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Infant Cereal Program in Nunavut: What Can We do Better?

Infant Cereal Program in Nunavut: What Can We do Better?. Vesselina Petkova, RD Territorial Coordinator, Canada Prenatal Nutrition Program (CPNP). Introduction. No disclosures or conflicts of interest

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Infant Cereal Program in Nunavut: What Can We do Better?

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  1. Infant Cereal Program in Nunavut: What Can We do Better? Vesselina Petkova, RD Territorial Coordinator, Canada Prenatal Nutrition Program (CPNP)

  2. Introduction • No disclosures or conflicts of interest • Will discuss process, barriers, and some outcomes related to infant cereal program implementation • Project in progress • Not an example of a perfect program • Sometimes more questions than answers • Share with you and get feedback

  3. What is Iron Deficiency Anemia • When low iron in the system = iron deficiency anemia (IDA) • Ferritin is the measure of body’s iron storage • Low iron store if ferritin < 12 ng/mL • Lack of iron interferes with ability to create haemoglobin (Hg) • Anemia when Hg less than 2 s.d. • Usually when Hg < 110 g / L • Hg responsible for distributing oxygen to tissue, including heart and brain ᐊᐅᐸᖅᑐᑦ ᐊᐅᑦ ᐊᐅᐸᖅᑐᑦ ᐊᐅᑦ ᐊᒡᔭᕐᓯᔨᐅᕗᑦ ᐊᓂᕐᓂᖃᕐᓇᖅᑐᒥᒃ

  4. Why does IDA matter • Negatively affects billions worldwide • Affects cognition, psychomotor development, work productivity and community capacity • High economic burden • Highest costing disease (other than TB) • Generally preventable • Damage caused by IDA can be permanent if not reversed early

  5. Infant Risk factors for IDA include: • Pregnancy outcomes (mothers’ anemic, low birth weight, premature infants) • Rapid growth – infancy (6-24 m.o.) • Nutrition behaviours / poor intake of iron: • Early discontinuation of breastfeeding • Poor nutritional status (food insecurity, low SES) • Low iron formula • Excessive / early cow’s milk intake • Delayed / improper introduction of solids

  6. Is it a problem in Nunavut? • At least 250 cases of anemia in children (0-5) managed and treated annually. • ~ 50 cases per 1000 children/year (~ 5 %) • True burden of the disease? • Vast majority of patients are asymptomatic. • Tip of the iceberg phenomenon

  7. Many more unknown cases? • Population screening provides proper prevalence. • No screening protocol implemented across the Territory. • Prevalence in Igloolik: • 48% had anemia • 28% had IDA - up to 8 x national averages! • 53% depleted iron stores Christofides 2005

  8. Infant Screening in Iqaluit • 6 m.o. - 5 y.o. • 2006 – May 2010 • N = 677, but 1291 readings

  9. 70% of anemia is mild

  10. Anemia by age group Age in Months

  11. Summary Iqaluit Anemia Screening • Prevalence rates are very high • Highest at 8 – 11 months. • If analysis is limited to infants < 24 months, then 42.7% of infants were anemic. • Majority is mild. • But 17% of the children had at least one reading below 100 g/L (moderate anemia)

  12. Venous Draws • Only 53 / 118 (~45%) patients went for venous blood work  to confirm diagnosis • 30% of those who went for blood work did not have a ferritin done to establish iron storage

  13. Infant Cereal Supplementation • Context and Background • Plan • Process • Outcomes and Feedback

  14. Objective: Reduce the Prevalence of IDA in Infants and Children • Step 1: identify IDA as a public health priority • “By 2013, the rate of anemia in infants and toddlers will be halved” • Step 2: commit to a focused strategy in order to address it • IDA program

  15. Nunavut Iron Deficiency Anemia Project Evaluation Strategy 2008

  16. Food-Based Intervention Options Considered ease of implementation, safety profile of a product, cost, and availability. • Fresh meats, including country food • Jarred meats distribution • Infant cereal distribution • Vitamin supplementation

  17. Project Goals • Provide iron-fortified infant cereal to Nunavut infants from 6-12 months of age, in quantity sufficient to meet the Recommended Dietary Allowance of 11 mg/day for iron. • Deliver cereal to infants via collaboration between community-based CPNP projects and Health Centers • Determine if iron-fortified infant cereal is acceptable to mothers and infants.

  18. Implementation 1st phase:2009-2010 • Provision of cereal • Through CPNP community based programs, with support of local Health Centers • 15 communities around Nunavut • Order and distribution of cereal • Partnership with Northwest Company

  19. Cost and Funding • Need: average of 3 boxes per month per child x 6 months • Cost of cereal: ~ $5/box (incl. shipping) • ~ $ 90 per child • Total cost: $60,000 provided by CPNP • CPNP workers’ time and wages not included

  20. Educational information

  21. Evaluation of 1st Phase • Feedback from CPNP workers and mothers who received cereal. • Process: • # of boxes of cereal distributed • # of users & who used cereal • perspective of CPNP workers • Acceptability of cereal

  22. Outcomes • All 15 communities received cereal. • Very few provided detailed information on distribution • Systematic tracking wasn’t implemented • Some workers simply stated – ‘most’ distributed • Also not clear on the number of users • Unexpected issues related to program success such as Heinz recall of unrelated product

  23. CPNP Workers’ Perspective • Most centers found the program easy to administer • A request for ‘not so much paper work’ • Asked to track how many users and how many boxes distributed at a time • “I got it but never opened it… I didn’t know what to do with it”

  24. CPNP Workers’ Perspective • There was a major stress with where to keep the cereal stock • General request for fewer boxes • Knowing there is an expiry date • Feeling responsible for complete distribution

  25. Acceptable to Children? • 50% like, 30% neutral, 20% dislike taste • Some mothers say children won’t eat it • “My child doesn’t like the flavor, can we get flavored?” • 50% of mothers admit to sharing cereal with other members of household • Typically sibling outside age group

  26. Acceptable to Mothers? • 100% mothers support CPNP program to continue • 75% would purchase cereal if available Feedback from CPNP workers: • “some mothers feel uncomfortable taking the cereal… almost implying they were poor and couldn’t afford the cereal” • Felt that some mothers used it but not as the predominant infant food source

  27. Summary • Iron fortified infant cereal is one part of decreasing iron deficiency anemia amongst infants • Program helps with broader goals of food security • Accepted by most mothers and infants • General support for program and its continuation

  28. Next Steps • Fully implement cereal program • In all communities • Integrated in regular CPNP programming • Address barriers (storage, summer break...) • Continue to develop education and communication strategy • Evaluate health outcomes • implementation of screening program

  29. Next Steps • How to better integrate program with health centre? • How to integrate with local store? • Are there locally sustainable options using country food? • What to do with anemia that is NOT iron deficiency?

  30. Thanks to: CPNP community workers Mothers who provided feedback V. Avinashi S. Zlotkin Public Health Nutritionists R. Jetty G. Osborne CPNP

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