Penny Mary E, Creed-Kanashiro Hilary M, Robert Rebecca C, Narro M Rocio, Caulfield Laura E, Black Robert E
Instituto de Investigación Nutricional, La Molina, Lima, Peru.
Lancet. 2005;365(9474):1863-72. doi: 10.1016/S0140-6736(05)66426-4.
Malnutrition is the underlying cause of half of child mortality. Many programmes attempt to remedy this issue but there is a lack of evidence on effective ways to decrease child malnutrition.
We did a cluster-randomised trial of an educational intervention in a poor periurban area (ie, shanty town) of Peru. Guided by formative research, the intervention aimed to enhance the quality and coverage of existing nutrition education and to introduce an accreditation system in six government health facilities compared with six control facilities. The primary outcome measure was growth that was measured by weight, length, and Z scores for weight-for-age and length-for-age at age 18 months. Main secondary outcomes were the percentage of children receiving recommended feeding practices and the 24-h dietary intake of energy, iron, and zinc from complementary food at ages 6, 9, 12, and 18 months. Analysis was by intention to treat.
We enrolled a birth cohort of 187 infants from the catchment areas of intervention centres and 190 from control areas. Caregivers in intervention areas were more likely to report receiving nutrition advice from the health service than were caregivers in control health facilities (16 [52%] of 31 vs 9 [24%] of 37, p=0.02). At 6 months more babies in intervention areas were fed nutrient-dense thick foods at lunch (a recommended complementary feeding practice) than were controls (48 [31%] of 157 vs 29 [20%] of 147; difference between groups 19 [11%], p=0.03). Fewer children in intervention areas failed to meet dietary requirements for energy (8 months: 30 [18%] of 170 vs 45 [27%] of 167, p=0.04; 12 months: 64 [38%] of 168 vs 82 [49%] of 167, p=0.043), iron (8 months: 155 [91%] of 170 vs 161 [96%] of 167, 9 months: 152 [93%] of 163 vs 165 [99%] of 166, p=0.047), and zinc (9 months: 125 [77%] of 163 vs 145 [87%] of 166, p=0.012) than did controls. Children in control areas were more likely to have stunted growth (ie, length for age less than 2 SD below the reference population median) at 18 months than children in intervention groups (26 [16%] of 165 vs 8 [5%] of 171; adjusted odds ratio 3.04 [95% CI 1.21-7.64]). Adjusted mean changes in weight gain, length gain, and Z scores were all significantly better in the intervention area than in the control area.
Improvement of nutrition education delivered through health services can decrease the prevalence of stunted growth in childhood in areas where access to food is not a limiting factor.
营养不良是导致半数儿童死亡的根本原因。许多项目试图解决这一问题，但缺乏关于有效降低儿童营养不良的方法的证据。
我们在秘鲁一个贫困的城郊地区（即棚户区）进行了一项关于教育干预的整群随机试验。在形成性研究的指导下，该干预旨在提高现有营养教育的质量和覆盖面，并在六个政府卫生设施中引入认证系统，与六个对照设施进行比较。主要结局指标是18个月时通过体重、身长以及年龄别体重和年龄别身长的Z评分来衡量的生长情况。主要次要结局是接受推荐喂养方式的儿童百分比以及6、9、12和18个月时从辅食中摄入的能量、铁和锌的24小时膳食摄入量。分析采用意向性分析。
我们从干预中心的集水区招募了187名婴儿的出生队列，从对照区招募了190名。与对照卫生设施的照料者相比，干预区的照料者更有可能报告从卫生服务中获得营养建议（31名中的16名[52%]对37名中的9名[24%]，p = 0.02）。在6个月时，干预区比对照区有更多婴儿在午餐时食用营养丰富的稠状食物（一种推荐的辅食喂养方式）（157名中的48名[31%]对147名中的29名[20%]；组间差异19名[11%]，p = 0.03）。干预区未能满足能量膳食要求的儿童较少（8个月时：170名中的30名[18%]对167名中的45名[27%]，p = 0.04；12个月时：168名中的64名[38%]对167名中的82名[49%]，p = 0.043），铁（8个月时：170名中的155名[91%]对167名中的161名[96%]，9个月时：163名中的152名[93%]对166名中的165名[99%]，p = 0.047）和锌（9个月时：163名中的125名[77%]对166名中的145名[87%]，p = 0.012）。对照区的儿童在18个月时比干预组的儿童更有可能生长发育迟缓（即年龄别身长低于参考人群中位数2个标准差）（165名中的26名[16%]对171名中的8名[5%]；调整后的优势比为3.04[95%置信区间1.21 - 7.64]）。干预区体重增加、身长增加和Z评分的调整后平均变化均显著优于对照区。
在食物获取不是限制因素的地区，通过卫生服务提供的营养教育的改善可以降低儿童期生长发育迟缓的患病率。
