What works? Interventions for maternal and child undernutrition and survival. Combined treatment with growth hormone and luteinizing hormone releasing hormone-analogue (LHRHa) of pubertal children with familial short stature. Clinical efficacy of group-based treatment for childhood obesity compared with routinely given individual counseling.
We reviewed interventions that affect maternal and child undernutrition and nutrition-related outcomes. These interventions included promotion of breastfeeding; strategies to promote complementary feeding, with or without provision of food supplements; micronutrient interventions; general supportive strategies to improve family and community nutrition; and reduction of disease burden (promotion of handwashing and strategies to reduce the burden of malaria in pregnancy). We showed that although strategies for breastfeeding promotion have a large effect on survival, their effect on stunting is small. In populations with sufficient food, education about complementary feeding increased height-for-age Z score by 0.25 (95% CI 0.01-0.49), whereas provision of food supplements (with or without education) in populations with insufficient food increased the height-for-age Z score by 0.41 (0.05-0.76). Management of severe acute malnutrition according to WHO guidelines reduced the case-fatality rate by 55% (risk ratio 0.45, 0.32-0.62), and recent studies suggest that newer commodities, such as ready-to-use therapeutic foods, can be used to manage severe acute malnutrition in community settings. Effective micronutrient interventions for pregnant women included supplementation with iron folate (which increased haemoglobin at term by 12 g/L, 2.93-21.07) and micronutrients (which reduced the risk of low birthweight at term by 16% (relative risk 0.84, 0.74-0.95). Recommended micronutrient interventions for children included strategies for supplementation of vitamin A (in the neonatal period and late infancy), preventive zinc supplements, iron supplements for children in areas where malaria is not endemic, and universal promotion of iodised salt. We used a cohort model to assess the potential effect of these interventions on mothers and children in the 36 countries that have 90% of children with stunted linear growth. The model showed that existing interventions that were designed to improve nutrition and prevent related disease could reduce stunting at 36 months by 36%; mortality between birth and 36 months by about 25%; and disability-adjusted life-years associated with stunting, severe wasting, intrauterine growth restriction, and micronutrient deficiencies by about 25%. To eliminate stunting in the longer term, these interventions should be supplemented by improvements in the underlying determinants of undernutrition, such as poverty, poor education, disease burden, and lack of women's empowerment. We evaluated the 12 month growth of 18 pubertal children with familial short stature randomly assigned to clinical follow-up (group A), GH treatment alone (group B) and GH+LHRH analogue (LHRHa) treatment (group C). Height velocity increased significantly compared to baseline in groups A and B (4.7 +/- 0.4 vs 6.6 +/- 0.6 and 4.4 +/- 0.3 vs 8 +/- 1 respectively), but not in C (5 +/- 0.5 vs 6.5 +/- 0.4). Moreover in group B height and height prognosis standard deviation score SDS) also were higher (-2.2 +/- 0.2 vs -1.7 +/- 0.2 and 1.8 +/- 0.3 vs -1 +/- 0.2, respectively). Comparisons among the groups showed a significant increase in group B vs the other groups of height velocity SDS (3.9 +/- 1.3 vs 0.4 + 1 and 0.3 +/- 0.7) and of height prognosis SDS (-1 +/- 0.2 vs -2.4 +/- 0.3 and -2.4 +/- 0.3). In conclusion, after one-year treatment, GH seems to be more effective in stimulating growth than GH +/- LHRHa, even if studies of longer duration and/or follow-up are needed. The aim of the study was to compare the efficacy of group treatment stressing a health-promoting lifestyle with routine counseling in the treatment of childhood obesity.
                Seventy obese children (weight for height 115-182%) aged 7-9 years were randomized either to routine counseling (two appointments for children) or to family-based group treatment (15 separate sessions for parents and children). These sessions included nutrition education, physical activity education and behavioral therapy.
                Children's weights and heights were measured at baseline, after the 6-month intervention and after the 6-month follow-up. The change of weight for height based on Finnish growth charts was used as the primary, and changes in body mass index (BMI) and BMI standard deviation scores (BMI-SDS) as secondary outcome measures.
                Children attending the group treatment lost more weight for height (6.8%) than children receiving routine counseling (1.8%) (P=0.001). The difference was significant when the data were analyzed in four groups by the cut-off limits of 0, -5 and -10% for the change in weight for height. The respective decreases in BMI were 0.8 vs 0.0 (P=0.003) and in BMI-SDS 0.3 vs 0.2 (P=0.022). The results remained similar in adjusted analyses. Both group and routine programs were feasible with a high, 87-99%, participation rate in sessions and appointments and very low, 3% or less, attrition rate from the programs. Six months after the intervention, beneficial effects were partly lost, but for changes in weight for height and BMI, the differences between the two treatment programs still were significant, and for BMI-SDS, there was a trend.
                Family-based group treatment that stresses a health-promoting lifestyle and is given separately for parents and children, offers an effective mode of therapy to treat obese school-aged children.
In addition to these randomized controlled trials, a body of lower quality evidence does exist relevant to two other important interventions; the use of supplemental enteral nutrition (Morin 1980; Belli 1988; Israel 1995) and the judicious use of surgical interventions in pre-pubertal children with refractory disease (Alperstein 1985; Lipson 1990; McLain 1990). Newer treatments, such as infliximab, are now becoming more widely used and may offer advantages in promoting growth. These effects are as yet unstudied. This review highlights the need for large, multi centre studies of the different treatment options in paediatric Crohn's disease and the importance of standardised measurements of growth, such as height velocity standard deviation scores and height standard deviation scores as outcome measures.