclusion of this study in our meta-analysis
confi rms the reduction in low birth weight (relative
risk [RR] 0·88, 95% CI 0·85–0·91) and SGA (0·89,
0·83–0·96) and is also indicative of a small eff ect on
preterm births (0·97, 0·94–0·99). These fi nd ings support
the potential replacement of iron-folate supplements in
pregnancy with multiple micronutrient supplements in
15. populations at risk.
Maternal calcium supplementation
Gestational hypertensive disorders are the second
leading cause of maternal morbidity and mortality and
are associated with increased risk of preterm birth and
fetal growth restriction.32,33 Calcium supplementation
during pregnancy in women at risk of low calcium intake
has been shown to reduce maternal hypertensive dis-
orders and preterm birth. A Cochrane review by Hofmeyr
and colleagues34 assessed 13 trials and showed that
calcium supplementation during pregnancy reduced the
incidence of gestational hypertension by 35%, pre-
eclampsia by 55%, and preterm births by 24% (table 1).
These estimates have been updated in a review24 of
15 randomised controlled trials, which also showed a
52% reduction in the incidence of pre-eclampsia and
confi rmed that these eff ects were only noted in popu-
lations at risk of low calcium intake.
Maternal iodine supplementation or fortifi cation
In nearly all regions aff ected by iodine defi ciency, use of
iodised salt is the most cost-eff ective way to avert defi ciency.
A Cochrane review35 suggests that although iodised salt is
an eff ective means to improve iodine status, no conclusions
can be drawn about physical and mental development in
children and mortality. In some regions of the world with
severe iodine defi ciency, salt iodisation alone might not be
suffi cient for control of iodine defi ciency in pregnancy; in
these circumstances iodised oil supplementation during
pregnancy can be a viable option (table 1). A review25 of
fi ve randomised trials of iodised oil supplementation in
pregnancy in iodine-defi cient populations showed a
73% reduction in cretinism and a 10–20% increase in
developmental scores in children. Existing evidence
16. supports continued focus on eff ective universal salt
iodisation for women of reproductive age and those who
are pregnant. Further high-quality controlled studies are
needed to address dosage and alternative strategies for
iodine supplementation in diff erent population groups
and settings.
Addressing maternal wasting and food insecurity with
balanced energy and protein supplementation
Maternal undernutrition is a risk factor for fetal growth
restriction and adverse perinatal outcomes.1 Several
nutritional interventions have been assessed in such
situations, including dietary advice to pregnant women,
provision of balanced energy protein supplements, and
Panel 2: Interventions to address adolescent nutrition and
preconception care
Women of lower socioeconomic status and young age are at risk
of being undernourished
and underweight. Ronnenberg and colleagues7 assessed the
association between
preconception anaemia and poor fetal and neonatal outcomes.
They showed that the risk
of being born low birthweight was signifi cantly greater with
moderate preconception
anaemia (odds ratio [OR] 6·5, 95% CI 1·6–26·7) and fetal
growth restriction (4·6, 1·5–13·5).
Important factors indirectly related to maternal, fetal, and
neonatal nutritional status
and pregnancy outcomes include young age at fi rst pregnancy
and repeated
pregnancies. Young girls who are not physically mature might
enter pregnancy with
depleted nutrition reserves and anaemia.8 Adolescent pregnancy
17. is associated with a
50% increased risk of stillbirths and neonatal deaths, and
increased risk of preterm
birth, low birthweight, and asphyxia.9–11 Adolescents are
especially prone to
complications of labour and delivery, such as obstructed and
prolonged labour,
vesico-vaginal fi stulae, and infectious morbidity.11 In societies
in which most births are
within a marital relationship, interventions to increase the age
at marriage and fi rst
pregnancy are important.12 Evidence suggests that programmes
for adolescent
mothers can reduce repeat adolescent pregnancies by 37% (95%
CI 12–51%) when they
teach parenting skills through home visitation and provide
young mothers with
education and vocational or job support.
Two reviews by Conde-Agudelo and colleagues13,14 assessed
the association between
inter-pregnancy intervals with maternal, newborn, and child
health outcomes and
found a J-shaped dose-response association for perinatal
outcomes. Short inter-
pregnancy intervals (<6 months) were associated with a higher
probability of maternal
anaemia (32%) and stillbirths (40%) whereas longer intervals
(>60 months) were
associated with an increased risk of pre-eclampsia.15 Both short
and long birth intervals
increase the risk for preterm births (OR 1·45 [95% CI 1·30–
1·61] for short term; OR 1·21
[95% CI 1·12–1·30] for long intervals), low birthweight (OR
1·65 [95% CI 1·27–2·14] for
short intervals; relative risk [RR] 1·37 [95% CI 1·21–1·55] for
18. long intervals), and
neonatal mortality (OR 1·31 [95% CI 0·96–1·79] for short
interval; RR 1·15 [95% CI
1·06–1·25] for long intervals). With repeated pregnancies and
advanced maternal age
there is increased risk of chromosomal abnormalities, and
increased risks of gestational
diabetes and hypertension, stillbirths (RR 1·62, 95% CI 1·50–
1·76), perinatal mortality
(RR 1·44, 95% CI 1·10–1·89), and low birthweight (RR 1·61,
95% CI 1·16–2·24).16,17
These fi ndings support the need to optimise age at fi rst
pregnancy and family size and
inter-pregnancy intervals. A global unmet need exists for family
planning with more
than 100 million unmarried women in developing countries not
using contraception.18
Optimisation of age at fi rst pregnancy must be coupled with
promotion of eff ective
contraceptive use and exclusive breastfeeding, so that women
can ideally space their
pregnancies 18–24 months apart.
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456 www.thelancet.com Vol 382 August 3, 2013
high protein or isocaloric protein supplementation. In
other contexts, prescription and promotion of low
energy diets to pregnant women who are either over-
weight or exhibit high weight gain in early gestation
have been assessed.36 Balanced energy protein supple-
mentation, providing about 25% of the total energy
supplement as protein, is deemed an important inter-
19. vention for preven tion of adverse perinatal outcomes in
mal nourished women.26,37 A Cochrane review38 con-
cluded that balanced energy protein supple mentation
reduced the incidence of SGA by 32% and risk of
stillbirths by 45% (table 1). An updated meta-analysis
showed that balanced energy protein supple mentation
increased birthweight by 73 g (95% CI 30–117) and
reduced risk of SGA by 34%, with more pronounced
eff ects in mal nourished women.26
Nutrition interventions in neonates
Delayed cord clamping
Early clamping of the umbilical cord after birth is a
common practice and permits immediate transfer of the
baby for care as required, whereas delaying of clamping
allows continued blood fl ow between the placenta and the
baby for a longer duration. A Cochrane review39 suggested
that delayed cord clamping in term neonates led to
signifi cant increase in newborn haemoglobin and higher
serum ferritin concentration at 6 months of age (table 239–45).
Another review40 of studies in preterm neonates concluded
that delayed cord clamping was associated with 39%
reduction in need for blood transfusion and a lower risk of
complications after birth. Although promising, these
strategies have as yet not been assessed for eff ect or
feasibility of implementation at scale in health systems.
Evidence reviewed Setting Estimates
Folic acid supplementation
Women of reproductive age Systematic review of fi ve
trials19 of periconceptual folic
acid supplementation
Developing and developed
20. countries
Signifi cant eff ects: NTDs (RR 0·28, 95% CI 0·15–0·52),
recurrence of NTDs (RR 0·32, 95% CI
0·17–0·60)
Non-signifi cant eff ects: other congenital abnormalities,
miscarriages, still births
Pregnant women Systematic review of
31 trials20
Mostly developed countries Signifi cant eff ects: mean
birthweight (MD 135·75, 95% CI 47·85–223·68), incidence of
megaloblastic anaemia (RR 0·21, 95% CI 0·11–0·38)
Non-signifi cant eff ects: preterm birth, still births, mean
predelivery haemoglobin, serum folate,
red cell folate
Iron and Iron-folate supplementation
Women of reproductive age Systematic review of 21 RCTs
and quasi-experimental
studies21
Developing and developed
countries. Intervention mostly
given in school settings. Mostly
eff ectiveness studies
Intermittent iron supplementation
Signifi cant eff ects: anaemia (RR 0·73, 95% CI 0·56–0·95),
serum haemoglobin concentration
(MD 4·58 g/L, 95% CI 2·56–6·59), serum ferritin concentration
(MD 8·32, 95% CI 4·97–11·66)
Non-signifi cant eff ects: iron defi ciency, adverse events,
depression
21. Pregnant women Systematic review of 43 RCTs
and quasi-experimental
studies22 (34 iron alone,
eight iron-folate)
Developed and developing
countries. Intervention
delivered in community or at
facility antenatal clinic. Mostly
eff ectiveness studies
Daily iron-alone supplementation
Signifi cant eff ects: low birthweight (RR 0·81, 95% CI 0·68–
0·97), birthweight (MD 30·81 g, 95% CI
5·94–55·68), serum haemoglobin concentration at term (MD
8·88 g/L, 95% CI 6·96–10·80),
anaemia at term (RR 0·30, 95% CI 0·19–0·46), iron defi ciency
(RR 0·43, 95% CI 0·27–0·66), iron
defi ciency anaemia (RR 0·33, 95% CI 0·16–0·69), side-eff ects
(RR 2·36, 95% CI 0·96–5·82)
Non-signifi cant eff ects: premature delivery, neonatal death,
congenital anomalies
Iron-folate supplementation
Signifi cant eff ects: birthweight (MD 57·7 g, 95% CI 7·66–
107·79), anaemia at term (RR 0·34, 95% CI
0·21–0·54), serum haemoglobin concentration at term (MD
16·13 g/L, 95% CI 12·74–19·52)
Non-signifi cant eff ects: low birthweight, premature birth,
neonatal death, congenital anomalies
MMN supplementation
Pregnant women Systematic review of
21 RCTs23
22. Developed and developing
countries. Studies compared
MMN with two or fewer
micronutrients
Signifi cant eff ects: low birthweight (RR 0·88, 95% CI 0·85–
0·91), SGA (RR 0·89, 95% CI
0·83–0·96), preterm birth (RR 0·97, 95% CI 0·94–0·99)
Non-signifi cant eff ects: miscarriage, maternal mortality,
perinatal mortality, stillbirths, and
neonatal mortality
Insuffi cient data for neurodevelopmental outcomes
Calcium supplementation
Pregnant women Systematic review of
15 RCTs24
Developed and developing
countries. Mostly eff ectiveness
trials
Signifi cant eff ects: pre-eclampsia (RR 0·48, 95% CI 0·34–
0·67), birthweight 85 g (95% CI
37–133), preterm birth (RR 0·76, 95% CI 0·60–0·97)
Non-signifi cant eff ects: perinatal mortality, low birthweight,
neonatal mortality
Iodine through iodisation of salt
Pregnant women Systematic review of fi ve
RCTs25
Mostly developing countries.
Mostly eff ectiveness trials
23. Signifi cant eff ects: cretinism at 4 years of age (RR 0·27, 95%
CI 0·12–0·60), developmental scores
10–20% higher in young children, birthweight 3·82–6·30%
higher
Maternal supplementation with balanced energy protein
Pregnant women Systematic review of 16 RCTs
and quasi-experimental
studies26
Developing and developed
countries
Signifi cant eff ects: SGA (RR 0·66, 95% CI 0·49–0·89),
stillbirths (RR 0·62, 95% CI 0·40–0·98,
birthweight (MD 73g, 95% CI 30–117)
Non-signifi cant eff ects: Bayley mental scores at 1 year
NTD=neural tube defects. RR=relative risk. MD=mean diff
erence. RCT=randomised controlled trial. MMN=multiple
micronutrient. SGA=small-for-gestational age.
Table 1: Review of nutrition interventions for women of
reproductive age and during pregnancy
Series
www.thelancet.com Vol 382 August 3, 2013 457
Neonatal vitamin K administration
Vitamin K defi ciency can result in bleeding in the fi rst
weeks of life and vitamin K is commonly given
prophylactically after birth for prevention of bleeding.
24. In the absence of vitamin K prophylaxis there is a
0·4–1·7% risk of development of clinically signifi cant
bleeding. A Cochrane review41 suggested that one dose
of intra muscular vitamin K, when compared with
placebo, reduced clinical bleeding at 1–7 days of life,
including bleeding after circumcision (table 2). Oral
and intra muscular vitamin K had much the same
eff ects on improved biochemical indices of coagulation
status at 1–7 days. Currently, vitamin K administration
after birth is largely restricted to births in health
facilities; no information is available on the public
health signifi cance of vitamin K defi ciency-related
bleeding in LMICs or population-based programmes
for prevention.
Neonatal vitamin A supplementation
A Cochrane review42 of oral or intramuscular vitamin A
supplementation to very low birthweight infants showed
reduced mortality and oxygen requirement at 1 month of
age compared with placebo (table 2).42 Although neonatal
vitamin A supplementation has also been shown to be
eff ective in reduction of all-cause mortality by 6 months
of age, evidence is confl icting, and might be related to
maternal vitamin A status.46 Although a Cochrane
review43 did report a 14% reduction in the risk of infant
mortality at 6 months of age, four more trials are
currently underway in Asia and Africa, and researchers
agree that these additional data will be needed before
development of recommendations for neonatal vitamin A
supplementation.
Kangaroo mother care
Kangaroo mother care denotes early skin-to-skin contact
between mother and baby at birth or soon thereafter, plus
early and continued breastfeeding, parental support, and
25. early discharge from hospital. A Cochrane review44 of
34 randomised controlled trials of early skin-to-skin care
in healthy neonates showed a signifi cant 27% increase in
breastfeeding at 1–4 months of age and increased dura-
tion of breastfeeding (table 2). In a Cochrane review45 of
16 randomised trials, kangaroo mother care in preterm
neonates was associated with a 40% reduction in the risk
of mortality, a 58% reduction in nosocomial infection or
sepsis, and a 77% reduction in prevalence of hypothermia.
The trials included in these analyses were done in health
facilities; although kangaroo mother care might also be
useful for home deliveries, there is not yet evidence of
eff ectiveness in community settings. Kangaroo mother
care was also shown to increase some measures of infant
growth, breastfeeding, and mother-infant attachment,45
but few studies provide objective evidence of any eff ect
on early child development.
Evidence reviewed Setting Estimates
Delayed cord clamping
Term neonates Systematic review of
11 RCTs39
Developing and
developed countries.
24 and 36 weeks’
gestation at birth
Signifi cant eff ects: increased newborn haemoglobin
conentration (MD 2·17 g/dL, 95% CI 0·28–4·06)
Non-signifi cant eff ects: postpartum haemorrhage, severe
postpartum haemorrhage
Delayed cord clamping was associated with an increased
requirement for phototherapy for jaundice
26. Preterm neonates Systematic review of
15 RCTs40
Developing and
developed countries
Signifi cant eff ects: reduced need for blood transfusion (RR
0·61, 95% CI 0·46–0·81), decrease in intraventricular
haemorrhage (RR 0·59, 95% CI 0·41–0·85), reduced risk of
necrotising enterocolitis (RR 0·62, 95% CI 0·43–0·90)
Peak bilirubin concentration was higher for delayed cord
clamping group (MD 15·01 mmol/L, 95% CI 5·62–24·40)
Neonatal vitamin K administration
Neonates Systematic review of two
RCTs for intramuscular
vitamin K and 11 RCTs for
oral vitamin K41
Developing and
developed countries
Signifi cant eff ects: One dose of intramuscular vitamin K
reduced clinical bleeding at 1–7 days and improved
biochemical indices of coagulation status. Oral vitamin K also
improved coagulation status
Vitamin A supplementation
Very low birthweight
infants
Systematic review of
nine RCTs42
27. Developed countries Signifi cant eff ects: reduced number of
deaths and oxygen requirement at 1 month of age.
Non-signifi cant eff ects: one large trial showed no signifi cant
eff ect on neurodevelopment assessment at
18–22 months of age
Term neonates Systematic review of fi ve
RCTs and quasi-
experimental studies43
Developing countries Signifi cant eff ects: reduction in infant
mortality at 6 months (RR 0·86, 95% CI 0·77–0·97)
Non-signifi cant eff ects: infant mortality at 12 months (RR
1·03, 95% CI 0·87–1·23)
Little data available for cause specifi c mortality, morbidity,
vitamin A defi ciency, anaemia, and adverse events
Kangaroo mother care for promotion of breastfeeding and care
of preterm and SGA infants
Healthy neonates Systematic review of
34 RCTs44
Developing and
developed countries
Signifi cant eff ects: increase in breastfeeding at 1–4 months
after birth (RR 1·27, 95% CI 1·06–1·53), increased
breastfeeding duration (MD 42·55 days, 95% CI 1·69–86·79)
Preterm neonates Systematic review of
16 RCTs45
Developing and
developed countries
28. Signifi cant eff ects: reduction in the risk of mortality (RR 0·60,
95% CI 0·39–0·93), reduction in nosocomial
infection and sepsis (RR 0·42, 95% CI 0·24–0·73), reduction in
hypothermia (RR 0·23, 95% CI 0·10–0·55), reduced
length of hospital stay (MD 2·4 days, 95% CI 0·7–4·1)
RCT=randomised controlled trial. MD=mean diff erence.
RR=relative risk. SGA=small-for-gestational age.
Table 2: Review of nutrition interventions in neonates
Series
458 www.thelancet.com Vol 382 August 3, 2013
Nutrition interventions in infants and children
Promotion of breastfeeding and supportive strategies
WHO recommends initiation of breastfeeding within 1 h
of birth, exclusive breastfeeding of infants till 6 months of
age, and continued breastfeeding until 2 years of age or
older.47 However, global progress on this intervention is
both uneven and suboptimum.48 The exact scientifi c basis
for the absolute early time window of feeding within the
fi rst hour after birth is weak.49,50 A systematic review51
suggests that breast feeding initiation within 24 h of birth
is associated with a 44–45% reduction in all-cause and
infection-related neonatal mortality, and is thought to
mainly operate through the eff ects of exclusive breast-
feeding. We updated the previous review by Imdad and
colleagues,52 which assessed the eff ect of promotion
interventions on occurrence of breastfeeding, and con-
cluded that counselling or educational inter ventions
increased exclusive breastfeeding by 43% at day 1, by 30%
29. till 1 month, and by 90% from 1–5 months. Signifi cant
reductions in occurrence of mothers not breast feeding
were also noted; 32% reduction at day 1, 30% till 1 month,
and 18% for 1–5 months53 (table 353–62). Com bined
individual and group counselling seemed to be better
than individual or group counselling alone. Although
these results show the potential for scaling up, none of
these trials address the issues of barriers around work
environments and supportive strategies such as maternity
leave provision. A Cochrane review63 of interventions in
the workplace to support breast feeding for women found
no trials. Although some trials are underway, much more
needs to be done to assess innovations and strategies to
promote breast feeding in working women, especially in
under privileged communities.
Promotion of dietary diversity and complementary
feeding
Complementary feeding for infants refers to the timely
introduction of safe and nutritionally rich foods in
addition to breast-feeding at about 6 months of age and
typically provided from 6 to 23 months of age.64 Diff erent
approaches have been used to create indicators of
dietary diversity and to study its association with child
mal nutrition. In seven Latin American surveys, Ruel
and Menon65 noted signifi cant associations between
comple mentary feeding practices and height-for-age
Z scores (HAZ). Similarly, analysis of Demographic
Health Survey data to create a dietary diversity score
based on seven food groups showed that increased
dietary diversity was positively associated with height-
for-age HAZ in nine of 11 countries.66 More recently,
WHO infant and young child feeding indicators were
studied in 14 Demographic Health Survey datasets from
low-income countries;67 consumption of a minimum
acceptable diet with dietary diversity reduced the risk of
30. both stunting and under weight whereas minimum
meal frequency was associated with lower risk of
underweight only.
In an update of a previous review of complemen-
tary feeding,68 we assessed 16 randomised and non-
randomised controlled trials and programmes
of moderate quality (table 3).54 We identifi ed ten studies
that assessed the eff ect of nutrition education and seven
studies that assessed the eff ect of provision of additional
complementary foods (one trial with three intervention
groups was in both these categories). Studies of nutrition
education in food secure populations showed a signifi cant
increase in height (standard mean diff erence [SMD]
0·35, 95% CI 0·08–0·62, four studies), and HAZ (0·22,
0·01–0·43, four studies), whereas the eff ect on stunting
was not statistically signifi cant (RR 0·70, 95% CI
0·49–1·01, four studies). We identifi ed a signifi cant eff ect
on weight gain (SMD 0·40, 95% CI 0·02–0·78, four
studies), whereas no eff ects were noted for weight-for-
age Z scores (WAZ; 0·12; 95% CI –0·02 to 0·26, four
studies). Studies of nutrition education in food insecure
populations (with an average daily per person income of
less than US$1·25) showed signifi cant eff ects on HAZ
(SMD 0·25, 95% CI 0·09–0·42, one study), stunting (RR
0·68, 95% CI 0·60–0·76, one study), and WAZ (SMD
0·26, 95% CI 0·12–0·41, two studies). The review54 did
not fi nd any eligible study that provided complementary
feeding (with or without education) in a food secure
population. Overall, the provision of complementary
foods in food insecure populations was associated with
signifi cant gains in HAZ (SMD 0·39; 95% CI 0·05–0·73,
seven studies) and WAZ (SMD 0·26, 95% CI 0·04–0·48,
three studies), whereas the eff ect on stunting did not
reach statistical signifi cance (RR 0·33, 95% CI 0·11–1·00,
seven studies).
31. Vitamin A supplementation in children
A Cochrane review55 of 43 randomised trials showed
that vitamin A supplementation reduced all-cause
mortality by 24% and diarrhoea-related mortality by
28% in children aged 6–59 months (table 3). Vitamin A
supple mentation also reduced the incidence of
diarrhoea and measles in this age group but there was
no eff ect on mortality and morbidity related to
respiratory infections. Although a large eff ectiveness
study69 from India assessing the eff ect of vitamin A
supplementation and deworming over several years
did not show a signifi cant eff ect on mortality from
vitamin A supplementation (mortality ratio 0·96,
95% CI 0·89–1·03), inclusion of these data with
previous results still shows a signifi cant, albeit lower,
eff ect on mortality (RR 0·88, 95% CI 0·84–0·94).55 We
believe that vitamin A supplementation continues to be
an eff ective intervention in children aged 6–59 months
in populations at risk of vitamin A defi ciency.
Iron supplementation in infants and children
A Cochrane review56 of 33 studies showed that inter-
mittent iron supplementation to children younger than
2 years reduced the risk of anaemia by 49% and iron
Series
www.thelancet.com Vol 382 August 3, 2013 459
defi ciency by 76% (table 3). The fi ndings also suggested
that inter mittent iron supplementation could be a
viable public health intervention in settings in which
daily supple mentation had not been implemented or
32. was not feasible. A review57 of the eff ect of iron
supplementation in children on mental and motor
development showed only small gains in mental
development and intelligence scores in supplemented
school-age children who were initially anaemic or iron-
defi cient. There was no con vincing evidence that iron
treatment had an eff ect on mental development in
children younger than 27 months.
Since the demonstration of increased risk of admis-
sion to hospital and serious illnesses with iron
supplementation,70 there has been concern about
adminis tration of iron supplements in malaria endemic
areas. WHO currently recommends administration of
iron supple ments in malaria endemic areas on the
stipulation that malaria prevention and treatment is
made available.71
Setting Estimates
Breast feeding promotion in infants
Systematic review of
110 RCTs and
quasi-experimental studies53
Developing and developed
countries
Signifi cant eff ects: educational or counselling interventions
increased EBF by 43% (95% CI 9–87) at day 1, by 30% (19–42)
till
1 month, and by 90% (54–134) from 1–6 months. Signifi cant
reductions in rates of no breastfeeding also noted; 32% (13–46)
at
33. day 1, 30% (20–38) 0–1 month, and 18% (11–23) for 1–6
months
Non-signifi cant eff ects: predominant and partial breastfeeding
Complementary feeding promotion in children 6–24 months of
age
16 RCTs and
quasi-experimental studies54
Mostly from food secure
populations. Various foods
used
Nutrition education in food secure populations
Signifi cant eff ects: increased height gain (SMD 0·35; 95% CI
0·08–0·62), HAZ (SMD 0·22; 95% CI 0·01–0·43), weight gain
(SMD 0·40,
95% CI 0·02–0·78)
Non-signifi cant eff ects: stunting, WAZ
Nutrition education in food insecure populations
Signifi cant eff ects: HAZ (SMD 0·25, 95% CI 0·09–0·42),
stunting (RR 0·68, 95% CI 0·60–0·76), WAZ (SMD 0·26, 95%
CI 0·12–0·41)
Complementary food provision with or without education in
food insecure populations
Signifi cant eff ects: HAZ (SMD 0·39, 95% CI 0·05–0·73),
WAZ (SMD 0·26, 95% CI 0·04–0·48)
Non-signifi cant eff ects: stunting (RR 0·33, 95% CI 0·11–1·00)
Preventive vitamin A supplementation in children 6 months to 5
years of age
Systematic review of
43 RCTs55
34. Developing and developed
countries
Signifi cant eff ects: reduced all-cause mortality (RR 0·76, 95%
CI 0·69–0·83), reduced diarrhoea-related mortality (RR 0·72,
95% CI
0·57–0·91), reduced incidence of diarrhoea (RR 0·85, 95% CI
0·82–0·87), reduced incidence of measles (RR 0·50, 95% CI
0·37–0·67)
Non-signifi cant eff ects: measles-related and ARI-related
mortality
Iron supplementation in children
Systematic review of
33 RCTs and
quasi-experimental studies56
LMICs. Participant’s ages
ranged from neonates to
19 years
Intermittent iron supplementation
Signifi cant eff ects: decreased anaemia (RR 0·51, 95% CI
0·37–0·72), decreased iron defi ciency (RR 0·24, 95% CI 0·06–
0·91), increased
haemoglobin concentration (MD 5·20 g/L, 95% CI 2·51–7·88),
increased ferritin concentration (MD 14·17 mcg/L, 95% CI
3·53–24·81)
Non-signifi cant eff ects: HAZ, WAZ
Evidence for mental development, motor skill development,
school performance, and physical capacity was assessed by very
few
studies and showed no clear eff ect
Systematic review of
35. 17 RCTs57
Developing and developed
countries. In children aged
6 months to 15 years
Signifi cant eff ects: increased mental development score (SMD
0·30, 95% CI 0·15–0·46), increased intelligence quotient scores
(≥8 years age; SMD 0·41, 95% CI 0·20–0·62)
Non-signifi cant eff ects: Bayley mental development index in
younger children (≤27 months old), motor development
MMN supplementation including iron in children
Systematic review of
18 trials58
Mostly developing
countries. In children aged
6 months to 16 years
MMN supplementation
Signifi cant eff ects: increased length (MD 0·13, 95% CI 0·06–
0·21), increased weight (MD 0·14, 95% CI 0·03–0·25)
MMN might be associated with marginal increase in fl uid
intelligence and academic performance in healthy school
children
Systematic review of
17 RCTs59
Developing countries.
Mostly eff ectiveness
studies. In children aged
6 months to 11 years
36. Micronutrient powders
Signifi cant eff ects: Reduced anaemia (RR 0·66, 95% CI 0·57–
0·77), reduced iron defi ciency anaemia (RR 0·43, 95% CI
0·35–0·52),
reduced retinol defi ciency (RR 0·79, 95% CI 0·64–0·98).
Improved haemoglobin concentrations (SMD 0·98, 95% CI
0·55–1·40).
MNP was associated with a signifi cant increase in diarrhoea
(RR 1·04, 95% CI 1·01–1·06)
Non-signifi cant eff ects: serum ferritin, zinc defi ciency,
stunting, wasting, underweight, HAZ, WAZ, WHZ, fever, URI
Zinc supplementation in children
Systematic review of
18 RCTs60,61
Mostly developing
countries. In children
younger than 5 years
Preventive zinc supplementation
Signifi cant eff ects: mean height improved by 0·37 cm (SD
0·25) in children supplemented for 24 weeks, diarrhoea reduced
by
13% (95% CI 6–19), pneumonia reduced by 19% (95% CI 10–
27)
Non-signifi cant eff ects: mortality (cause specifi c and all-
cause)
Systematic review of
13 trials62
Developing and developed
countries. In children
younger than 5 years
37. Non-signifi cant eff ects: Mental developmental index,
psychomotor development index
RCT=randomised controlled trial. EBF=exclusive breastfeeding.
HAZ=height-for-age Z score. WAZ=weight-for-age Z score.
WHZ=weight-for-height Z score. MMN=multiple micronutrient.
ARI=acute respiratory
infection. URI=upper-respiratory infection. SMD=standard
mean diff erence. MD=mean diff erence. RR=relative risk.
Table 3: Review of evidence for nutrition interventions for
infants and children
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460 www.thelancet.com Vol 382 August 3, 2013
Multiple micronutrient supplementation in children
Although the theoretical benefi ts of strategies to improve
diet quality and micronutrient density of foods consumed
by small children are well recognised, few resource-poor
countries have clear policies in support of integrated
strategies to control micronutrient defi ciencies in
young children.72 Available options include the provision
of multiple micronutrients via supplements, micro-
nutrient powders, or fortifi ed ready-to-use foods includ-
ing lipid-based nutrient supplements. A compre hensive
review of the eff ects of multiple micronutrients compared
with two or fewer micronutrients showed small benefi ts
on linear growth (mean diff erence [MD] 0·13, 95% CI
0·06–0·21) and weight gain (0·14, 0·03–0·25) but with
little evidence of eff ect on morbidity outcomes as
suggested by individual studies (table 3).58 Another
38. review73 of the eff ect of multiple micronutrient supple-
mentation on improvement of cognitive perfor mance in
children concluded that multiple micro nutrient supple-
mentation might be associated with a marginal increase
in reasoning abilities but not with acquired skills
and knowledge.
Micronutrient powders are increasingly in use at
scale in programmes to address iron and multiple
micronutrient defi ciencies in children. We reviewed
16 randomised controlled trials to assess the eff ectiveness
of micronutrient powders and estimated that they
signifi cantly improved haemoglobin concentration and
reduced IDA by 57% and retinol defi ciency by 21%.59 We
noted no evidence of benefi t on linear growth. However,
in-line with fi ndings from an earlier review of liquid iron
supplementation trials,74 use of micronutrient powders
was shown to be associated with a signifi cant increase in
the incidence of diarrhoea (RR 1·04, 95% CI 1·01–1·06),
largely because of results from a recent large cluster-
randomised controlled trial of micronutrient powders
in Pakistan in malnourished children.75 These fi nd-
ings underscore the need for further assessment of
micronutrient powder programmes in varying contexts
for safety and benefi ts.
Preventive zinc supplementation in children
Preventive zinc supplementation in populations at risk
of zinc defi ciency reduces the risk of morbidity from
child hood diarrhoea and acute lower respiratory infec-
tions and might increase linear growth and weight gain
in infants and young children.60,76 A review by Yakoob
and colleagues61 assessed 18 studies from developing
coun tries and showed that preventive zinc supple-
mentation reduced the incidence of diarrhoea by 13%
and pneumonia by 19%, with a non-signifi cant 9%
39. reduction in all-cause mortality (table 3). However,
subgroup analysis showed that there was a signifi cant
18% reduction in all-cause mortality in children aged
12–59 months. A daily dose of 10 mg zinc per day over
24 weeks in children younger than 5 years could lead to
an estimated net gain of 0·37 cm (SD 0·25) in height in
zinc-supplemented children compared with placebo.60
There is no convincing evidence that zinc supple-
mentation in infants or children results in improved
motor or mental development.62
Disease prevention and management
Several interventions have the potential to aff ect health and
nutrition outcomes through reduction in the burden of
infectious diseases. Table 477–88 summarises the evidence
for interventions for disease prevention and management.
Prevention and treatment of severe acute
malnutrition
A substantial global burden of wasting exists, especially
severe acute malnutrition (SAM; weight-for-height Z score
[WHZ] <–3), which coexists with moderate acute mal-
nutrition (MAM; WHZ <–2). In stable non-emer gency
situations with endemic malnutrition, MAM can often
present in combination with stunting. Most of the inter-
ventions previously discussed should be imple mented to
prevent the development of SAM in food insecure popu-
lations. Several approaches for prevention and treatment
are in use. Although the provision of comple mentary and
supplementary foods could be considered in targeted food
distribution pro grammes, other ways to stimulate access
and purchasing power can be conceived. Where markets
are fragmented or food access is constrained, appropriate
food supple ments might be considered as in-kind
transfers. WHO recommends inpatient treatment for
40. children with complicated SAM, with stabilisation and
appro priate treatment of infections, fl uid management,
and dietary therapy and also supports community-based
care for uncomplicated SAM.89 Although facility-based
treatment of SAM remains important, community
manage ment of SAM continues to grow rapidly globally.
This shift in treatment norms from centralised, inpatient
care towards community-based models allows more
aff ected children to be reached and is cost eff ective. Up to
an estimated 15% of cases of SAM will need initial facility-
based care, whereas the rest can receive only community-
based treatment.90
Facility-based management of SAM according to the
WHO protocol
A scientifi c literature review by Schofi eld and Ashworth91
showed that between the 1950s and 1990s, case fatality
rates were typically 20–30% in children with SAM treated
in hospitals or rehabilitation units, and rates were higher
(50–60%) for oedematous malnutrition. A previous
review4 of existing studies had estimated that following
the WHO protocol, as opposed to standard care, would
lead to a 55% reduction in deaths (RR 0·45, 95% CI
0·32–0·62; random eff ects).
In view of the limitations of analysis and variable quality
of studies in the previous review, we updated the review to
assess the eff ect of the WHO protocol or adaptations
thereof on recovery and case fatality of children with SAM.
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www.thelancet.com Vol 382 August 3, 2013 461
41. Case fatality rates ranged from 3·4% to 35%. The highest
case fatality rate stemmed from a cohort of children with
HIV infection.92,93 Only two studies provided information
on recovery rates, which were 79·7% and 83·3%.94,95 In
summary, the WHO protocol is substantiated through
much evidence, based both on research and expert
opinion. However, a clear need exists for continued work
to improve staff training and quality96 to achieve high rates
of survival across various resource-constrained settings.
Community-based management of SAM
The products used to deliver nutrients for management
of SAM and MAM, and the approaches used to target
and deliver these products, evolved rapidly during the
past decade. Innovations include new formulations and
packaging and a shift from institutional to community-
based management.
We reviewed interventions to treat SAM in community
settings, and were largely able to pool studies comparing
Settings Estimates
WASH interventions
Overview of three
systematic reviews77
Developing
countries
Signifi cant eff ects: reduced risk of diarrhoea with hand
washing with soap (RR 0·52, 95% CI 0·34–0·65), with
improved water quality, and with excreta disposal
DHS data from 65 countries78 Developing
42. countries
Signifi cant eff ects: a recent World Bank report78 based on
analysis of trends in DHS data suggests that open
defecation explained 54% of international variation in child
height by contrast with GDP, which only
explained 29%. A 20 percentage point reduction in open
defecation was associated with a 0·1 SD increase in
child height
A Cochrane review of the eff ect of WASH interventions on
nutrition outcomes is underway87
Maternal deworming
Systematic review of
fi ve RCTs79
Developing
countries
Non-signifi cant eff ects: one dose of anthelminthic in second
trimester of pregnancy had a non-signifi cant
eff ect on maternal anaemia, low birthweight, preterm births,
and perinatal mortality
Deworming in children (for soil-transmitted intestinal worms)
Systematic review of
34 RCTs80
Developing
countries
Non-signifi cant eff ects: one-dose deworming had a non-signifi
cant eff ect on haemoglobin and weight gain.
For multiple doses at 1 year follow up, there was a non-signifi
43. cant eff ect on weight, haemoglobin, cognition,
and school attendance
Treatment after confi rmed infection
Signifi cant eff ects: one-dose of deworming drugs increased
weight (0·58 kg, 95% CI 0·40–0·76) and
haemoglobin (0·37 g/dL, 95% CI 0·1–0·64). Evidence on
cognition was inconclusive
These analyses are corroborated by the large-scale DEVTA
trial88 of regular deworming and VAS over 5 years,
which also did not show any benefi ts on weight gain or
mortality
Feeding practices in diarrhoea
Review of 29 RCTs81 Developing
countries
Signifi cant eff ects: in acute diarrhoea, lactose-free diets, when
compared with lactose-containing diets,
signifi cantly reduced incidence of diarrhoea (SMD –0·36, 95%
CI –0·62 to –0·10) and treatment failure
(RR 0·53, 95% CI 0·40–0·70)
Non-signifi cant eff ects: weight gain
Zinc therapy for diarrhoea
Systematic review of
13 studies82
Mostly Asia Signifi cant eff ects: reduced all-cause mortality
reduced by 46% (95% CI 12–68), diarrhoea-related
admissions to hospital by 23% (95% CI 15–31)
Non-signifi cant eff ects: diarrhoea-specifi c mortality,
diarrhoea-prevalence
Zinc reduced duration of acute diarrhoea by 0·50 days and
persistent diarrhoea by 0·68 days
44. IPTp/ITN for malaria in pregnancy
Systematic review of
16 RCTs83
Mostly Africa Signifi cant eff ects: Anti-malarials to prevent
malaria in all pregnant women reduced antenatal parasitemia
(RR 0·53, 95% CI 0·33–0·86), increased birthweight (MD 126·7
g, 95% CI 88·64–164·75), reduced low
birthweight by 43% (RR 0·57, 95% CI 0·46–0·72) and severe
antenatal anaemia 38% (RR 0·62, 95% CI 0·50–0·78)
Non-signifi cant eff ects: perinatal deaths
Systematic review of
six RCTs84
Developing
countries
Signifi cant eff ects: ITNs in pregnancy reduced low
birthweight (RR 0·77, 95% CI 0·61–0·98) and reduced fetal
loss (fi rst to fourth pregnancy; RR 0·67, 95% CI 0·47–0·97)
Non-signifi cant eff ects: anaemia and clinical malaria
Malaria prophylaxis in children
Systematic review of
seven RCTs85
Developing
countries of
West Africa
Signifi cant eff ects: Reduced clinical malaria episodes (RR
0·26; 95% CI 0·17–0·38), reduced severe malaria
45. episodes (RR 0·27, 95% CI 0·10–0·76). IPTc also reduced risk
of moderately severe anaemia (RR 0·71, 95% CI
0·52–0·98)
Non-signifi cant eff ects: all-cause mortality
Systematic review of
22 RCTs86
Developing
countries in
Africa
Signifi cant eff ects: ITNs improved packed cell volume of
children by 1·7 absolute packed cell volume percent.
When the control group used untreated nets, the diff erence was
0·4 absolute packed cell volume percent.
ITNs and IRS reduced malaria-attributable mortality in children
(1–59 months) by 55% (95% CI 49–61) in
Plasmodium falciparum settings
WASH=water, sanitation, and hygiene. RCT=randomised
controlled trial. DHS=Demographic and Health Survey.
GDP=gross domestic product. RR=relative risk. MD=mean
diff erence. SMD=standard mean diff erence. WAZ=weight-for-
age Z score. HAZ=height-for-age Z score. DEVTA=de-worming
and enhanced vitamin A. IPTp=intermittent
preventive treatment of malaria in pregnancy. IPTc=IPT in
children. ITN=insecticide-treated bednets. IRS=indoor residual
spraying.
Table 4: Review of evidence for disease prevention and
management
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46. 462 www.thelancet.com Vol 382 August 3, 2013
ready-to-use therapeutic foods (RUTF) with standard
care, as opposed to rigorous evaluation of eff ectiveness of
the approach in programme settings.97 We identifi ed no
signifi cant diff erences in mortality; however, children
who received RUTF had faster rates of weight gain and
had 51% greater likelihood to recover (defi ned as attaining
WHZ ≥ –2) than did those receiving standard care.
Notably, a new randomised controlled trial98 compared
standard RUTF with RUTF and additional 7 day course
of antibiotics, either amoxicillin or cefdinir, in children
with uncomplicated SAM. This trial showed that the
children receiving an antibiotic had a lower mortality
rate, faster recovery rate, and higher weight gain com-
pared with children receiving placebo. Although further
research on this topic is needed, especially in children
with HIV infection, this study shows that eff ective
community management of SAM might require an
approach that goes beyond merely the choice of specially
formulated foods to the entire package of care.
Substantial programmatic evidence supports use of
RUTF for community-based treatment,99 which has sub-
stantially changed the approach to treatment of SAM. Yet
because of the nature of the evidence, establishing eff ect
estimates for the overall approach to community manage-
ment has proved challenging. Available evidence shows
some positive eff ects with the use of RUTF compared
with standard care for the treatment of SAM in
community settings, yet the diff erences were for the
most part small and several outcomes had substantial
hetero geneity. An emphasis not only on the choice of
commodities, but also on the quality of programme
47. design and implementation is crucial to improvement of
outcomes for children with SAM, as is research to fi ll
information gaps, such as opti mum treatment methods
and approaches for treat ment of breastfed infants
younger than 6 months.
Interventions for prevention and management
of obesity
Obesity is increasing in many populations and is one of
the most important challenges of the 21st century.
Obese women are at an increased risk of adverse
pregnancy outcomes. A Cochrane review100 assessed
the eff ectiveness of interventions (eating, exercise,
behaviour modifi cation, or counselling) that reduce
weight in obese pregnant women and identifi ed no
evaluable trials. Some studies assessed the eff ect of diet,
exercise, or both for weight reduction in women after
childbirth, and showed that women who exercised did
not lose signifi cantly more weight, but women who took
part in a diet (MD –1·70 kg, 95% CI –2·08 to –1·32), or
diet plus exercise programme (–2·89 kg; –4·83 to –0·95),
did so. These interventions did not seem to adversely
eff ect breastfeeding performance in any setting.101
We identifi ed six reviews that examined breastfeeding
in infancy and its association with obesity prevalence
or average body-mass index (BMI) in childhood or
adulthood.102–107 All studies suggested a small protective
eff ect of breastfeeding on obesity later in life, although
the magnitude of the eff ect varied between reviews and
the strength of the aff ect of confounding was unclear.
The largest prospective follow up study in healthy term
infants in Belarus showed that improving the duration
and exclusivity of breastfeeding did not prevent over-
weight or obesity in children, nor did it aff ect insulin-
48. like growth factor I concentrations at age 11·5 years.108
These fi ndings suggest that despite the myriad
advantages of breastfeeding, population strategies to
increase the duration and exclusivity of breastfeeding
are unlikely to curb the obesity epidemic.
A Cochrane review107 examined the eff ects of obesity
prevention interventions delivered for more than 12 weeks
on changes in BMI and BMI Z scores in children and
suggested a signifi cant benefi cial eff ect across age groups
with a SMD of –0·15 kg/m (95% CI –0·21 to –0·09). The
subgroup analysis showed sig nifi cant eff ects for children
aged 6–12 years with non-signifi cant eff ects in younger
children and adoles cents. Interventions that combined
physical activity and diet were more eff ective than either
delivered alone. Findings suggested that short-term inter-
ventions (<12 months duration) were more eff ective than
were those delivered over a longer duration (SMD –0·17,
95% CI –0·25 to –0·09 and SMD –0·12, 95% CI
–0·21 to –0·03, respectively); however, there was sub stan-
tial heterogeneity in all pooled estimates. Another
review109 of interventions to treat obesity in children
showed that combined behavioural and life style inter-
ventions or self-help could benefi t over weight children
and adolescents. Overall the evidence of eff ectiveness of
all obesity prevention and therapeutic interventions is
weak, underscoring the need for high-quality research in
this discipline.
Delivery platforms and strategies for
implementation of nutrition-specifi c
interventions
Delivery strategies are crucial to achieve coverage
with nutrition-specifi c interventions and to reach popu-
lations in need. A range of channels can provide oppor-
tunities for scaling up and reaching large segments of
49. the population.
Fortifi cation of staple foods and specifi c foods
A detailed discussion of fortifi cation strategies is
beyond the scope of this review. As supported by the
Copenhagen consensus,110 fortifi cation is one the most
cost-eff ective strategies to reach populations at large.
Further discussion of fortifi cation as a means for delivery
of key micronutrients is provided in panel 3111–118 and the
accom panying report by Stuart Gillespie and colleagues.119
Cash transfer programmes
Financial incentives are widely used as policy strategies to
ameliorate poverty, reduce fi nancial barriers, and improve
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www.thelancet.com Vol 382 August 3, 2013 463
population health. We reviewed relevant studies reporting
the eff ect of fi nancial incentives on coverage of health and
nutrition interventions and behaviours targeting children
younger than 5 years.120 The aff ect of fi nancial incentive
programmes on fi ve categories of interventions (breast-
feeding practices, immunisation coverage, diarrhoea man-
age ment, healthcare use, and other preventive strategies)
was assessed. The review concluded that fi nancial incen-
tives have the potential to promote increased coverage of
several important child health interventions, but the
quality of evidence available was low. The more pronounced
eff ects seemed to be achieved by programmes that directly
removed user fees for access to health services.120 Some
indication of eff ect was also noted for programmes that
conditioned fi nan cial incentives on participation in health
50. education and attendance to health-care visits. Further
information on the benefi t of such programmes for health
and nutrition outcomes is provided in the accompanying
report by Stuart Gillespie and colleagues.119
Community-based platforms for nutrition education
and promotion
Community-based interventions to improve maternal,
newborn, and child health are now widely recognised as
important strategies to deliver key maternal and child
survival interventions121 and have been shown to reduce
inequities in childhood pneumonia and diarrhoea
deaths.122 These interventions are delivered by health-care
personnel or lay individuals, and implemented locally in
homes, villages, or any defi ned community group. A full
spectrum of promotive, preventive, and curative inter-
ventions can be delivered via community platforms,
Panel 3: Eff ect of fortifi cation strategies
Food fortifi cation is safe and cost eff ective in the prevention
of
micronutrient defi ciencies and has been widely practised in
developed countries for more than a century.111 Foods can be
fortifi ed at three levels: mass or universal, targeted, and
household. Mass or universal fortifi cation—ideally legislated
to be
mandatory for industries—has the potential to produce foods
and food products that are widely consumed by the general
population (eg, salt iodisation and fl our fortifi cation with iron
and folate). Mass fortifi cation is by far the most cost-eff ective
nutrition intervention, particularly when produced by medium-
to-large scale industries.111 Targeted fortifi cation (eg,
nutrient-
fortifi ed complementary foods for children aged 6–24 months)
51. is
important for subgroups of nutritionally vulnerable populations
and populations in emergency situations whose nutrient intake
is
insuffi cient through available diets. Targeted fortifi cation is
also
eff ective in resource poor settings where family foods do not
include animal-source foods that are typically necessary to meet
nutrient requirements of young children. Home fortifi cation
involves addition of nutrients directly to food consumed by
women or children, or both, in the form of micronutrient
powders or small quantities of food-based fortifi ed lipid
spreads
(eg, lipid-based nutrient supplement). Such direct addition of
micronutrients to foods is diff erent from foods fortifi ed in the
preparatory processes, has the advantage that it does not require
changing dietary practices, and has little eff ect on the taste of
food. However, addition of micronutrient powders to prepared
foods has characteristics akin to supplementation as opposed to
foods fortifi ed at source. Biofortifi cation of food crops
(fortifi cation of food at source) is an alternative to more
common
fortifi cation interventions and is rapidly advancing in
technology
with much success, particularly with regard to increasing iron,
provitamin A, zinc, and folate contents in staple foods.112
Despite many limitations to establishing causality during
assessment of food fortifi cation programmes, several studies
have reported outcomes. Fortifi cation for children shows
signifi cant benefi ts on serum micronutrient concentrations,
which could indirectly be used to work out the population-level
eff ect. A meta-analysis of multiple micronutrient fortifi cation
in
children shows an increase in haemoglobin concentrations by
52. 0·87 g/dL (95% CI 0·57–1·16) and reduced risk of anaemia by
57% (relative risk [RR] 0·43; 95% CI 0·26–0·71). The mean
ferritin
increase with fortifi cation was 11·3 μg/L (95% CI 3·3–19·2)
compared with control groups. Fortifi cation also increased
vitamin A serum concentrations compared with control groups
(four studies, mean retinol increase 3·7 μg/dL, 95% CI 1·3–
6·1).113
A meta-analysis of 60 trials showed that iron fortifi cation of
foods resulted in 41% reduction in the risks of anaemia (RR
0·59,
95% CI 0·48–0·71, p< 0·001) and a 52% reduction in iron
defi ciency (0·48, 0·38–0·62, p<0·001).114 Other studies have
also
shown that use of vitamin D fortifi ed bread increased serum
25-hydroxyvitamin D concentration as eff ectively as the
cholecalciferol supplement in women.115 Zinc fortifi cation has
also shown signifi cantly higher zinc concentrations in serum
and
erythrocytes and lower serum copper concentrations compared
with a placebo group in preterm infants.116
Fortifi cation has the greatest potential to improve the
nutritional
status of a population when implemented within a
comprehensive nutrition strategy. Key issues to ensure a
sustainable programme include: identifi cation of the right food
(accounting for bioavailability, interaction with food,
availability,
acceptability, and cost) and target population, ensuring quality
of
product, and consumption of suffi cient quantity of the fortifi
ed
foods.117 To accomplish these aims, there needs to be demand
that
is sustained through behaviour change communication at the
53. consumer level and ready access to a suffi cient supply of
products
that maintain standards set through legislative process from
production to point-of-consumption. Government monitoring of
compliance to standards and public-private partnerships are
essential to ensure a competitive market for fortifi ed
products.118
Fortifi cation seems to be a potentially eff ective strategy but
evidence of benefi ts on morbidity and functional outcomes
from
large-scale programmes in developing countries is scarce.
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464 www.thelancet.com Vol 382 August 3, 2013
including provision of basic antenatal, natal, and
postnatal care; preventive essential newborn care;
breastfeeding counselling; man age ment and referral
of sick neonates; development of skills in behaviour
change communication; and com munity mobilisation
strategies to promote birth and new born care prepared-
ness. For example, a review123 of community-based
packages of care suggested that these inter ventions can
improve rates of facility births by 28% (RR 1·28, 95% CI
1·04–1·59) and result in a doubling of the rate of
initiation of breastfeeding within 1 h (RR 2·25, 95% CI
1·70–2·97). Lewin and colleagues124 reviewed 82 studies
with lay health workers and showed moderate quality
evidence of eff ect on initiation of breastfeeding (RR 1·36,
95% CI 1·14–1·61), any breastfeeding (1·24, 1·10–1·39),
and exclusive breastfeeding (2·78, 1·74–4·44) when
compared with usual care. Although much of the
evidence from large-scale programmes using community
54. health workers is of poor quality, process indicators and
assessments do suggest that community health workers
are able to implement many of these projects at scale,
and have substantial potential to improve the uptake of
child health and nutrition outcomes among diffi cult to
reach populations.125 It is important to underscore the
crucial importance of community engagement and buy-
in to ensure eff ective community outreach programmes,
behaviour change, and access.
Integrated management of childhood illnesses
WHO, in collaboration with UNICEF and other agencies,
developed the Integrated Management of Childhood
Illness (IMCI) strategy in the 1990s.126 IMCI includes
both curative and preventive interventions targeted at
improve ment of health practices at health facilities and at
home. The strategy includes three components: improve-
ments in case management; improvements in health
systems; and improvements in family and com munity
practices. Assessments of IMCI in Uganda, Tanzania,
Bangladesh, Brazil, Peru, South Africa, China, Armenia,
Nigeria, and Morocco have shown various benefi ts in
health service quality, mortality reduction, and health-
care cost savings.127 In Tanzania, implemen tation of IMCI
was associated with signifi cant improve ments in equity
diff erentials for six child health indicators, with the
largest improvements noted for stunting in children
between 24 and 59 months of age.128 Much the same
fi ndings were reported from Bangladesh, where imple-
men tation of IMCI was asso ciated with a signifi cant
Panel 4: Nutrition in emergencies
Irrespective of the underlying cause, humanitarian emergencies
are often characterised by high and rising rates of severe acute
55. malnutrition (SAM), moderate acute malnutrition (MAM), and
micronutrient defi ciencies in children (and sometimes adults).
The foremost intent of nutrition-specifi c interventions in such
situations is to prevent mortality, and involves management of
wasting and resolution of specifi c nutrient defi ciencies, and
ensuring adequate food consumption. The humanitarian
community largely agrees that emergency nutrition
interventions have improved in the past 10–15 years in terms of
coverage, scale of operations, reporting standards, and
eff ectiveness (assessed by Sphere133 and other standards of
practice). Until the early 2000s, nutrition programming in
emergencies was dominated by facility-based therapeutic care,
targeted or blanket supplementary feeding, and provision of
micronutrient supplements.134–136 More recently, the focus
has
widened, with attention being given to both short-term and
longer-term concerns, and to a choice of actions from a more
comprehensive range of interventions.137 The options for
eff ective management for both SAM and MAM in emergencies
have improved in the past 10–15 years as products used have
been improved and coverage has increased through
community-based treatment. Potential alternatives to the use
of food to address seasonal or emergency-driven peaks in
wasting are being explored, including combinations of food
plus cash, cash alone, or vouchers; however, cost-eff ectiveness
studies of various strategies are scarce. There is evidence that
in
contexts in which markets have not been seriously disrupted,
appropriate foods are readily accessible, and rates of
undernutrition are not dangerously high, alternatives or
complements to food-based rations might be viable and
potentially cost-eff ective.138,139
Concern has also grown about the potential trade-off s between
long-term versus short-term objectives of emergency nutrition
56. interventions. Although life-saving actions are justifi ably
prioritised over the prevention of chronic diseases, food
assistance programmes suitable for acute emergencies might be
less appropriate for protracted situations.140 This has important
implications when thinking through seasonal blanket
distribution
of ready-to-use foods to prevent a worsening of levels of acute
malnutrition. As a result of the diffi culty of generating
experimental data specifi c to programming in emergencies,141
the
discipline has evolved relying less on randomised controlled
trials
and more on the sharing of lessons learned, which are used to
inform technical or operational guidelines disseminated by
WHO
and UN bodies.142–144 Although practice must still be
improved in
many areas, and outcomes better documented, it remains
crucially important to secure appropriate resources to support
nutrition actions in this most challenging of disciplines and to
assess outcomes for future learning. The nutritional status of
individuals assessed and treated in emergency contexts overlaps
substantially with non-emergency settings. Although
high-quality programmatic research can and must help improve
the design and outcome of eff ective emergency nutrition
interventions, these interventions should be seen as entry points
that support, rather than supplant, longer-term actions seeking
to address underlying causes of poor nutrition.
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www.thelancet.com Vol 382 August 3, 2013 465
increase in exclusive breastfeeding and com paratively
57. faster reduction in the prevalence of stunting in children
aged 24–59 months.129
School-based delivery platforms
Many countries have school feeding programmes
targeting children who are older than 5 years. The main
purpose of such programmes is to provide incentives
for school enrolment and evidence of nutrition benefi ts
is scarce. A Cochrane review130 of 18 relevant studies of
the eff ectiveness of school feeding programmes in
improving physical and psychosocial health for
disadvantaged school pupils reported an increase in
school attendance by 4–6 days annually and weight
gains averaging 0·39 kg (95% CI 0·11–0·67) over
11 months and 0·71 kg (0·48–0·95) over 19 months. The
results were inconclusive for height gain, so there must
be caution that these programmes do not lead to obesity.
A detailed discussion of school feeding programmes is
provided in the accompanying report by Stuart Gillespie
and colleagues.119 Notwithstanding the scarce evidence,
schools off er an enormous opportunity for promotion of
health and nutrition for older children and adolescents
and could have an important role in future.
Child health days
Child health days have been introduced in weak health
systems to rapidly enhance coverage of essential child
survival interventions. There are few robust assessments
or reported experiences with child health days, which
commonly include delivery of vitamin A supplements,
immunisations, insecticide-treated nets, and deworming
drugs. Available evidence suggests that these days can
achieve greater coverage than stand-alone campaigns
in previously low-coverage countries.131 A descriptive
review132 of scale-up of child health days from 1999 to
58. 2009 suggests that these days were more eff ective than
stand-alone campaigns, provided that the number of
interventions did not exceed four. The overall equity
eff ect of these approaches are uncertain and further
studies are needed to establish how best to integrate this
approach within routine health-care services.
Delivery of nutrition interventions in
humanitarian emergency settings
Delivery strategies for nutrition interventions in human-
i tarian emergencies necessitate a diff erent approach to
what might be deemed optimum in stable circumstances.
In view of variability in the characteristics of emergencies
and protracted population displace ment, humanitarian
emergencies might closely mirror situ ations of endemic
malnutrition in food insecure settings. Hence prevention
and health promotion strategies, such as breastfeeding
and complementary feeding education and support,
should also become essential parts of the packages of
interventions in emergency contexts (panel 4133–144).
Panel 5: Evidence for emerging interventions
Household air pollution
Household air pollution (HAP) from solid fuels used in simple
stoves for cooking and heating, is recognised as a risk factor for
several health outcomes with important consequences for child
survival, including pneumonia,146 low birthweight, and
stillbirths.147 A review of observational studies148 shows
signifi cant risk reduction estimates for HAP for low
birthweight
(29%), stillbirth (34%), stunting (21%), and all-cause mortality
(27%). Reduction of exposure to HAP could substantially
reduce
risk of several important outcomes for child survival. One
randomised controlled trial in rural Guatemala,149 with an
59. improved stove intervention, reduced average exposure to
indoor air pollution by 50% and resulted in a reduction in
physician-diagnosed pneumonia (relative risk [RR] 0·84, 95%
CI
0·63–1·13) although this diff erence was not statistically
signifi cant. However, this fi nding was supported by the results
of an exposure-response analysis which showed a statistically
signifi cant reduction in the same outcome (0·82, 0·70–0·98).
This intervention also resulted in a reduction in low birthweight
(0·74, 95% CI 0·33–1·66), with babies weighing 89 g more
(95% CI –27 to 204) than those in the control group.150 A
range
of interventions, including both clean fuels and improved solid
fuel stoves are available, but substantial challenges remain in
achieving sustained use of low-cost low-emission technologies
at scale in low-income households.
Maternal vitamin D supplementation
Vitamin D is an essential requirement of the body at any age.
Vitamin D can be acquired through three main channels:
through the skin via exposure to sunlight, from the diet, and
from supplements or fortifi ed foods. However, natural low-cost
sources of dietary sources of vitamin D are very scarce. A
systematic review151 assessing the association of vitamin D
status in pregnancy, suggests that women with circulating
25-hydroxyvitamin D (25[OH]D) concentrations of less than
50 nmol/L in pregnancy have an increased risk of preeclampsia
(odds ratio [OR] 2·09, 95% CI 1·50–2·90), gestational diabetes
mellitus (1·38, 1·12–1·70), preterm birth (1·58, 1·08–2·31) and
small-for-gestation age ([SGA] 1·52, 1·08–2·15). A long-term
cohort study152 did not fi nd any association of low maternal
vitamin D concentrations with bone mineral content in late
childhood. Similarly, a Cochrane review153 assessed the
eff ectiveness of vitamin D supplementation in pregnancy and
revealed little evidence of benefi ts on functional pregnancy
outcomes, although signifi cant increase in serum vitamin D
60. concentrations at term were noted and borderline reduction in
low birthweight was reported in three trials (RR 0·48, 95% CI
0·23–1·01). The number of high-quality trials with maternal
vitamin D supplementation is too small to draw conclusions on
its usefulness and safety.
(Continues on next page)
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466 www.thelancet.com Vol 382 August 3, 2013
(Continued from previous page)
Maternal zinc supplementation
A Cochrane review154 suggests that zinc supplementation in
pregnancy results in a 14% reduction in preterm birth (RR 0·86,
95% CI 0·76–0·97). This decrease was not accompanied by a
similar reduction in stillbirths, neonatal death, SGA, or low
birthweight. No subgroup diff erences were identifi ed in
women
with low versus normal zinc nutrition levels or in women who
complied with their treatment versus those who did not. We
conclude that there is presently insuffi cient evidence for a
benefi cial role of isolated zinc supplementation in pregnancy.
Omega-3 fatty acid supplementation
Several reviews155–162 have been done to assess the eff
ectiveness
of maternal supplementation with omega-3 fatty acids during
pregnancy and its eff ects on various outcomes including
nutritional, morbidity, mortality, cognitive, and
neurodevelopmental measures. Findings from these reviews,
consisting of studies done in developed countries and of
61. variable quality, suggest that marine omega-3 fatty acids
administered in pregnancy reduce the rate of preterm birth and
increase birthweight. However, a Cochrane review155 suggests
that there is not enough evidence to support the routine use of
marine oil supplements or other prostaglandin precursors
during pregnancy to reduce the risk of pre-eclampsia, preterm
birth, low birthweight, or SGA. A review163 of the intake of
omega-3 and omega-6 fatty acids in low-income countries
showed that the total omega-3 fatty acid supply was below the
recommended intake range for infants and young children, and
below the minimum recommended level for pregnant and
lactating women, in the nine countries with the lowest gross
domestic product. The review noted that supply of omega-3
fatty acids could be increased by using vegetable oils with
higher alpha-linolenic acid and by increasing fi sh production
through fi sh farming. Another review164 on the eff ect of fatty
acid status on immune function of children in low-income
countries suggested that fatty acid interventions could yield
immune benefi ts in children in poor settings, especially in
non-breastfed children and in relation to infl ammatory
disorders, such as persistent enteropathy, although more trials
are needed for a conclusive association.
Antenatal psychosocial assessment and mental health support
Stable maternal mental health during pregnancy is crucial for
the development of the early mother–child relationship and for
health. Although there is ample evidence of the link between
maternal mental health and child health and growth,165 there is
insuffi cient evidence to support routine psycho-social
screening
for all pregnant women.166 There is promising evidence that
cognitive-behaviour therapy-based interventions provided by
community health workers to pregnant women, can eff ectively
reduce depression at 3 months post-partum (adjusted OR 0·22,
95% CI 0·14–0·36) and at 1-year follow-up (0·23, 0·15–
0·36).167
62. However, there was no eff ect on weight gain or linear growth
in
infancy. There is a need for further robust trials of maternal
mental health interventions with longer term follow up.
Role of massage for promoting growth in preterm Infants
Preterm infants have been noted to benefi t from massage
therapy and the suggested mechanisms include increased vagal
activity and gastric motility, which leads to increased
concentrations of insulin and Insulin-like growth factor 1.168 A
Cochrane review169 of the eff ect of massage in preterm infants
showed that massage increased daily weight gain by 5 g,
reduced the length of hospital stay by 4·5 days, and had a slight
eff ect on development and weight gain at 4–6 months,
although the evidence was of weak quality. A more recent
review170 of the eff ects of massage therapy for preterm infants
showed that 5–10 days of moderate pressure massage, typically
15 min three-times daily, resulted in improved weight gain
(mean for studies 28–48%) and bone density, and reduced
length of hospital stay. Related evidence from studies of
emollient therapy in preterm infants from the developing world
suggest potential synergistic benefi ts of skin barrier protection,
thermoregulation, and light massage.
Vitamin D supplementation in children
In view of the widespread defi ciency of vitamin D and
associated health consequences and rickets, preventive vitamin
D supplementation to high-risk populations, including infants
and toddlers, might be a useful strategy. A Cochrane review of
vitamin D supplementation in children in at-risk populations is
underway, and an existing review171 of postnatal
supplementation shows relatively few studies assessing eff ects
on bone density, growth, and other functional outcomes.
Zinc supplementation for treatment of newborn infections
and childhood pneumonia
63. A Cochrane review172 suggests that zinc supplementation in
addition to antibiotics in children with severe and non-severe
pneumonia did not have a signifi cant eff ect on clinical
recovery or duration of hospital stay. Other recent studies
show mixed eff ects across a range of severity of disease,173–
176
showing the need for larger well-powered studies for the
treatment of severe pneumonia with zinc in populations
at-risk of defi ciency. Two trials177,178 of adjunctive zinc
supplementation in presumed serious infections in neonates
and young infants show disparate fi ndings, underscoring the
need for further well-designed and adequately powered
studies of zinc as an adjunct to the treatment of serious
infections in infancy.
Lipid-based nutrient supplementation
Lipid-based nutrient supplements (LNS, in the form of
vegetable oil, peanut butter, milk powder, sugar, vitamins, and
minerals) are used in small quantities (20 g) to meet
micronutrient requirements in children, in combination with a
normal diet. Randomised controlled trials in Malawi179,180 and
Ghana181,182 have shown signifi cant benefi ts on iron status
and
linear growth. Further evidence of benefi ts and absence of
adverse eff ects are needed to assess the feasibility of use of
LNS
in programme settings and randomised controlled trials are
underway—three in Africa and one in Asia—which should
provide more information.
Series
www.thelancet.com Vol 382 August 3, 2013 467
64. Emerging interventions that need further
evidence
We also reviewed interventions that are not currently
recommended but that have potential and future prospects
for inclusion in regular programmes. These interventions,
which have possible eff ects on nutritional outcomes in
women and children, include strategies to reduce house-
hold air pollution, maternal vitamin D supple mentation,
maternal zinc supplementation, omega 3 fatty acids
supple mentation in pregnancy, antenatal psycho social
assessment and cognitive behaviour therapy for depres-
sion, emollient and massage therapy for preterm infants,
vitamin D supplementation in children, zinc therapy for
pneumonia, and lipid-based nutrient supple ments. Some
of the existing evidence around these interventions is
summarised in panel 5.146–182
Modelling the eff ect of scaling up coverage of
nutrition interventions in countries with the
highest burden
We used the Lives Saved Tool (LiST) to model the potential
eff ect on child health and mortality in 2012 of scaling up a
set of ten nutrition-specifi c interven tions that could aff ect
stunting and severe wasting183 (panel 6,4,122,145,184–188 fi
gure 2).
Although included in costing, we did not model the
promotion and use of iodised salt. For modelling, we
Figure 2: Linkages between risk factors, interventions, and
mortality in LiST
LiST=Lives Saved Tool. MMN=multiple micronutrients.
BEP=balanced energy protein. SGA=small-for-gestational-age.
SAM=severe acute malnutrition. MAM=moderate AM.
Folic acid
65. fortification
MMN, BEP Breastfeeding
promotion
Complementary
feeding,
education, and
supplementation
Vitamin A
supplementation
Zinc
supplementation
Diarrhoea incidence
Breastfeeding
practices
Neonatal
mortality
by cause
Birth risk defined
by maternal age,
parity, and spacing
Birth outcomes
(SGA and preterm)
Stunting
Wasting
Mortality by cause
66. 1–59 months
Management of MAMManagement of SAM
Risk factors
Interventions
Mortality
Panel 6: Overview of the Lives Saved Tool (LiST)
To model the eff ect of scaling up the ten proven nutrition-
specifi c interventions on the health of children we used the
Lives Saved Tool (LiST). This model has been developed under
the auspices of the Child Health Epidemiology Reference Group
(CHERG) to allow users to estimate the eff ect of scaling up
interventions on maternal and child health. The present version
of the model is based on previous modelling exercises,
including The Lancet’s 2008 Maternal and Child Undernutrition
series.4,122,145,184 A more detailed description of the LiST
model is
provided in appendix pp 3–7 and at the LiST website.
The LiST has been characterised as a linear, mathematical
model that is deterministic.185 It describes fi xed associations
between inputs and outputs that will produce the same outputs
each time the model is run. In LiST the primary inputs are
coverage of interventions and the outputs are changes in
population level of risk factors (such as wasting or stunting
rates, or birth outcomes such as prematurity or size at birth)
and cause-specifi c mortality (neonatal, mortality in children
aged 1–59 months, maternal mortality, and stillbirths). The
association between an input (change in intervention
coverage) with one or more outputs is specifi ed in terms of the
eff ectiveness of the intervention for reduction of the
probability
of that outcome. The outcome can be cause-specifi c mortality
67. or a risk factor. The overarching assumption in LiST is that
mortality rates and cause of death structure will not change
except in response to changes in coverage of interventions. The
model assumes that changes in distal variables, such as increase
in income per person or mothers’ education, will aff ect
mortality by increasing coverage of interventions or reducing
risk factors.
Figure 2 shows the linkages in LiST between risk factors,
interventions, and mortality. For example, the input of multiple
micronutrients consumed by pregnant women has an eff ect on
birth outcomes. It directly aff ects the probability of a child
being
born small-for-gestational-age (SGA). A child born SGA will in
turn have an increased risk of dying during the neonatal period
and those who survive through the fi rst month of life then have
an increased risk of being stunted. Stunted children have higher
risks of mortality from 1 to 59 months of age.
A second example is promotion of breastfeeding. Scaling up
breastfeeding promotion will aff ect breastfeeding practice,
shifting the distribution of mothers who exclusively,
predominately, or partly breastfeed their child or do not
breastfeed. Within the model, this intervention is examined
separately for the fi rst month of life and for the period of
1–5 months. Within each of the two time periods there is a
diff erent relative risk of dying of pneumonia and diarrhoea
associated with each breastfeeding practice and an eff ect on
diarrhoea incidence. So within the model, breastfeeding
promotion has an eff ect on breastfeeding practices, which in
turn
has a direct eff ect on mortality in the neonatal and 1–23 month
period. Additionally, there is an eff ect on diarrhoea incidence,
which then has an eff ect on stunting rates and mortality.
The assumptions of the eff ects of the ten nutrition interventions
68. we used in the modelling are shown in appendix pp 13–16. For
each of the interventions we have also shown the 95% CIs
around
the estimates, which were used in the sensitivity analyses. The
source and methods used to develop these assumptions and
others used in the model are described in a series of
reports.186–188
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468 www.thelancet.com Vol 382 August 3, 2013
selected 34 countries with more than 90% of the burden
of stunt ing (fi gure 3; appendix pp 8–12) and took 2011 as
the base year. The present coverage level for each
intervention was taken from the latest available esti mates
from large-scale surveys and eff ective ness of interventions
(see LiST for details). We modelled the eff ect of scaling up
the follow ing ten nutrition inter ventions: periconceptional
folic acid supplementation or fortifi ca tion, maternal
balanced energy protein supple men tation, maternal cal-
cium supple men tation, multiple micro nutrient supple -
men tation in pregnancy, promotion of breast feeding,
appro priate complementary feeding, vitamin A and pre-
ven tive zinc supplementation in chil dren 6–59 months of
age, management of SAM, and management of MAM,
from their present level of coverage to 90% (or retention
of present coverage when higher than 90%). Appendix pp
13–16 list the estimates of eff ect considered for each
intervention. The con version of intervention eff ects of
preventive zinc supple mentation and complementary
feeding strategies from linear growth to stunting eff ects
in LiST is detailed in appendix pp 17–22. We assessed the
69. eff ect of this scale up scenario on mortality in children
younger than 5 years, rates of breastfeeding, stunting,
and wasting.
Our model suggested that if these ten nutrition
interventions were scaled up to 90% coverage, mortality
in children younger than 5 years could be reduced by 15%
(range 9–19), with a 35% (19–43) reduction in diarrhoea-
specifi c mortality, a 29% (16–37) reduction in pneumonia-
specifi c mortality, and a 39% (23–47) reduction in
measles-specifi c mortality (fi gure 4). The analysis also
showed fewer deaths attributable to congenital anomalies
and birth asphyxia related to periconceptual folic acid use
and a reduction in SGA (fi gure 4; appendix pp 23–24).
This scale up had a little eff ect on maternal mortality
(data not shown). Scaling up of all ten interventions to
90% coverage was also associated with a mean 20·3%
(range 10·2–28·9) reduc tion in stunting and a 61·4%
(35·7–72) reduction in severe wasting. The maximum
eff ect for severe wasting was noted in children in the
12–23 months age group (appendix p 25).
The analysis suggested that the interventions with the
largest potential aff ect on mortality in children younger
than 5 years are management of SAM, preventive
zinc supplementation, and promotion of breastfeeding
(fi gure 5). Analysis of community support strategies for
breastfeeding suggested that achieving 90% coverage of
breastfeeding promotion could increase exclusive breast-
feeding by 15% (7–22) in children younger than 1 month
and by 20% (13–26) in children aged 1–5 months.
Diarrhoea
deaths
Pneumonia
71. 1 200 000
1 400 000
N
um
be
r o
f d
ea
th
s
Cause-specific deaths in children <5 years and neonates
Baseline
Nutrition interventions scaled up
Figure 4: Eff ect of scale up of interventions on cause-specifi c
deaths
Error bars are ranges.
Ethiopia
Kenya
Tanzania
Yemen
South Africa
Madagascar
73. India
Nepal
Bangladesh
Myanmar
Vietnam
Philippines
Indonesia
High burden countries
Other countries
Guatemala
Figure 3: Countries with the highest burden of malnutrition
These 34 countries account for 90% of the global burden of
malnutrition.
For more on the Lives Saved
Tool see http://www.jhsph.edu/
iip/LiST
Series
www.thelancet.com Vol 382 August 3, 2013 469
Implementation of nutrition-specifi c packages
of care