Sự tăng trưởng thể chất và sức khỏe của trẻ dưới 2 tuổi có mẹ được bổ sung vi chất dinh dưỡng trước và trong quá trình mang thai tại thái nguyên tt tiếng anh

THAI NGUYEN UNIVERSITY ------ NGUYEN THI XUAN HUONG PHYSICAL AND HEALTH GROWTH AMONG UNDER 2-YEAR CHILDREN BORN TO MOTHERS RECEIVING MICRONUTRIENT SUPPLEMENTATION BEFORE AND DURI

THAI NGUYEN UNIVERSITY

- -

NGUYEN THI XUAN HUONG

PHYSICAL AND HEALTH GROWTH AMONG UNDER 2-YEAR

CHILDREN BORN TO MOTHERS RECEIVING

MICRONUTRIENT SUPPLEMENTATION BEFORE AND

DURING PREGNANCY IN THAI NGUYEN

Speciality: Pediatrics Code number: 62720135

MINISTRY OF EDUCATION AND TRAINING

THAI NGUYEN UNIVERSITY

Mã số: 62720135

THAI NGUYEN, 2019

UNIVERSITY OF MEDICINE AND PHARMACY

THAI NGUYEN UNIVERSITY

Supervisor:

1 Ass.Prof.Ph.D Nguyen Thanh Trung

The dissertation is available for reference at

- The library of Thai Nguyen University of Medicine and Pharmacy

- Learing resource centre of Thai Nguyen University

- The National Medical Library

INTRODUCTION

Growth is a fundamental biological feature of children Research on growth is considered the basic science of Pediatrics Pediatricians, the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO) emphasize that the first 1,000 days of life, from conception to the age of two, is a very important period and considered as “golden days” in children’s life

This is a special stage that provides the foundation for lifelong health and has long term impact on the physical, mental and motor development later in life The 1000 golden days are a window of opportunity that provides

up to 60% of children’s potential to increase their height in the future In Vietnam, the rate of malnourished children is still high According to the

2015 statistics of the National Institute of Nutrition, underweight prevalence accounted for 14.1%, stunting accounted for 24.6% Undernutrition was especially high in the mountainous and Central Highlands regions The proportion of children under 5 years old with nutritional anemia is 29.2% The nutritional status of mothers before and during pregnancy is also poor Studies worldwide have shown that maternal nutritional status, especially micronutrient status during pregnancy, is a major determinant

of birthweight and height development potential This means that maternal nutritional status must be prepared before pregnancy and should

be maintained well throughout pregnancy There are plenty studies that examined the role of nutrition and micronutrient on child physical development in the first 1000 golden days However, evidents on the effects micronutrient supplement before and during pregnancy on later period of child physical and health development are limited

Therefore, we carried out the thesis: "Physical and health growth among under 2-year children born to mothers receiving micronutrient supplementation before and during pregnancy in Thai Nguyen" The objectives are:

1 To evaluate the physical and health growth of under -2 year children born to mothers receiving micronutrient supplements before and during pregnancy in Thai Nguyen

2 To identify factors affecting the physical and health growth of children under 2 years of age whose mothers receiving micronutrient supplements before and during pregnancy in Thai Nguyen

1 Necessity of the research

Stunting is a public health problem in developing countries The World Health Organization has set a goal to reduce stunting by 40% in children under 5 years old by 2025 compared to the year 2010, and also proposed many solutions to achieve this goal, including supplement micronutrients for mothers before and during pregnacy Thus the title of this thesis is topical, consistent with the trend of the world and the national nutrition program

NEW CONTRIBUTIONS OF THE THESIS

1 The project is the first project in Vietnam to study the growth and health of children aged 0-24 months whose mothers received micronutrient supplements before and during pregnancy in Thai Nguyen

2 The study has provided data on physical and health growth of children aged 0-24 months in Thai Nguyen and has found a number of factors affecting physical growth and health of children in Thai Nguyen

3 Research has shown the important role of multiple micronutrient supplementation before pregnancy on pregnancy outcomes Children born to mothers who received pre-pregnancy multiple micronutrient supplementation, following by prenatal iron-folic acid supplementation, had higher birth weight and height and lower neonatal anemia rate compared to those born to mothers who received folic acid or iron - folic acid supplementation before pregnancy

THESIS STRUCTURE

The thesis consists of 143 pages In addition to the introduction (3 pages), the conclusion (3 pages) and the recommendation (1 page), there are

4 chapters: Chapter 1: Literature review (40 pages); Chapter 2:

Methodology (18 pages); Chapter 3: Results (48 pages); Chapter 4: Discussion (32 pages) The thesis has 36 tables, 11 figures, 171 references (Vietnamese: 59; English: 112)

Chapter1 LITERATURE REVIEW

1 Physical growth of children

1.1 Growth in weight

Weight is a measure usually carried out in all basic and routine surveys It is very important measure to assess physical fitness, nutrition and growth It is also universal, simple and easy to measure

1.2 Growth in height

Height (length) is one of the most basic dimensions in anthropometric surveys The height represent the length of the whole body so it is used to

assess the growth of children, the form of adult stature Height is a faithful

measure of growth, height reflects good past life and is evidence that reflects nutrition Long-term malnourished children will slow height development

1.3 Head circumference (or occipital-forehead circumference)

The head circumference is a measurement used in anthropology, correlates with brain mass and cognitive function The measurement of the head circumference allows indirect assessment of the secondary abnormalities of the brain due to pathological processes Therefore, the American Society of Pediatrics recommends measuring the head circumference when visiting children, especially among children under 2 years of age

1.4 Mid upper arm circumference

Mid upper arm circumference (MUAC) is one of the anthropometric indicators commonly used in field surveys It allows to assess the muscle mass and it also reflects the nutritional status of children MUAC can be used to quickly classify nutritional status in the community WHO has set

a threshold for assessing the nutritional status of children: MUAC ≥ 13.5cm: Normal, MUAC 11.5 to less than 12.5cm: moderate acute malnutrition, MUAC <11.5cm: severe acute malnutrition

2 Nutritional status and health of children

Assessing the health of an individual or a community is a challenge, because health is an abstract concept and difficult to measure In the scope of the thesis, we only mention one aspect of child health: nutritional status and some common acute diseases in children in the community: undernutrition, anemia, acute respiratory infections and diarrhea

Malnutrition is a condition in which the body lacks protein, energy and micronutrients The disease is common in children under 5 years old, manifesting in many different levels, or more or less affecting the

physical and health development of children The first two years after birth are the fastest growing stages of the body, the period of greatest risk

of malnutrition The survey results on the nutritional status of children, the rate of underweight malnutrition children in Vietnam has decreased but remained high, in 2012 was 16.2%, in 2013 was 15.3%, in 2014 is 14.5% and in 2015 is 14.1% However, the national rate of stunting malnutrition remains at 26.7% in 2012, 25.9% in 2013, 24.9% in 2014 and 24.6% in 2015

According to the nutrition surveillance in 2009 - 2010, the rate of anemia in the ecological regions remains almost average and seriously in Northwestern mountain area The younger the age group was, the higher the risk of anemia was: the group of 0-12 months and 12-24 months has the highest anemia rate of 45.3% and 44.4%, respectively; meanwhile, in the group of 24-35 months, this rate was only 27.5%

ARI is the leading cause of disease burden, and the third leading cause of death for children under 5 in Vietnam

In Vietnam, the regions with the highest prevalence of diarrhea are the North West, Central Highlands, Red River Delta, and those with the lowest rate of diarrhea are the South East and the North Central Coast

3 Factors affecting the physical growth, nutritional status and health

of children under 2 years of age

The growth process of children from the time of pregnancy to birth and growth is influenced by many factors: nutrition, genetics, environment and society Just like growth, there are many weaknesses affecting the nutritional and health status of children: Nutrition, socioeconomic, food safety, environment, genetic and biological factors The impact of each factor on growth and health varies according to the developmental stage of the child, with motivating factors, and factors that cause restriction These factors do not work separately but they are closely related and determine the nature of development

Chapter 2: METHODOLOGY

2.1 Research subjects

Subjects of study are mother and child pairs in which mothers are supplemented with micronutrient before and during pregnancy and divided into 3 groups:

Group 1: Children who are born by mothers receiving Folic acid (FA) weekly before pregnancy and receiving iron + folic acid (IFA) daily during pregnancy

Group 2: Children who are born by mothers who receive IFA supplements weekly before becoming pregnant and receive IFA supplements daily during pregnancy

Group 3: Children who are children of mothers receive multiple micronutrient (MM) weekly before pregnancy and daily IFA supplement during pregnancy

2.1.1 Selection criteria for research

- Children of mothers who participated in micronutrient intake before and during pregnancy, we followed children from birth to 24 months of age

- The families who agree to allow the children to participate in the study and sign the agreement to participate in the study

2.1.2 Exclusion criteria from research

- Children with birth defects

- Die before 24 months

- Parents who do not agree to accept the study or refuse to continue to participate at any time

2.2 Location and time

Cohort studies monitor the physical and health growth of babies born

by women who have been fortified with micronutrients before and during pregnancy until they are 24 months old

2.3.2 Sample size, sample selection

1 2

/ 2

)]

1[ln(

/)1(/)1(

Inside:

p1: The rate of malnutrition is estimated in children of children of mothers who are supplemented with micronutrients, P1 = (RR) p0 p0: The rate of malnutrition is estimated among children of mothers

in the general population According to the results of the Nutrition Institute in 2012, the rate of malnourished children in the northern mountainous region is 20.9%

RR: Relative risk, it is estimated that the child group of mothers with micronutrient supplementation is less malnourished than 50% of mothers with micronutrient supplement, choose RR = 0.5

Instead of the formula, calculate the sample size of 953

The minimum sample size required in the study is 953 children In fact, we investigated 1151 children, during the data collection process, there were 90 children excluded from the study, 32 children gave up, 15 children roamed, 43 children did not participate fully The number of eligible children included in the data analysis was 1061 children

Step 3: Select the research object:

The mothers and children of mothers who have micronutrient

supplements before and during pregnancy were selected We made a list and matched the number of children and mothers to carry out vertical monitoring from birth to 24 months of age

2.4 Research indicators and variables

2.4.1 Research indicators

Research indicators for goal 1:

- Weight of children aged 0-24 months by age and gender, according to the group of micronutrient supplements

- Length of children aged 0-24 months by age and gender, according to the group of micronutrient supplements

- Head and arm rings of children from 0 to 24 months by age and gender, according to the group of micronutrient supplements

- The rate of malnutrition: being underweight, stunting, and lean by age, according to the group of micronutrients

- Percentage of anemia, ARI, TCC by age, by micronutrient supplement group

Research indicators for objective 2: Analysis of a number of factors affecting the physical and health growth of children under 2 years of age with mothers receiving micronutrient supplements before and during pregnancy

- Factors affecting the weight of children at birth, 12 months and 24 months

- Factors affecting the length of children at birth, 12 months and 24 months

- Factors affecting stunting, underweight of children at birth, 12 months and

24 months

- Factors affecting anemia, ARI, TCC of babies at birth, at 12 months and at

24 months

2.4.2 Variables and how to define variables

- Child's age: take the date of investigation except the child's date of birth and based on WHO 2006 standards

- Child's gender: Boys and girls

- Weight: In kg, take a decimal number after the comma

- Length, head, arm, and chest: In cm, take a decimal number after the comma

Classification of nutritional status

Use measurements of the child's age, gender, weight and height to calculate indicators: weight for age (WAZ), height for age (HZA), weight for height (WHZ) and Classification of malnutrition according to WHO

2006 Standard children when WAZ, HAZ, WHZ indexes are between -2 and +2

Malnutrition is recorded when the WAZ, HAZ, WHZ <- 2 indicators

- Underweight: When WAZ <- 2SD

- Stunting: When HZA <- 2SD

- Malnutrition is thin: When WHZ <- 2SD

Criteria for assessing anemia: based on the amount of Hemoglobin (Hb) Neonatal anemia when Hb <135 g / l

Children under 2 years old anemia when Hb <110 g / l

Pregnant mothers are anemic when Hb <110g / l

The unborn mother is anemic when Hb <120g / l

- Acute diarrhea: Children are considered TCC when they go out of loose stools splashing water 3 times or more in a day, the time is less than 14 days

- ARI: Children are diagnosed with acute respiratory infections when children have 2 or more signs in the following signs: cough, fever, runny nose, shortness of breath, fast breathing

Mother's ethnicity: Kinh and other ethnic groups

- Education level of mothers: According to the standards of the Ministry

of Education and Training

+ Primary school: finish grade 5

+ Middle school: finish grade 9

+ High school: finish grade 12

+ On high school: apprenticeship or university, postgraduate

- Height of mother: Normal: 45 1.45m, low <1.45m

- BMI of the mother before pregnancy: BMI = Weight / Height 2 Normal BMI ≥ 18.5 kg / m2; BMI <18.5 kg / m2: chronic energy deficiency, BMI> 25 kg / m2 is overweight, obesity

- Number of kilograms of weight gain of mothers during pregnancy: Normal ≥ 9 kg, <9 kg: little increase

- Maternal occupation: Agricultural or other occupations (Teachers, workers, accountants, business)

- Maternal micronutrient supplemented before pregnancy: FA, IFA,

MM

- Preterm birth: gestational age at birth <37 weeks

- Low birth weight: Birth weight <2500g

- Light weight for gestational age: Underweight for gestational age is considered a useful health monitoring indicator for newborns We use INTERGROWTH-21st standard in 2014

- Child feeding practices: Evaluated at 8 times of 1,3, 6, 9, 12, 15,18 and

24 months of age, including practice of breastfeeding and complementary feeding, using criteria WHO

2.5 Analyzing and processing data

The data was analyzed and processed with Stata10 software The statistical tests are selected appropriately to ensure accuracy

2.6 Ethics

The study was approved by the Ethics Council in Biomedical Research Institute of Sociology and Sociology in Vietnam and agreed by

local authorities Parents are informed about the purpose, rights and

responsibilities of participating in the study and voluntarily participate in the study The study participants received nutritional counseling before intervention

Chapter 3: RESULTS

3.1 General information about the research sample

The study included 1061 mother and child pairs, of which 338 mothers were supplemented with micronutrients, 342 mothers were supplemented with iron-acid folic and 380 mothers were supplemented with folic acid Farming mothers accounted primary part (82%); ethnic minority mothers account for nearly half (49.4%) The number of boys was 544, accounting for 51.27% Girls were 517, accounting for 48.73% The rate of underweight babies under 2500g accounts for 5.1%, the rate

of premature babies under 37 weeks is 9.4%, 12.1% of low birth weight babies with respect to gestational age There was no difference in individual characteristics, child feeding practices and household characteristics in 3 study groups

3.2 Physical and health growth of children under 2 years old

3.2.1 Physical growth of children under 2 years old

Table 3.1 Average weight and length of children from 0-24 months old

Boy (n =544)

(X± SD)

Girl(n = 517) (X ± SD) p

Table 3.2 Average weight of 3 groups of children from 0 – 24 months old (kg)

Group FA (X ± SD) P

Group MM (X ± SD)

Group IFA (X ± SD)

Group FA (X ± SD) p

Table 3 3 Average length of 3 research groups of children from 0 – 24

Group FA (X ± SD)

P Group MM (X ± SD)

Group IFA (X ± SD)

3.2 2 Nutritional status and health of children under 2 years old

Table 3.4 Rate of disease by age

ARI (%) (n= 1061)

Acute

diarrhea

(%) (n= 1061)

Underweight (%)

Stunting (%)

Wasting (%)

of 1 month of age, tends to increase with age, highest in the age of 15-24 months The rate of anemia in children is still high in all ages Uneven prevalence of acute respiratory infections at different ages, highest at the age of 15 months The rate of acute diarrhea is uneven at different ages and higher in the age group of 6-12 months

Figure 3.1 Stunting rate by age of 3 research groups

Comment: Stunting rate increases with age, especially after 18 months There was no difference in stunting rate between the three study groups

Figure 3.2 The rate of underweight malnutrition according to the age of the three study groups

Comment: The rate of underweight malnutrition gradually increases with age, especially after 12 months of age There was no difference in the prevalence of underweight among the three study groups

Figure 3.3 The prevalence of anemia according to the age of the 3 study groups

micronutrient before pregnancy had a lower rate of anemia at birth than those of mothers who received iron-folic acid supplement or iron