In this year’s FrieslandCampina Institute (FCI) Asia Pacific Symposium held in Ho Chi Minh City, Vietnam, eminent speakers and key opinion leaders in paediatric nutrition reviewed the current burden of malnutrition and its long-term consequences, with focus on children in the Asia Pacifi c region. Participants were also provided a platform to discuss nutritional defi cits in children – particularly in infants who fail to thrive (FTT) and those who are born small for gestational age (SGA) – and share best practices in dietary management of these children through an interactive case discussion.
Double burden of malnutrition in Asia
Dr Van Khanh Tran
Vice Head, Micronutrients
Head, Human Resources and Administration
National Institute of Nutrition
A phenomenon known as the double burden of malnutrition (DBM), characterised by the coexistence of both undernutrition and overnutrition in the same population, has recently emerged as a global problem. Often, undernutrition in childhood leads to a higher risk for overnutrition and its associated complications later in life. Many nations are exposed to nutrient deficiencies and excesses concurrently, impacting individuals, households and populations.1 This occurrence is attributed to an increased consumption of energy-dense, processed foods in place of traditional meals, and an increasingly sedentary lifestyle.2
Globally, more than 200 million children fail to achieve their developmental potential as a result of malnutrition. Malnutrition in all its forms remains high across all regions of the world: 150.8 million children (22.2%) under five are still stunted and 50.5 million children under five are wasted, while 38.3 million children under 5 years are overweight. In 2018, more than half of all stunted children and almost half of all overweight children under 5 years lived in Asia.3 In general, there has been a decline of stunting in this region with a plateau in the rate of reduction. Concurrently, there has been a steady increase in the number of overweight and obese children in many countries around the world, and this trend is likely to prevail.4 In Vietnam, for instance, despite the rapid and sustained decline in the number of underweight and stunted children, the prevalence of stunting remains to be among the highest in the world (29.3% in 2010).5 This is accompanied by an increase in the trend of childhood overweight and obesity, seen in about 5.0% of Vietnamese children.6
In its Global Nutrition Report in 2018, the WHO highlighted that every country in the world is affected by malnutrition in one or more of its forms.3 Figure 1 shows each country’s burden of childhood stunting, anaemia and/or overweight status in adult women.
Adequate nutrition in utero and during early childhood provides a means to support growth and development in general.7 It also allows for metabolic programming in the foetus to support the regulation of hormones and genetic material. Optimum nutrition during the prenatal and postnatal periods, in infants and in children is key to promoting long-term cognitive and educational performance, immunity, work capacity, and in preventing noncommunicable diseases (NCDs).8
There is growing evidence linking adverse nutritional and growth patterns early in life (i.e. in utero, perinatally and in childhood) to increased risks of cognitive, immunologic, and metabolic diseases in adulthood.9,10 For instance, stunting has been shown to be directly linked not only to short adult stature but also to suboptimal cognitive function later in life.1,11 Stunting is associated with poor test scores on fine motor hand movements later in childhood, and also leads to lower IQ scores and lower levels of academic achievement.12 Therefore, many nutrition programmes, particularly in the developing world, have made the elimination of stunting their primary objective. Conversely, childhood obesity has been found to be strongly correlated with adult obesity, which is associated with the development of hypertension, diabetes, and cardiovascular disease.13 Paradoxically, low birth weight infants have also been observed to become overweight adults with selective abdominal fat deposition, a risk factor for metabolic syndrome (Figure 2).10 The burden of these NCDs is likely to be greater in many Asian countries than in other parts of the world.1
[Reproduced with permission from The Commission on Nutrition, ACC/SCN. Ending Malnutrition by 2020: An Agenda for Change in the Millennium. Available at https://www.unscn.org/uploads/web/ news//2000-FEB-Ending-Malnutrition-by-2020-Agenda-for-Change-in-the-Millennium-Report.Pdf. Accessed 2 October 2019.]
The WHO has set forth an action plan addressing DBM with the following objectives: (1) elevate nutrition in the national development agenda, (2) protect, promote and support optimal breastfeeding and complementary feeding practices, (3) strengthen and enforce legal frameworks that protect, promote and support healthy diets, (4) improve accessibility, quality and implementation of nutrition services across public health programmes and settings, and (5) use financing mechanisms to reinforce healthy diets.14 The plan of action for each country in Asia Pacific should therefore be geared towards addressing DBM as more than just protein-energy malnutrition (PEM), which was previously prioritised.15
Protein intake, growth and obesity: Population studies in pregnancy and childhood
Professor Vincent W. V. Jaddoe
Erasmus University Medical Center
Sophia Children’s Hospital
Rotterdam, the Netherlands
Barker proposed that adverse nutrition in early life, including prenatally as measured by birth weight, increased susceptibility to the metabolic syndrome which includes obesity, diabetes, insulin insensitivity, hypertension, and hyperlipidaemia and complications that include coronary heart disease and stroke.16 Periods of rapid postnatal growth associated with high-energy intake seem to be risk factors, along with a high-energy Western diet.16,17 This was observed in a cohort of 300,000 Dutch men, a third of whom were exposed to famine in the 1940s. In this historical cohort study, it was observed that famine exposure during the first half of pregnancy was associated with significantly higher rates of obesity, while exposure during the second half of pregnancy and the first few months of postnatal life was associated with significantly lower obesity rates.18 Persistent epigenetic marks of less DNA methylation of insulin-like growth factor (IGF)-2 were also found six decades later in those who were periconceptually exposed to famine as compared with their unexposed, same sex siblings. These findings support the notion that the nutritional status of the mother prior to conception and early in her pregnancy plays a critical role in the metabolic development of the foetus.19
A prospective population-based study of young adult subjects followed from early foetal life and known as the Generation R study provides further insight into the relationship of metabolic disorders with body composition.20 It was found that in this cohort, there was a mismatch between foetal and infant growth, and that infants with higher postnatal growth rates but with a history of foetal growth restriction are at a higher risk of having increased visceral and liver fat.21
Overall, adequate protein intake during pregnancy and during the postnatal period supports optimal growth of infants. Subjects in the Generation R study with mothers who consumed more than three glasses of milk per day appeared to have greater foetal weight gain than those who had less. The association seems to be due to milk protein or milk components closely associated with protein, more than the carbohydrate or fat content of milk (Figure 3).22
[Adapted from Heppe DHM, van Dam RM, Willemsen SP, den Breeijen H, Raat H, et al. Am J Clin Nutr 2011;94:501-509.]
Limited interventional studies have found that lower protein intake during infancy was associated with persistent effects in lowering body mass index (BMI) until school age. A European double-blind randomised controlled trial showed that lower protein intake during infancy led to persistent lowering of BMI until 24 months.23 This effect lasted until the subjects were 6 years old.24
The effects of dietary intervention on body composition for different metabolic profiles require further evaluation. The Generation R Next programme will attempt to evaluate the effects of lifestyle interventions during preconception and early pregnancy on birth outcomes, body composition and childhood diseases.25
Managing failure to thrive and small for gestational age
Professor Damayanti Rusli Sjarif
Dr Cipto Mangunkusumo National Referral Hospital
Associate Professor Muhammad Yazid Jalaludin
University of Malaya
Kuala Lumpur, Malaysia
Failure to thrive
Failure to thrive (FTT) in childhood is a state of undernutrition due to inadequate caloric intake, inadequate caloric absorption, or excessive caloric expenditure. Although failure to thrive is often defined as a weight for age that falls below the 5th percentile on multiple occasions or weight deceleration that crosses two major percentile lines on a growth chart, use of any single indicator has a low positive predictive value.26 Left untreated, wasting associated with FTT could lead to stunting. Other long-term consequences, such as defect of cognitive function, cardiometabolic illnesses in adulthood, or even mortality, have also been noted in some cases.27
Case 1: Failure-to-thrive
A 4.5-month-old male infant was born term with weight 3.1 kg and length 48 cm. He was exclusively breastfed from birth until 4 months but was noted to have feeding difficulty and slow weight gain while on enteral formula. The mother revealed that she suffered from hyperemesis during pregnancy and delivered the baby via caesarean delivery due to failed labour induction. At the time of evaluation, the patient weighed 4.5 kg, measured 58.8 cm in length and had a 40 cm head circumference. He was noted to have head lag and gross motor delay. There was diffi culty lifting his head and chest while lying face down. Lastly, he was noted to be severely underweight (i.e. less than -2 SD WAZ).
Upon further inquiry, both parents reported a history of atopy (mother had asthma and father had allergic rhinitis). The infant’s mouth became swollen during the first breastfeeding. Further, he seemed nauseated after breastfeeding for 15 minutes and was found to be restless in the evening. Due to weight faltering, he received formula supplementation, which caused diarrhoea. A stool benzidine test was done, which increased the probability of the diagnosis of cow’s milk protein allergy (CMPA). He was started on free amino acid-based formula and thereafter was noted to be 6.72 kg at 6 months, with an improvement of his WAZ score near median (Figure 4). He measured 62 cm in length and had a head circumference of 41 cm. He was able to lift his head and chest while on his stomach.
Studies have shown that compensatory growth or rapid weight gain following undernutrition in early life is associated with an increased risk of childhood obesity as a result of rebound adiposity.28 It is recommended to monitor this patient for rebound adiposity in the future.
Malnutrition in infancy and childhood continues to be a challenge in the region. There is a window of opportunity to reduce cognitive deficits in the first 2 years of life and hence, early detection of infants at-risk for FTT and prompt treatment should be applied accordingly.
Small for gestational age
Small for gestational age (SGA) refers to infants born 2 SDS below the mean or below the 10th centile of a population-specifi c birth weight versus the gestational age plot.29 Alternately, it may refer to infants below the 10th centile of birth-weight-for-gestational age, gender-specific reference population.30,31 SGA may occur due to maternal causes, such as environmental infl uences, substance abuse and medical
conditions. Some foetal conditions such as chromosomal, genetic and congenital defects may also lead to this condition.32 Placental insufficiency, abruptio, infarction and structural abnormalities are also known to contribute to this.33
Case 2: Small for gestational age
A 5-year-old boy born term at 2.3 kg weighed 14 kg (weight standard deviation score [SDS] -2.42) and measured 95 cm (height SDS -2.95). His mid-parental height was 166.5 cm (height SDS -1.51). His height was <3rd percentile of boys his age.
Catch-up growth usually occurs during the first 2 years in about 85% of SGA children.34 Usually, SGA children demonstrate catch-up growth during the first 6 months after birth and by 2 years of age, around 13% would be below the normal population height standards (-2 SDS). A small minority (5%) continues to catch-up in height during childhood and by 18 years of age, about 8% would remain short. The relative risk of short stature at 18 years of age is 5 to 7 times that of children born with normal birth size. This constitutes about 14% to 22% of short adults.35–38
‘Optimal catch-up growth’ means that term SGA infants have catch-up growth that crosses two centile levels, i.e. from <10th to the interval between 25th and 50th in the first several months. Those who are able to maintain on track growth at median level by two years of age has the lowest risk of adverse health outcomes. Those who have inadequate or excessive catch-up growth often develop adverse health outcomes, such as being overweight or obese.39
SGA infants require adequate nutrients to achieve normal postnatal growth but the specific requirements for most nutrients for SGA infants are unknown. Breastfeeding is regarded as the optimal means of administering 110 to 135 kcal/kg/day to provide for additional energy for catch-up growth.40 Healthy catch-up growth is demonstrated by an increase in linear growth and lean body mass, while unhealthy catch-up growth is associated with an increase in fat mass, central adiposity, and insulin resistance. SGA infants are prone to persistent deficits in muscle mass but normal or excessive gains in fat.41
The early identification of children with growth failure through well-defined criteria and diagnostic work-up is necessary. Recommendations for evaluation of children with growth failure is presented below (Figure 5).42
[Adapted from Growth Hormone Research Society. J Clin Endocrinol Metab 2000;85:3990-3993.]
In some cases, long-term use of recombinant human growth hormone may be indicated for short children born SGA without signs of persistent catch-up growth.43
After ruling out pathological causes of growth delay in patients who are constitutionally small, reassurance is the key approach to treatment.44 It is recommended for these children to have routine growth monitoring as they often tend to catch-up in their adolescence.
Watch the conference highlight video
4th FrieslandCampina Institute Asia Pacific Symposium 2019The theme of the 4th FrieslandCampina Institute Asia Pacific Symposium 2019 was ‘The Nutritional Influence: Current perspectives and novel approaches to improving the nutritional status of Asian children’.
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