Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana

Formative research for the development of a market-based home fortification programme for young children in Niger

The objective of this formative research was to assess the acceptability of a micronutrient powder (Sprinkles(®)) and a lipid-based nutrient supplement (Nutributter(®)), and to explore people's willingness to pay for these products in a resource-poor context like Niger. In four sites, 84 focus group discussions among mothers, fathers and grandmothers of children 6-23 months were conducted, as well as 80 key informant interviews of mothers who participated in a home study where their children 6-23 months were given either Sprinkles(®) or Nutributter(®) to use either for a period of 4 weeks, or they were given both products over the 4-week period, i.e. Sprinkles(®) for 2 weeks and Nutributter(®) for an additional 2 weeks. The mothers understood how to use the products and generally used the products correctly. Both products were highly acceptable to adults and most children. In Niamey, where the 4-week home study used both products for 2 weeks each, the mothers tended to prefer Nutributter(®). The mothers who used either product were pleased with the improvements they saw in their children's health, including increased appetite, weight gain and increased energy and activity. A few mothers were concerned with how they would be able to provide for their child's increased appetite. Most participants across all four sites reported that they would be willing and able to afford to buy a single sachet of either Sprinkles(®) at a cost of US$0.03 or Nutributter(®) at a cost of US$0.08 several times a week. This study provides evidence that both of these products were are highly acceptable in different settings in Niger and suggests that delivery of Nutributter(®) or Sprinkles(®) at a low or subsidized cost through a market-based system may be possible in Niger, if an appropriate distribution system can be identified.

Implementation of a programme to market a complementary food supplement (Ying Yang Bao) and impacts on anaemia and feeding practices in Shanxi, China

In China, a full fat soy powder mixed with multiple micronutrient powders (Ying Yang Bao (YYB)) was developed, and the efficacy of YYB was shown in controlling anaemia and improving child growth and development. However, prior to 2008, there was no sustainable way to provide YYB to vulnerable populations, except through free distribution by the government. This study was to test the concept of public-private partnership (PPP) to deliver YYB and to evaluate the effectiveness of marketing YYB through PPP. Programme activities included development of a complementary food supplement (CFS) national standard, product concept test, product development and marketing, behavior change communication, monitoring and evaluation. Baseline and end-line surveys were used to evaluate product awareness, purchasing and the impacts of the project on anaemia and feeding practices. A Chinese CFS standard was approved. Caregivers and their 6- to-24-month-old children participated in the baseline (n=226) and the end-line survey (n=221). A concept test at the baseline survey showed that 78% of caregivers were willing to buy YYB at 0.1 USD. After developing the product and implementing the intervention for 8 months, 59.6% of surveyed caregivers purchased YYB. While not significant, the prevalence of anaemia was marginally lower at the end line (28.8%) than at the baseline (36.2%). For those purchasing YYB, the risk of anaemia was significantly reduced by 87% of odds (P<0.009). The end-line survey found that feeding practices had improved significantly following the intervention. An enabling policy and regulatory environment in which CFSs are defined and parameters for appropriate marketing are identified as a prerequisite for marketing YYB or other nutritious CFS. Public and private advocacy and marketing could successfully increase awareness of YYB and access and use through market channels. The YYB project may be effective for reducing anaemia and improving feeding practices.

Anemia and Helicobacter pylori seroreactivity in a rural Haitian population

Anemia is a significant health concern worldwide and can be the result of nutritional, environmental, social, and infectious etiologies. We estimated the prevalence of anemia in 336 pre-school children and 132 adults in the rural Central Plateau of Haiti and assessed associations with age, sex, household size, water source, sanitation, and Helicobacter pylori seroreactivity using logistic regression analysis; 80.1% (269/336) of children and 63.6% (84/132) of adults were anemic. Among children, younger age was associated with increased prevalence of anemia (adjusted odds ratio [aOR] = 4.1, 95% confidence interval [CI] = 1.5-11.1 for children 6-11 months compared with children 48-59 months). Among adults, 50.8% were H. pylori-seropositive, and seropositivity was inversely associated with anemia (aOR = 0.4, 95% CI = 0.2-0.9). Anemia prevalence in this region of Haiti is very high and not attributable to sanitary conditions or a high prevalence of H. pylori infection.

Relationship of the availability of micronutrient powder with iron status and hemoglobin among women and children in the Kakuma Refugee Camp, Kenya

BACKGROUND

Micronutrient powder is a potential strategy to improve iron status and reduce anemia in refugee populations.

OBJECTIVE

To evaluate the effect of the availability of home fortification with a micronutrient powder containing 2.5 mg of sodium iron ethylenediaminetetraacetate (NaFeEDTA) on iron status and hemoglobin in women and children in the Kakuma Refugee Camp in northwest Kenya.

METHODS

Hemoglobin and soluble transferrin receptor were measured in 410 children 6 to 59 months of age and 458 women of childbearing age at baseline (just before micronutrient powder was distributed, along with the regular food ration) and at midline (6 months) and endline (13 months)follow-up visits.

RESULTS

At the baseline, midline, and endline visits, respectively, the mean (+/- SE) hemoglobin concentration in women was 121.4 +/- 0.8, 120.8 +/- 0.9, and 120.6 +/- 1.0 g/L (p = .42); the prevalence of anemia (hemoglobin < 120 g/L) was 42.6%, 41.3%, and 41.7% (p = .92); and the mean soluble transferrin receptor concentration was 24.1 +/- 0.5, 20.7 +/- 0.7, and 20.8 +/- 0.7 nmol/L (p = .0006). In children, the mean hemoglobin concentration was 105.7 +/- 0.6, 109.0 30322 1.5, and 105.5 +/- 0.3 g/L (p = .95), respectively; the prevalence of anemia (hemoglobin < 110 g/L) was 55.5%, 52.3%, and 59.8% (p = .26); and the mean soluble transferrin receptor concentration was 36.1 +/- 0.7, 29.5 +/- 1.9, and 28.4 +/- 3.2 nmol/L (p = .02), in models that were adjusted for age using least squares means regression.

CONCLUSIONS

In children and in women of childbearing age, the availability of micronutrient powder was associated with a small improvement in iron status but no significant change in hemoglobin in this refugee camp setting.

Beyond food insecurity: how context can improve complementary feeding interventions

BACKGROUND

The role of context has not been elaborated with respect to current recommendations for complementary feeding interventions, apart from a gross distinction based on food security.

OBJECTIVE

Our objective was to compare two food-insecure settings in sub-Saharan Africa to determine how context (i.e., the set of local social, cultural, and physical circumstances) influences complementary feeding practices and nutrient intakes and how the results can help in the design of a suitable intervention strategy.

METHODS

We conducted formative research using 24-hour dietary recalls, household interviews, and focus group discussions with mothers of 6- to 12-month-old infants in rural Zimbabwe (n = 32) and Pemba Island, Zanzibar, Tanzania (n = 44).

RESULTS

In both settings, many infants had suboptimal nutrient intakes, poor dietary diversity, and poor hygiene. Breastfeeding practices were poor in Pemba, and the infants' diet had low energy density in Zimbabwe. Beyond food insecurity, contextual determinants of practices included inaccurate indigenous knowledge, time-consuming maternal livelihoods, family eating behaviors, local agriculture, and the local ecosystem. Both settings would require nutrition education, but it should target the broader indigenous ways of learning and family eating behaviors in order to achieve the necessary behavior change. A home-based fortificant would probably be enough for Pemban children, because the ecosystem of the island provides sufficient sources of macronutrients. However, Zimbabwean children appear to need a fortified food-based supplement to overcome the poor agricultural and economic context.

CONCLUSIONS

Assessing context was essential to intervention design. A framework to guide future formative research is proposed.

Short-term evaluation of the impact of a food program on the micronutrient nutritional status of Argentinean children under the age of six

This study was undertaken to evaluate the impact of Plan Más Vida (PMV) on the micronutrient nutritional condition of children aged 1 to 6 years 1 year after PMV implementation. The food program was intended for low-income families from the province of Buenos Aires, Argentina and provided supplementary diets. A prospective, nonexperimental study was carried out. Children (472 at baseline and 474 after 1 year) were divided into two groups (1-2 and 2-6 years of age). Biochemical tests (hemogram, ferritin, zinc, vitamin A, and folic acid), anthropometric assessments (weight and height), and dietary surveys (24-h recall) were performed. Chronic growth retardation (-2 height/age Z-score) was present in 2.8% and 8.7% of 1-2- and 2-6-year-old children, respectively; 14.4% in the former and 8.8% in the latter group had overweight/obesity. No significant changes were recorded 1 year after PMV implementation. Whereas anemia values decreased (55.3% to 39.1%, p = 0.003) and serum zinc values increased in 1-2-year-old children, the risk for vitamin A deficiency decreased significantly in both age groups. The evaluation of the early impact of PMV actions provided important nutritional data that should be used by provincial health authorities to conduct future evaluations.

Effect of daily versus weekly home fortification with multiple micronutrient powder on haemoglobin concentration of young children in a rural area, Lao People's Democratic Republic: a randomised trial

BACKGROUND

Multiple micronutrient deficiencies, in particular iron deficiency anaemia (IDA) is a severe public health problem in Lao People's Democratic Republic (Lao PDR). Because of the practical difficulties encountered in improving the nutritional adequacy of traditional complementary foods and the limitations associated with the use of liquid iron supplementation for the treatment and prevention of IDA in infants and young children, recently, home-fortification with multivitamins and minerals sprinkles was recommended. This study aims to compare the effect of twice weekly versus daily supplementation with multivitamins and minerals powder (MMP) on anaemia prevalence, haemoglobin concentration, and growth in infants and young children in a rural community in Lao PDR.

METHODS

A randomized trial was conducted in six rural communities. Children aged 6 to 52 months (n = 336) were randomly assigned to a control group (n = 110) or to one of two intervention groups receiving either two sachets per week (n = 115) or a daily sachet (n = 111) of MMP for 24 weeks; 331 children completed the study. A finger prick of blood was taken at baseline, at week 12, and again at week 24 to determine haemoglobin concentration. Anthropometric measurements were taken every 4 weeks. The McNemar test was used to assess within group differences at three time points in the study subjects with anaemia and one-way ANOVA was used to assess changes in mean haemoglobin concentration in the treatment groups.

RESULTS

MMP supplementation resulted in significant improvements in haemoglobin concentration and in the reduction of anaemia prevalence in the two treatment groups compared with the control group (p <0.001). The severely to moderately anaemic children (Hb <100 g/L) on daily supplementation recovered faster than those on twice weekly supplementation. MMP was well accepted and compliance was high in both treatment groups. Overall, the improvement in the weight for age Z-score was very small and not statistically significant across the three study groups.

CONCLUSIONS

MMP supplementation had positive effects in reduction of anaemia prevalence and in improving haemoglobin concentration. For severely to moderately anaemic children, daily MMP supplementation was more effective in improving haemoglobin concentration and reducing anaemia prevalence. A longer intervention period is probably needed to have a positive effect on growth.

Oral iron supplements for children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library, PUBMED, MEDLINE, LILACS; and trial registry databases, all up to June 2011. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children below 18 years of age. We included trials comparing orally administered iron, iron with antimalarial treatment, or iron with folic acid versus placebo or no treatment. Iron fortification was excluded. Antihelminthics could be administered to either group. Additional micronutrients had to be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were clinical (symptomatic) malaria, severe malaria, and death. Two authors independently selected the studies and extracted the data. We assessed heterogeneity and conducted subgroup analyses by the presence of anaemia at baseline, age, and malaria endemicity. We assessed risk of bias using domain-based evaluation. We performed a fixed-effect meta-analysis for all outcomes and random-effects meta-analysis for hematological outcomes. We adjusted analyses for cluster randomized trials.

MAIN RESULTS

Seventy-one trials (45,353 children) were included. For clinical malaria, no significant difference between iron alone and placebo was detected, (risk ratio (RR) 0.99, 95% confidence intervals (CI) 0.90 to 1.09, 13 trials). The results were similar in the subgroups of non-anaemic children and children below 2 years of age. There was no significant difference in deaths in hyper- and holoendemic areas, risk difference +1.93 per 1000 children (95% CI -1.78 to 5.64, 13 trials, 17,898 children). Iron administered for treatment of anaemia resulted in a larger increase in haemoglobin than iron given for prevention, and the benefit was similar in hyper- or holoendemic and lower endemicity settings. Iron and folic acid supplementation resulted in mixed results for severe malaria. Overall, the risk for clinical malaria was higher with iron or with iron plus folic acid in trials where services did not provide for malaria surveillance and treatment. Iron with antimalarial treatment significantly reduced malaria. Iron supplementation during an acute attack of malaria did not increase the risk for parasitological failure, (RR 0.96, 95% CI 0.74 to 1.24, three trials) or deaths.

AUTHORS' CONCLUSIONS

Iron alone or with antimalaria treatment does not increase the risk of clinical malaria or death when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

Legislation should support optimal breastfeeding practices and access to low-cost, high-quality complementary foods: Indonesia provides a case study

It is important to support women to exclusively breastfeed for 6 months and continue breastfeeding for 24 months and beyond. It is also necessary to provide the poor with access to affordable ways to improve the quality of complementary foods. Currently, many countries do not have the legal and policy environment necessary to support exclusive and continued breastfeeding. Legislative and policy changes are also necessary for introducing complementary food supplements, allowing them to be marketed to those who need them, and ensuring that marketing remains appropriate and in full compliance with the International Code of Marketing of Breastmilk Substitutes. This paper aims to illustrate the above with examples from Indonesia and to identify legislative requirements for supporting breastfeeding and enabling appropriate access to high-quality complementary food supplements for children 6-24 months of age. Requirements include improved information, training, monitoring and enforcement systems for the International Code of Marketing of Breastmilk Substitutes; implementation and monitoring of the Baby-Friendly Hospital Initiative; establishment of a registration category for complementary food supplements to enhance availability of high-quality, low-cost fortified products to help improve young child feeding; clear identification and marketing of these products as complementary food supplements for 6-24-month-olds so as to promote proper use and not interfere with breastfeeding.

Essential fats: how do they affect growth and development of infants and young children in developing countries? A literature review

Omega-3 and omega-6 fatty acids, particularly docosahexaenoic acid (DHA), are known to play an essential role in the development of the brain and retina. Intakes in pregnancy and early life affect growth and cognitive performance later in childhood. However, total fat intake, alpha-linolenic acid (ALA) and DHA intakes are often low among pregnant and lactating women, infants and young children in developing countries. As breast milk is one of the best sources of ALA and DHA, breastfed infants are less likely to be at risk of insufficient intakes than those not breastfed. Enhancing intake of ALA through plant food products (soy beans and oil, canola oil, and foods containing these products such as lipid-based nutrient supplements) has been shown to be feasible. However, because of the low conversion rates of ALA to DHA, it may be more efficient to increase DHA status through increasing fish consumption or DHA fortification, but these approaches may be more costly. In addition, breastfeeding up to 2 years and beyond is recommended to ensure an adequate essential fat intake in early life. Data from developing countries have shown that a higher omega-3 fatty acid intake or supplementation during pregnancy may result in small improvements in birthweight, length and gestational age based on two randomized controlled trials and one cross-sectional study. More rigorous randomized controlled trials are needed to confirm this effect. Limited data from developing countries suggest that ALA or DHA supplementation during lactation and in infants may be beneficial for growth and development of young children 6-24 months of age in these settings. These benefits are more pronounced in undernourished children. However, there is no evidence for improvements in growth following omega-3 fatty acid supplementation in children >2 years of age.

Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age

BACKGROUND

Vitamin and mineral deficiencies, particularly those of iron, vitamin A and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Micronutrient powders (MNP) are single-dose packets containing multiple vitamins and minerals in powder form that can be sprinkled onto any semi-solid food.The use of MNP for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age.

OBJECTIVES

To assess the effects and safety of home (point-of-use) fortification of foods with multiple micronutrient powders on nutritional, health and developmental outcomes in children under two years of age.

SEARCH STRATEGY

We searched the following databases in February 2011: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (1948 to week 2 February 2011), EMBASE (1980 to Week 6 2011), CINAHL (1937 to current), CPCI-S (1990 to 19 February 2011), Science Citation Index (1970 to 19 February 2011), African Index Medicus (searched 23 February 2011), POPLINE (searched 21 February 2011), ClinicalTrials.gov (searched 23 February 2011), mRCT (searched 23 February 2011), and World Health Organization International Clinical Trials Registry Platform (ICTRP) (searched 23 February 2011). We also contacted relevant organisations (25 January 2011) for the identification of ongoing and unpublished studies.

SELECTION CRITERIA

We included randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were children under the age of two years at the time of intervention, with no specific health problems. The intervention was consumption of food fortified at the point of use with multiple micronutrient powders formulated with at least iron, zinc and vitamin A compared with placebo, no intervention or the use of iron containing supplements, which is the standard practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies and assessed the risk of bias of the included studies.

MAIN RESULTS

We included eight trials (3748 participants) conducted in low income countries in Asia, Africa and the Caribbean, where anaemia is a public health problem. The interventions lasted between two and 12 months and the powder formulations contained between five and 15 nutrients. Six trials compared the use of MNP versus no intervention or a placebo and the other two compared the use of MNP versus daily iron drops. Most of the included trials were assessed as at low risk of bias.Home fortification with MNP reduced anaemia by 31% (six trials, RR 0.69; 95% CI 0.60 to 0.78) and iron deficiency by 51% (four trials, RR 0.49; 95% CI 0.35 to 0.67) in infants and young children when compared with no intervention or placebo, but we did not find an effect on growth.In comparison with daily iron supplementation, the use of MNP produced similar results on anaemia (one trial, RR 0.89; 95% CI 0.58 to 1.39) and haemoglobin concentrations (two trials, MD -2.36 g/L; 95% CI -10.30 to 5.58); however, given the limited amount of data these results should be interpreted cautiously.No deaths were reported in the trials and information on side effects and morbidity, including malaria, was scarce.It seems that the use of MNP is efficacious among infants and young children six to 23 months of age living in settings with different prevalences of anaemia and malaria endemicity, regardless of whether the intervention lasts two, six or 12 months or whether recipients are male or female.

AUTHORS' CONCLUSIONS

Home fortification of foods with multiple micronutrient powders is an effective intervention to reduce anaemia and iron deficiency in children six months to 23 months of age. The provision of MNP is better than no intervention or placebo and possibly comparable to commonly used daily iron supplementation. The benefits of this intervention as a child survival strategy or on developmental outcomes are unclear. Data on effects on malaria outcomes are lacking and further investigation of morbidity outcomes is needed. The micronutrient powders containing multiple nutrients are well accepted but adherence is variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

Effects of Multimicronutrient Home Fortification on Anemia and Growth in Bhutanese Refugee Children

Background

Anemia remains a significant public health problem in refugee settings. Home fortification with micronutrient powders has been proposed as a feasible option to alleviate micronutrient deficiencies; its efficacy in reducing anemia in children aged 6 to 24 months has been demonstrated in several trials.

Objective

To evaluate the effectiveness of a large-scale micronutrient powder distribution program in reducing anemia prevalence and promoting growth in refugee children aged 6 to 59 months.

Methods

Four representative cross-sectional surveys were conducted 13 months before and 7, 14, and 26 months after initiation of the supplementation program. Data collected on children aged 6 to 59 months included hemoglobin concentration, anthropometric indicators, morbidity, feeding practices, and information on the micronutrient distribution program. The study had a pre—post design with no control group.

Results

The overall prevalence of anemia in children did not change significantly between baseline (43.3%) and endpoint (40.2%). The prevalence of moderate anemia decreased over the same period from 18.9% to 14.4% ( p < .05). The levels of severe anemia were negligible (< 1%) in all surveys. The prevalence of stunting decreased significantly from 39.2% at baseline to 23.4% at endpoint ( p < .001), a relative decrease of 40%. Reported coverage, use, and acceptance of micronutrient supplements remained consistently high throughout the study.

Conclusions

In the absence of a control group, changes in key outcomes should be interpreted with caution. The minor effect on hemoglobin status requires further investigation of underlying causes of anemia in this population. The large positive effect on linear growth may be a significant benefit of supplementation if confirmed by future studies.

Simulation methods to estimate design power: an overview for applied research

BACKGROUND

Estimating the required sample size and statistical power for a study is an integral part of study design. For standard designs, power equations provide an efficient solution to the problem, but they are unavailable for many complex study designs that arise in practice. For such complex study designs, computer simulation is a useful alternative for estimating study power. Although this approach is well known among statisticians, in our experience many epidemiologists and social scientists are unfamiliar with the technique. This article aims to address this knowledge gap.

METHODS

We review an approach to estimate study power for individual- or cluster-randomized designs using computer simulation. This flexible approach arises naturally from the model used to derive conventional power equations, but extends those methods to accommodate arbitrarily complex designs. The method is universally applicable to a broad range of designs and outcomes, and we present the material in a way that is approachable for quantitative, applied researchers. We illustrate the method using two examples (one simple, one complex) based on sanitation and nutritional interventions to improve child growth.

RESULTS

We first show how simulation reproduces conventional power estimates for simple randomized designs over a broad range of sample scenarios to familiarize the reader with the approach. We then demonstrate how to extend the simulation approach to more complex designs. Finally, we discuss extensions to the examples in the article, and provide computer code to efficiently run the example simulations in both R and Stata.

CONCLUSIONS

Simulation methods offer a flexible option to estimate statistical power for standard and non-traditional study designs and parameters of interest. The approach we have described is universally applicable for evaluating study designs used in epidemiologic and social science research.

The acceptance and feasibility of replacement feeding at 6 months as an HIV prevention method in Lilongwe, Malawi: results from the BAN study

International guidelines recommend EBF to age 6 months among HIV-infected mothers choosing to breast-feed and cessation thereafter if replacement feeding is acceptable, feasible, affordable, sustainable, and safe. When mothers wean, they are challenged to provide an adequate replacement diet. This study investigates the use and acceptability of a lipid-based nutrient supplement (LNS) as a breast-milk substitute when provided to infants (6-12 mo) of HIV-positive mothers, as part of the Breast-feeding, Antiretroviral, and Nutrition (BAN) Study. A sub-sample of mothers (n = 45) participated in interviews that explored EBF, weaning, and strategies to feed LNS. Mothers reported several weaning strategies, including gradual reduction of breast-feeding, expressing breast-milk into a cup, and separation of mother and child. LNS, a peanut-based micronutrient fortified paste, was highly accepted and incorporated into the traditional diet. Weaning is a feasible HIV prevention method among this population in Malawi when supported by the provision of LNS as a breast-milk substitute.

Why nutritional iron deficiency persists as a worldwide problem

The earliest studies of food iron absorption employing biosynthetically incorporated radioisotopes were published in the 1950s. Wheat flour has been fortified with iron in Canada, the United Kingdom, and the United States since the 1940s. However, half a century later, nutritional iron deficiency (ID) is estimated to affect 1.5-2 billion people worldwide. The reasons for the apparently limited impact of health and nutrition policies aimed at reducing the prevalence of ID in developing countries are complex. They include uncertainty about the actual prevalence of ID, particularly in regions where malaria and other infections are endemic, failure of policy makers to recognize the relationships between ID and both impaired productivity and increased morbidity, concerns about safety and the risks to iron-sufficient individuals if mass fortification is introduced, and technical obstacles that make it difficult to add bioavailable iron to the diets of those at greatest risk. It is, however, likely that the next decade will see a marked reduction in the prevalence of ID worldwide. More specific assessment tools are being standardized and applied to population surveys. The importance of preventing ID during critical periods of the life cycle is receiving increased attention. Innovative approaches to the delivery of bioavailable iron have been shown to be efficacious. The importance of integrating strategies to improve iron nutrition with other health measures, and economic and social policies addressing poverty as well as trade and agriculture, are receiving increasing consideration.

Acceptability of lipid-based nutrient supplements (LNS) among Ghanaian infants and pregnant or lactating women

Inadequate micronutrient intake during pregnancy, lactation and infancy is a major problem in many developing countries. Lipid-based nutrient supplements (LNS) can improve micronutrient status, growth and development of infants, and also have potential to improve nutritional status of pregnant and lactating women. The objective of the study was to test the acceptability of LNS designed for infants (LNS-20gM) and pregnant or lactating women (LNS-P&L). Participants were infants (n = 22, mean age = 8 months) and pregnant or lactating women (n = 24) attending routine services at a hospital in Ghana. Infants consumed 45 g of a test meal consisting of one part LNS-20gM and three parts fermented maize porridge, while women consumed 50 g of a similar test meal containing LNS-P&L instead. Participants also used their respective LNS at home for 14 days. Primary outcome was the proportion of the test meal consumed. On average, infants consumed 76.2% of the test meal [95% (confidence interval) CI: 65.7, 86.7], while women consumed 87.1% (95% CI: 82.6, 91.6). During the 14-day period, median daily consumption of LNS-20gM was 19.3 g, very close to the recommended 20 g d(-1), while that of LNS-P&L was one sachet, as recommended. We conclude that LNS-20gM and LNS-P&L were well accepted.

Micronutrient fortified milk improves iron status, anemia and growth among children 1-4 years: a double masked, randomized, controlled trial

Background

Multiple micronutrient deficiencies are highly prevalent among preschool children and often lead to anemia and growth faltering. Given the limited success of supplementation and health education programs, fortification of foods could be a viable and sustainable option. We report results from a community based double-masked, randomized trial among children 1–4 years evaluating the effects of micronutrients (especially of zinc and iron) delivered through fortified milk on growth, anemia and iron status markers as part of a four group study design, running two studies simultaneously.

Methods and Findings

Enrolled children (n = 633) were randomly allocated to receive either micronutrients fortified milk (MN = 316) or control milk (Co = 317). Intervention of MN milk provided additional 7.8 mg zinc, 9.6 mg iron, 4.2 µg selenium, 0.27 mg copper, 156 µg vitamin A, 40.2 mg vitamin C, and 7.5 mg vitamin E per day (three serves) for one year. Anthropometry was recorded at baseline, mid- and end-study. Hematological parameters were estimated at baseline and end-study. Both groups were comparable at baseline. Compliance was over 85% and did not vary between groups. Compared to children consuming Co milk, children consuming MN milk showed significant improvement in weight gain (difference of mean: 0.21 kg/year; 95% confidence interval [CI] 0.12 to 0.31, p<0.001) and height gain (difference of mean: 0.51 cm/year; 95% CI 0.27 to 0.75, p<0.001). Mean hemoglobin (Hb) (difference of 13.6 g/L; 95% CI 11.1 to 16.0, p<0.001) and serum ferritin levels (difference of 7.9 µg/L; 95% CI 5.4 to 10.5, p<0.001) also improved. Children in MN group had 88% (odds ratio = 0.12, 95% CI 0.08 to 0.20, p<0.001) lower risk of iron deficiency anemia.

Conclusions/Significance

Milk provides an acceptable and effective vehicle for delivery of specific micronutrients, especially zinc and iron. Micronutrient bundle improved growth and iron status and reduced anemia in children 1–4 years old.

Trial Registration

ClinicalTrials.gov NCT00255385

Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe

Supplementation with lipid-based nutrient supplements (LiNS) is promoted as an approach to prevent child undernutrition and growth faltering. Previous LiNS studies have not tested the effects of improving the underlying diet prior to providing LiNS. Formative research was conducted in rural Zimbabwe to develop feeding messages to improve complementary feeding with and without LiNS. Two rounds of Trials of Improved Practices were conducted with mothers of infants aged 6-12 months to assess the feasibility of improving infant diets using (1) only locally available resources and (2) locally available resources plus 20 g of LiNS as Nutributter®/day. Common feeding problems were poor dietary diversity and low energy density. Popular improved practices were to process locally available foods so that infants could swallow them and add processed local foods to enrich porridges. Consumption of beans, fruits, green leafy vegetables, and peanut/seed butters increased after counselling (P < 0.05). Intakes of energy, protein, vitamin A, folate, calcium, iron and zinc from complementary foods increased significantly after counselling with or without the provision of Nutributter (P < 0.05). Intakes of fat, folate, iron, and zinc increased only (fat) or more so (folate, iron, and zinc) with the provision of Nutributter (P < 0.05). While provision of LiNS was crucial to ensure adequate intakes of iron and zinc, educational messages that were barrier-specific and delivered directly to mothers were crucial to improving the underlying diet.

Examination of facilitators and barriers to home-based supplemental feeding with ready-to-use food for underweight children in western Uganda

Poor complementary feeding practices and low-quality complementary foods are significant causes of growth faltering and child mortality throughout the developing world. Ready-to-use foods (RUF) are energy-dense, lipid-based products that do not require cooking or refrigeration that have been used to prevent and treat malnutrition among vulnerable children. The effectiveness of these products in improving child nutritional status depends on household use by caregivers. To identify the key facilitators and barriers that influence appropriate in-home RUF consumption by supplemental feeding program beneficiaries, we conducted individual interviews among caregivers (n = 80), RUF producers (n = 8) and program staff (n = 10) involved in the Byokulia Bisemeye mu Bantu supplemental feeding program in Bundibugyo, Uganda. By documenting caregiver perceptions and feeding practices related to RUF, we developed a conceptual framework of factors that affect appropriate feeding with RUF. Findings suggest that locally produced RUF is well received by caregivers and children, and is perceived by caregivers and the community to be a healthy supplemental food for malnourished children. However, child feeding practices, including sharing of RUF within households, compromise the nutrient delivery to the intended child. Interventions and educational messages informed by this study can help to improve RUF delivery to targeted beneficiaries.

Formative Research Exploring Acceptability, Utilization, and Promotion in Order to Develop a Micronutrient Powder (Sprinkles) Intervention among Luo Families in Western Kenya

Background

There is a lack of peer-reviewed literature describing in detail the formative research to develop Sprinkles interventions.

Objective

To describe community members' reactions to and experiences using Sprinkles, with an emphasis on acceptability, utilization, and promotion.

Methods

Fourteen initial focus group discussions on Sprinkles and a 25-family home study were conducted. For the home study, each child 6 to 59 months of age in the household received 30 sachets (1 per day). The initial 14 focus group discussions included mothers, grandmothers, vendors, women who purchased from vendors, and adults in the general population. Home study families were recruited from participants in the initial 14 focus group discussions who had at least one child 6 to 59 months of age.

Results

Sprinkles were highly acceptable to adults and most children; some children thought Sprinkles were sugar. Most home study families prepared and used Sprinkles correctly. All families reported positive effects, particularly increased appetite, and recommended Sprinkles; none experienced major problems. Potential barriers identified were lack of knowledge of and experience with Sprinkles, availability of Sprinkles, and cost. Promotional messages targeted to mothers, fathers, all child-care providers, and doctors focused on the positive health effects of Sprinkles.

Conclusions

Issues related to Sprinkles preparation, use, and barriers required attention before implementation. Locally appropriate visual and written instructions were developed for dissemination. Intervention training sessions and promotions were tailored to answer frequently asked questions, increase knowledge of Sprinkles, and provide tangible evidence of health benefits. Information needs and perceptions changed quickly after use of Sprinkles. Existing levels of Sprinkles awareness and knowledge should be considered when designing interventions.

Effect of in-home fortification of complementary feeding on intellectual development of Chinese children

OBJECTIVE

To explore the effect of in-home fortification of complementary feeding on intellectual development of Chinese children aged below 24 months.

METHODS

One thousand and four hundred seventy eight children aged 4-12 months were recruited and divided into study groups (formula 1 group and formula 2 group) and control group. In two study groups, in addition to the usual complementary food, children were fed with a sachet of fortified food supplement each day. Protein and micronutrients were provided in formula 1 group. Formula 2 group had the same energy intake as the formula 1 group . In addition to measurement of physical growth and detection of hemoglobin level, Development Quotient (DQ) or Intelligence Quotient (IQ) was assessed.

RESULTS

The DQ of children aged below 24 months was 97.2, 95.5, and 93.8 in formula 1 group, formula 2 group and control group, respectively, and the differences were statistically significant (P < 0.05). The DQ of children in formula 1 group, formula 2 group, and control group was 92.7, 90.4, and 88.3 respectively in the first follow up showing statistically significant differences (P < 0.05). And, DQ of children in formula 1 group, formula 2 group and control group were 96.7, 94.5, and 93.7 respectively in the second follow up, showing statistically significant differences (P < 0.05). Full-IQ of children in the formula 1 group was 3.1 and 4.5 points higher than that in formula 2 group and in control group respectively. Verbal IQ of children in the formula 1 group was 2.1 and 5 points higher than that in formula 2 group and control group respectively. Performance IQ was 2.5 and 3.1 points higher than that in formula 2 group and control group respectively. All above mentioned comparisons were statistically significant.

CONCLUSION

Fortification of complementary feeding showed persistent effect on intelligence development of young children which could persist to 6 years of age. The critical time for correction of anemia could be under 18 months.

Use of lipid-based nutrient supplements (LNS) to improve the nutrient adequacy of general food distribution rations for vulnerable sub-groups in emergency settings

The term 'lipid-based nutrient supplements' (LNS) refers generically to a range of fortified, lipid-based products, including products like Ready-to-Use Therapeutic Foods (RUTF) (a large daily ration with relatively low micronutrient concentration) as well as highly concentrated supplements (1-4 teaspoons/day, providing <100 kcal/day) to be used for 'point-of-use' fortification. RUTF have been successfully used for the management of severe acute malnutrition (SAM) among children in emergency settings. Recent research on smaller doses of LNS for prevention of malnutrition has created interest in their potential use in emergency settings to ensure a more nutritionally adequate ration for the most vulnerable groups [e.g. infants and children between 6 and 24 months of age, and pregnant and lactating women (PLW)]. Currently, the main food and nutrition interventions in emergency settings include general food distribution (GFD) rations, which are provided to the affected population as a whole, and selective (or supplementary) feeding programs (SFP), which are to be provided to nutritionally vulnerable or malnourished individuals. In addition to logistical and operational challenges that may limit the intended effect of these programs, the nutritional quality of the food commodities provided may be insufficient to meet the needs of infants and young children and PLW. Because these subgroups have particularly high nutrient needs for growth and development, meeting these needs is challenging in settings where the ration is limited to a few food commodities, with little access to a diverse diet and bioavailable sources of micronutrients. In recent years, there has been increased attention to adding micronutrient interventions, on top of the other food-based interventions (such as GFDs and SFPs), to fill micronutrient gaps in diets in emergency settings. The focus of this document is the potential role of LNS in meeting the nutritional needs of these vulnerable subgroups, with the goal of preventing malnutrition in emergency-affected populations. The document addresses the desired nutritional formulation of LNS for these target groups, taking into account the expected bioavailability of relevant nutrients and toxicity concerns. It also discusses the recommended chemical forms of the fortificants in LNS; stability and shelf-life considerations; production, packaging and distribution of LNS in the context of emergencies; and cost implications of the addition of LNS to current GFD rations for vulnerable groups. To develop the desired nutritional formulation of LNS for these purposes, we calculated the current nutrient content of commonly provided GFD rations and determined the nutritional 'gaps' (of both micro- and macronutrients) of these rations for each of the target groups (i.e. children 6-35 months of age and PLW). For fat and protein, both quantity and quality were evaluated. Through an iterative process, we determined the formulation of a small dose of LNS that would best meet the recommended nutrient intakes for each group in combination with other foods in the GFD ration [composed of a grain, pulse, oil, sugar and salt, but excluding a fortified blended food (FBF)], as well as breast milk for children 6-24 months of age, while avoiding excess levels of any one nutrient to the extent possible. The composition of the LNS used for these calculations is based on an existing LNS product (Nutributter, Malaunay, France, Nutriset), but with less sugar and more oil. Two different approaches were used: (1) developing two different formulations of LNS, one to be used for infants and children 6-35 months of age and a separate one for PLW; and (2) developing a single formulation that could be used for all of these subgroups. We used commodity cost data to estimate the cost of adding an LNS product to the GFD ration. The results indicate that the typical GFD ration currently provided in emergency settings--based on cereals, pulse, an FBF such as corn-soy blend (CSB), oil, salt and sugar-does not meet the nutritional needs of infants and young children and PLW. The hypothetical intake from a ration composed of food aid commodities (based on the current USAID/USDA specifications for exported food aid commodities used in emergency settings), and including breast milk for children 6-24 months of age, provided less than 75% of the recommended intake for several micronutrients for certain age/physiologic groups, including calcium, iron, zinc, B vitamins such as riboflavin, B6 and B12, and fat-soluble vitamins such as D, E and K. It also generally contained lower than recommended levels of fat and essential fatty acids. The initial LNS formulation for each target group was designed to provide 100% of the recommended amount (RDA or RNI) for most micronutrients per daily dose (20 g, approximately 118 kcal) of LNS. This would ensure consumption of the recommended levels of each nutrient even if the 'base' diet changed. However, because such a formulation could provide excess amounts of certain nutrients when consumed in combination with the 'base' diet (especially when the 'base' diet contains fortified foods), we made adjustments in the LNS formulation when there was a risk of greatly exceeding the Upper Level for certain subgroups and there were relevant concerns about adverse effects from chronic consumption of such amounts. For most nutrients, consumption of toxic amounts is highly unlikely with the proposed LNS formulations. The 'one-size' LNS formulation was designed so that one 'dose' (20 g) would be provided to infants and young children and two 'doses' (i.e. 40 g/day) would be provided to PLW. This 'one-size' formulation was based on the LNS formulation developed for children 6-35 months of age. Although the resulting formulation is not a perfect match for the unique nutritional needs of each subgroup, there are several practical advantages to using such an approach. As anticipated, addition of LNS to the GFD ration, even after eliminating the FBF (e.g. CSB), increases the cost. The 'revised' ration without CSB but with LNS would cost 34-52% more (food only) than the 'typical' GFD diet for a hypothetical mother-infant pair, depending on how many LNS 'doses' were provided to the mother. However, depending on the contribution of food costs to overall program costs, the overall increase in costs may be significantly less. Although cost is an important consideration, options to improve the nutritional quality of foods provided in emergency settings should also be assessed with regard to effectiveness in maintaining and improving nutritional outcomes. Another consideration is whether a specialized product like LNS is more easily targeted to the individuals for whom it is intended, thus reducing inter- and intra-household sharing, a common concern with other fortified products such as CSB. This could have substantial cost implications because programs usually compensate for sharing by inflating the amount of FBF provided. This document is intended to be a starting point for considering the incorporation of LNS in the food packages provided in emergency settings. Our goal was to examine the potential nutritional benefits but also the challenges of adopting such a strategy. There are many different options for emergency nutrition programs, and there are also many considerations governing which option to choose. This document is intended to encourage further evaluation of all of these options.

Current and Potential Role of Specially Formulated Foods and Food Supplements for Preventing Malnutrition among 6- to 23-Month-Old Children and for Treating Moderate Malnutrition among 6- to 59-Month-Old Children

Reducing child malnutrition requires nutritious food, breastfeeding, improved hygiene, health services, and (prenatal) care. Poverty and food insecurity seriously constrain the accessibility of nutritious diets that have high protein quality, adequate micronutrient content and bioavailability, macrominerals and essential fatty acids, low antinutrient content, and high nutrient density. Diets based largely on plant sources with few animal-source and fortified foods do not meet these requirements and need to be improved by processing (dehulling, germinating, fermenting), fortification, and adding animal-source foods, e.g., milk, or other specific nutrients. Options include using specially formulated foods (fortified blended foods, commercial infant cereals, or ready-to-use foods [RUFs; pastes, compressed bars, or biscuits]) or complementary food supplements (micronutrient powders or powdered complementary food supplements containing micronutrients, protein, amino acids, and/or enzymes or lipid-based nutrient supplements (120 to 250 kcal/day), typically containing milk powder, high-quality vegetable oil, peanut paste, sugar, and micronutrients. Most supplementary feeding programs for moderately malnourished children supply fortified blended foods, such as corn–soy blend, with oil and sugar, which have shortcomings, including too many antinutrients, no milk (important for growth), suboptimal micronutrient content, high bulk, and high viscosity. Thus, for feeding young or malnourished children, fortified blended foods need to be improved or replaced. Based on success with ready-to-use therapeutic foods (RUTFs) for treating severe acute malnutrition, modifying these recipes is also considered. Commodities for reducing child malnutrition should be chosen on the basis of nutritional needs, program circumstances, availability of commodities, and likelihood of impact. Data are urgently required to compare the impact of new or modified commodities with that of current fortified blended foods and of RUTF developed for treating severe acute malnutrition.

Oral iron supplementation for preventing or treating anaemia among children in malaria-endemic areas

BACKGROUND

Iron-deficiency anaemia is common during childhood. Iron supplementation has been claimed to increase the risk of malaria.

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

We searched The Cochrane Library (2009, issue 1); MEDLINE; EMBASE; LILACS and metaRegister of Controlled Trials, all up to March 2009. We scanned references of included trials.

SELECTION CRITERIA

Individually and cluster-randomized controlled trials conducted in hypoendemic to holoendemic malaria regions and including children < 18 years. We included trials comparing orally administered iron with or without folic acid vs. placebo or no treatment. Iron fortification was excluded. Antimalarials and/or antiparasitics could be administered to either group. Additional micronutrients could only be administered equally to both groups.

DATA COLLECTION AND ANALYSIS

The primary outcomes were malaria-related events and deaths. Secondary outcomes included haemoglobin, anaemia, other infections, growth, hospitalizations, and clinic visits. We assessed risk of bias using domain-based evaluation. Two authors independently selected studies and extracted data. We contacted authors for missing data. We assessed heterogeneity. We performed fixed-effect meta-analysis and presented random-effects results when heterogeneity was present. We present pooled risk ratios (RR) with 95% confidence intervals (CIs). We used adjusted analyses for cluster-randomized trials.

MAIN RESULTS

Sixty-eight trials (42,981 children) fulfilled the inclusion criteria. Iron supplementation did not increase the risk of clinical malaria (RR 1.00, 95% CI 0.88 to 1.13; 22,724 children, 14 trials, random-effects model). The risk was similar among children who were non-anaemic at baseline (RR 0.96, 95% CI 0.85 to 1.09). An increased risk of malaria with iron was observed in trials that did not provide malaria surveillance and treatment. The risk of malaria parasitaemia was higher with iron (RR 1.13, 95% CI 1.01 to 1.26), but there was no difference in adequately concealed trials. Iron + antimalarial was protective for malaria (four trials). Iron did not increase the risk of parasitological failure when given during malaria (three trials). There was no increased risk of death across all trials comparing iron versus placebo (RR 1.11, 95% CI 0.91 to 1.36; 21,272 children, 12 trials). Iron supplementation increased haemoglobin, with significant heterogeneity, and malaria endemicity did not affect this effect. Growth and other infections were mostly not affected by iron supplementation.

AUTHORS' CONCLUSIONS

Iron does not increase the risk of clinical malaria or death, when regular malaria surveillance and treatment services are provided. There is no need to screen for anaemia prior to iron supplementation.

Malawian mothers' attitudes towards the use of two supplementary foods for moderately malnourished children

The efficacy of lipid-based nutrient supplements (LNS) versus corn-soy blend (CSB) in promoting the growth of moderately malnourished children is currently being tested, but information about maternal attitudes towards the two supplements is lacking. This research studied 504 Malawian mothers' attitudes about LNS and CSB through exit interviews completed at the end of three 12-week clinical trials and compared differences between the groups. Exploratory analyses of factors associated with withholding of supplements during fever, diarrhea, and cough were performed using logistic regression. Mothers generally had similar, positive attitudes towards LNS and CSB. Both supplements were said to be highly acceptable, children learned to eat them within two weeks, and mothers were willing to use them again. Mothers in the LNS group were reportedly more likely to withhold supplements from their children during cough, due to its sweetness, and were willing to pay more for a one-week supply of supplement than mothers in the CSB group. Maternal literacy was negatively and child's weight-for-height z-score was positively associated with withholding of supplements during illness. Our results indicate that the sweetness in LNS should be reduced, and programs using supplements in Malawi could include advice on appropriate feeding of supplements during illness.

Effects of nutrient fortified complementary food supplements on anemia of infants and young children in poor rural of Gansu

OBJECTIVE

To assess the effectiveness of complementary food supplements with protein and multi-micronutrients on hemoglobin and anemia in infants and young children.

METHODS

In 5 poor counties of Gansu, 984 children aged 6-12 months were enrolled and divided into two groups. In addition to the usual home-made complementary food, all the children were fed one sachet of either Formula I or Formula II supplements each day. Protein and micronutrients were provided in Formula I, while the same energy intake was secured in Formula II as in Formula I. A massive dose of vitamin A was supplemented to all the children every 6 months. Hemoglobin test was done at the same time.

RESULTS

Prevalence of anemia was about 35% in both Formula I and Formula II group at baseline, and there were no differences in hemoglobin concentration between the two groups. During the 6-month and 12-month supplementation, hemoglobin of children in Formula I group was higher than that in Formula II group (P < 0.05), and hemoglobin increase in Formula I group was significantly higher than that in Formula II group (P < 0.001). After 6- and 12-month supplementation, the prevalence of anemia in Formula I group dropped to 19.1% and 8.2% respectively, and it was 28.0% and 12.4% in Formula 2 group. The prevalence of anemia in Formula I group was significantly lower than that in Formula II group (P < 0.05). After adjusting age and hemoglobin level at baseline, the hemoglobin increase at age of 24 months in formula 1 group was higher (10.7 g/L vs 7.9 g/L, P < 0.0001).

CONCLUSION

Micronutrient fortified complementary food supplements, with large-dose vitamin A, is effective for children aged 6-12 months in terms of iron deficiency prevention.

Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour

BACKGROUND

Therapeutic feeding with micronutrient-fortified lipid-based nutrient supplements (LNSs) has proven useful in the rehabilitation of severely malnourished children. We recently reported that complementary feeding of 6-18-mo-old infants with an LNS known as FS50 was associated with improved linear growth and a reduction in the incidence of severe stunting during the supplementation period.

OBJECTIVE

Our objective was to assess whether a reduction in stunting seen with 12-mo LNS supplementation was sustained over a subsequent 2-y nonintervention period.

DESIGN

One hundred eighty-two 6-mo-old healthy rural Malawian infants were randomly assigned to receive daily supplementation for 12 mo with 71 g of maize-soy flour [likuni phala (LP); control group, 282 kcal] or either 50 g of FS50 (264 kcal; main intervention group), or 25 g of FS25 (130 kcal). Main outcome measures were incidence of severe stunting and mean z score changes in weight-for-age, length-for-age, and weight-for-length during a 36-mo follow-up period.

RESULTS

The cumulative 36-mo incidence of severe stunting was 19.6% in LP, 3.6% in FS50, and 10.3% in FS25 groups (P = 0.03). Mean weight-for-age changes were -1.09, -0.76, and -1.22 (P = 0.04); mean length-for-age changes were -0.47, -0.37, and -0.71 (P = 0.10); and mean weight-for-length changes were -1.52, -1.18, and -1.48 (P = 0.27). All differences were more marked among individuals with baseline length-for-age below the median. Differences in length developed during the intervention at age 10-18 mo, whereas weight differences continued to increase after the intervention.

CONCLUSIONS

Twelve-month-long complementary feeding with 50 g/d FS50 is likely to have a positive and sustained impact on the incidence of severe stunting in rural Malawi. Half-dose intervention may not have the same effect. This trial was registered at (clinicaltrials.gov) as NCT00131209.

Research needed to strengthen science and programs for the control of iron deficiency and its consequences in young children

The purpose of this article is to highlight critical research needs for the effective prevention and control of iron deficiency and its consequences in children living in low-income countries. Four types of research are highlighted: The first involves scaling up interventions that we know are effective, namely iron supplementation of pregnant women, delayed cord clamping at delivery, immediate and exclusive breast-feeding, and continued exclusive breast-feeding for approximately 6 mo. The second entails evaluation research of alternative interventions that are likely to work, to find the most cost-effective strategies for a given social, economic, and epidemiological context. This research is especially needed to expand the implementation of appropriate complementary feeding interventions. In this area, research needs to be designed to provide causal evidence, to measure cost-effectiveness, and to measure potential effect modifiers. The third is efficacy research to discover promising practices where we lack proven interventions. Examples include how to detect infants younger than 6 mo who are at high risk of iron deficiency, efficacious and safe interventions for those young high-risk infants, and best protocols for the treatment of severe anemia. The fourth includes basic research to elucidate physiological processes and mechanisms underlying the risks and benefits of supplemental iron for children exposed to infectious diseases, especially malaria. Strategic research in all 4 areas will ensure that interventions to control pediatric iron deficiency are integrated into national programs and global initiatives to make pregnancy safer, reduce newborn deaths, and promote child development, health, and survival.

Iron deficiency in young children in low-income countries and new approaches for its prevention

Anemia resulting from severe iron deficiency (ID) is the most prevalent and widespread nutrition-related health problem in infants and young children in low-income countries and has proven very resistant to prevention through public health interventions. Accumulative evidence from animal and human studies suggests that such deficiencies are associated with large adverse effects on child cognitive and motor development. Therefore, effective interventions to improve iron status will have large health benefits. Action to reduce young child ID would benefit from overarching policy and programmatic guidance that informs decision makers about what to do, when to do it, and how to do it. The impetus for new approaches to prevent ID in young children reflects growing recognition of the need to intervene early and often and for better vehicles to deliver iron. Prevention of ID requires strong delivery systems that enhance consumer demand and promote compliance. When this occurs, the prevalence of anemia is greatly reduced.

Oral zinc for treating diarrhoea in children

BACKGROUND

Diarrhoea causes around two million child deaths annually. Zinc supplementation could help reduce the duration and severity of diarrhoea, and is recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH STRATEGY

In November 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation (>/= 5 mg/day for any duration) with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and methodological quality, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.

MAIN RESULTS

Eighteen trials enrolling 6165 participants met our inclusion criteria. In acute diarrhoea, zinc resulted in a shorter diarrhoea duration (MD -12.27 h, 95% CI -23.02 to -1.52 h; 2741 children, 9 trials), and less diarrhoea at day three (RR 0.69, 95% CI 0.59 to 0.81; 1073 children, 2 trials), day five (RR 0.55, 95% CI 0.32 to 0.95; 346 children, 2 trials), and day seven (RR 0.71, 95% CI 0.52 to 0.98; 4087 children, 7 trials). The four trials (1458 children) that reported on diarrhoea severity used different units and time points, and the effect of zinc was less clear. Subgroup analyses by age (trials with only children aged less than six months) showed no benefit with zinc. Subgroup analyses by nutritional status, geographical region, background zinc deficiency, zinc type, and study setting did not affect the results' significance. Zinc also reduced the duration of persistent diarrhoea (MD -15.84 h, 95% CI -25.43 to -6.24 h; 529 children, 5 trials). Few trials reported on severity, and results were inconsistent. No trial reported serious adverse events, but vomiting was more common in zinc-treated children with acute diarrhoea (RR 1.71, 95% 1.27 to 2.30; 4727 children, 8 trials).

AUTHORS' CONCLUSIONS

In areas where diarrhoea is an important cause of child mortality, research evidence shows zinc is clearly of benefit in children aged six months or more.