The challenge of meeting nutrient needs of infants and young children during the period of complementary feeding: an evolutionary perspective

Complementary Feeding Diets Made of Local Foods Can Be Optimized, but Additional Interventions Will Be Needed to Meet Iron and Zinc Requirements in 6- to 23-Month-Old Children in Low- and Middle-Income Countries

Background:

The question whether diets composed of local foods can meet recommended nutrient intakes in children aged 6 to 23 months living in low- and middle-income countries is contested.

Objective:

To review evidence of studies evaluating whether (1) macro- and micronutrient requirements of children aged 6 to 23 months from low- and middle-income countries are met by the consumption of locally available foods (“observed intake”) and (2) nutrient requirements can be met when the use of local foods is optimized, using modeling techniques (“modeled intake”).

Methods:

Twenty-three articles were included after conducting a systematic literature search. To allow for comparisons between studies, findings of 15 observed intake studies were compared against their contribution to a standardized recommended nutrient intake from complementary foods. For studies with data on intake distribution, %< estimated average requirements were calculated.

Results:

Data from the observed intake studies indicate that children aged 6 to 23 months meet requirements of protein, while diets are inadequate in calcium, iron, and zinc. Also for energy, vitamin A, thiamin, riboflavin, niacin, folate, and vitamin C, children did not always fulfill their requirements. Very few studies reported on vitamin B6, B12, and magnesium, and no conclusions can be drawn for these nutrients. When diets are optimized using modeling techniques, most of these nutrient requirements can be met, with the exception of iron and zinc and in some settings calcium, folate, and B vitamins.

Conclusion:

Our findings suggest that optimizing the use of local foods in diets of children aged 6 to 23 months can improve nutrient intakes; however, additional cost-effective strategies are needed to ensure adequate intakes of iron and zinc.

The Role of Avocados in Complementary and Transitional Feeding

Infant dietary patterns tend to be insufficient sources of fruits, vegetables, and fiber, as well as excessive in salt, added sugars, and overall energy. Despite the serious long-term health risks associated with suboptimal fruit and vegetable intake, a large percentage of infants and toddlers in the U.S. do not consume any fruits or vegetables on a daily basis. Since not all fruits and vegetables are nutritionally similar, guidance on the optimal selection of fruits and vegetables should emphasize those with the greatest potential for nutrition and health benefits. A challenge is that the most popularly consumed fruits for this age group (i.e., apples, pears, bananas, grapes, strawberries) do not closely fit the current general recommendations since they tend to be overly sweet and/or high in sugar. Unsaturated oil-containing fruits such as avocados are nutritionally unique among fruits in that they are lower in sugar and higher in fiber and monounsaturated fatty acids than most other fruits, and they also have the proper consistency and texture for first foods with a neutral flavor spectrum. Taken together, avocados show promise for helping to meet the dietary needs of infants and toddlers, and should be considered for inclusion in future dietary recommendations for complementary and transitional feeding.

Mineral- and vitamin-enhanced micronutrient powder reduces stunting in full-term low-birth-weight infants receiving nutrition, health, and hygiene education: a 2 × 2 factorial, cluster-randomized trial in Bangladesh

BACKGROUND

The causes of stunting are complex but likely include prenatal effects, inadequate postnatal nutrient intake, and recurrent infections. Low-birth-weight (LBW) infants are at high risk of stunting. More than 25% of live births in low- and middle-income countries are at full term with low birth weight (FT-LBW). Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant.

OBJECTIVE

We investigated the independent and combined effects of a directed use of a water-based hand sanitizer (HS) and a mineral- and vitamin-enhanced micronutrient powder (MNP) (22 minerals and vitamins) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants.

DESIGN

The study was a prospective 2 × 2 factorial, cluster-randomized trial in 467 FT-LBW infants during 2 periods: from 0 to 5 mo postpartum (0-180 d postpartum) and from 6 to 12 mo postpartum (181-360 d postpartum) with the use of 48 clusters. All groups received the same general nutrition, health, and hygiene education (NHHE) at enrollment and throughout the 12 mo. Group assignments initially included the following 2 groups: no HS (control) group or HS from 0 to 5 mo postpartum. These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum: 1) no HS and no MNP (control), 2) HS only, 3) MNP only, and 4) HS and MNP.

RESULTS

When delivered in combination with NHHE, the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum. FT-LBW infants who received the MNP (with or without the HS) were significantly less likely to be stunted at 12 mo than were controls (OR: 0.35; 95% CI: 0.15, 0.84; P = 0.017).

CONCLUSIONS

The use of a mineral- and vitamin-enhanced MNP significantly reduced stunting in FT-LBW infants in this high-risk setting. The use of a water-based HS did not have an additive effect. This trial was registered at clinicaltrials.gov as NCT01455636.

Cost-Effectiveness of Price Subsidies on Fortified Packaged Infant Cereals in Reducing Iron Deficiency Anemia in 6-23-Month-Old-Children in Urban India

INTRODUCTION

Iron deficiency anaemia (IDA) is a major public health problem in India and especially harmful in early childhood due to its impact on cognitive development and increased all-cause mortality. We estimate the cost-effectiveness of price subsidies on fortified packaged infant cereals (F-PICs) in reducing IDA in 6-23-monthold children in urban India.

MATERIALS AND METHODS

Cost-effectiveness is estimated by comparing the net social cost of price subsidies with the disability-adjusted life-years (DALYs) averted with price subsidies. The net social costs correspond to the cost of the subsidy minus the monetary costs saved by reducing IDA. The estimation proceeds in three steps: 1) the current lifetime costs of IDA are assessed with a health economic model combining the prevalence of anemia, derived from a large population survey, with information on the health consequences of IDA and their costs in terms of mortality, morbidity, and DALYs. 2) The effects of price subsidies on the demand for F-PICs are assessed with a market survey among 4801 households in 12 large Indian cities. 3) The cost-effectiveness is calculated by combining the findings of the first two steps with the results of a systematic review on the effectiveness of F-PICs in reducing IDA. We compare the cost-effectiveness of interventions that differ in the level of the subsidy and in the socio-economic strata (SES) eligible for the subsidy.

RESULTS

The lifetime social costs of IDA in 6-23-month-old children in large Indian cities amount to production losses of 3222 USD and to 726,000 DALYs. Poor households incur the highest costs, yet even wealthier households suffer substantial losses. The market survey reveals that few households currently buy F-PICs, with the share ranging from 14% to 36%. Wealthier households are generally more likely to buy FPICs. The costs of the subsidies per DALY averted range from 909 to 3649 USD. Interventions targeted at poorer households are most effective. Almost all interventions are cost saving from a societal perspective when taking into account the reduction of future production losses. Return per DALY averted ranges between gains of 1655 USD to a cost of 411 USD.

CONCLUSION

Price subsidies on F-PICs are a cost-effective way to reduce the social costs of IDA in 6-23-month-old children in large Indian cities. Interventions targeting poorer households are especially cost-effective.

Infant and young child feeding practices among children under 2 years of age and maternal exposure to infant and young child feeding messages and promotions in Dar es Salaam, Tanzania

There are limited data describing infant and young child feeding practices (IYCF) in urban Tanzania. This study assessed the types of foods consumed by children under 2 years of age and maternal exposure to promotions of these foods in Dar es Salaam, Tanzania. A cross-sectional survey was conducted among 305 mothers of children less than 24 months of age who attended child health services in October and November, 2014. Among infants less than 6 months of age, rates of exclusive breastfeeding were low (40.8%) and a high proportion (38.2%) received semi-solid foods. Continued breastfeeding among 20-23-month-olds was only 33.3%. Consumption of breastmilk substitutes was not prevalent, and only 3.9% of infants less than 6 months of age and 4.8% of 6-23 month-olds were fed formula. Among 6-23-month-olds, only 38.4% consumed a minimum acceptable diet (using a modified definition). The homemade complementary foods consumed by the majority of 6-23-month-olds (85.2%) were cereal-dominated and infrequently contained micronutrient-rich ingredients. Only 3.1% of 6-23-month-olds consumed commercially produced infant cereal on the day preceding the interview. In contrast, commercially produced snack foods were consumed by 23.1% of 6-23-month-olds. Maternal exposure to commercial promotions of breastmilk substitutes and commercially produced complementary foods was low (10.5% and 1.0%, respectively), while exposure to promotions of commercially produced snack foods was high (45.9%). Strategies are needed to improve IYCF practices, particularly with regard to exclusive and continued breastfeeding, increased dietary diversity and consumption of micronutrient-rich foods, and avoidance of feeding commercially produced snack foods.

Gut bacteria that prevent growth impairments transmitted by microbiota from malnourished children

Undernourished children exhibit impaired development of their gut microbiota. Transplanting microbiota from 6- and 18-month-old healthy or undernourished Malawian donors into young germ-free mice that were fed a Malawian diet revealed that immature microbiota from undernourished infants and children transmit impaired growth phenotypes. The representation of several age-discriminatory taxa in recipient animals correlated with lean body mass gain; liver, muscle, and brain metabolism; and bone morphology. Mice were cohoused shortly after receiving microbiota from healthy or severely stunted and underweight infants; age- and growth-discriminatory taxa from the microbiota of the former were able to invade that of the latter, which prevented growth impairments in recipient animals. Adding two invasive species, Ruminococcus gnavus and Clostridium symbiosum, to the microbiota from undernourished donors also ameliorated growth and metabolic abnormalities in recipient animals. These results provide evidence that microbiota immaturity is causally related to undernutrition and reveal potential therapeutic targets and agents.

Proposal of indicators to evaluate complementary feeding based on World Health Organization indicators

This study compares complementary feeding World Health Organization (WHO) indicators with those built in accordance with Brazilian recommendations (Ten Steps to Healthy Feeding). A cross-sectional study was carried out during the National Immunization Campaign against Poliomyelitis in Guarapuava-Paraná, Brazil, in 2012. Feeding data from 1,355 children aged 6-23 months were obtained through the 24 h diet recall. Based on five indicators, the proportion of adequacy was evaluated: introduction of solid, semi-solid, or soft foods; minimum dietary diversity; meal frequency; acceptable diet; and consumption of iron-rich foods. Complementary feeding showed adequacy higher than 85% in most WHO indicators, while review by the Ten Steps assessment method showed a less favorable circumstance and a high intake of unhealthy foods. WHO indicators may not reflect the complementary feeding conditions of children in countries with low malnutrition rates and an increased prevalence of overweight/obesity. The use of indicators according to the Ten Steps can be useful to identify problems and redirect actions aimed at promoting complementary feeding.

The prevalence of anemia and iron deficiency is more common in breastfed infants than their mothers in Bhaktapur, Nepal

Background/Objectives:

Iron deficiency anemia is a widespread public health problem, particularly in low- and middle-income countries. Maternal iron status around and during pregnancy may influence infant iron status. We examined multiple biomarkers to determine the prevalence of iron deficiency and anemia among breastfed infants and explored its relationship with maternal and infant characteristics in Bhaktapur, Nepal.

Subjects/Methods:

In a cross-sectional survey, we randomly selected 500 mother–infant pairs from Bhaktapur municipality. Blood was analyzed for hemoglobin, ferritin, total iron-binding capacity, transferrin receptors and C-reactive protein.

Results:

The altitude-adjusted prevalence of anemia was 49% among infants 2–6-month-old (hemaglobin (Hb) <10.8 g/dl) and 72% among infants 7–12-month-old (Hb <11.3 g/dl). Iron deficiency anemia, defined as anemia and serum ferritin <20 or <12 μg/l, affected 9 and 26% of infants of these same age groups. Twenty percent of mothers had anemia (Hb <12.3 g/dl), but only one-fifth was explained by depletion of iron stores. Significant predictors of infant iron status and anemia were infant age, sex and duration of exclusive breastfeeding and maternal ferritin concentrations.

Conclusions:

Our findings suggest that iron supplementation in pregnancy is likely to have resulted in a low prevalence of postpartum anemia. The higher prevalence of anemia and iron deficiency among breastfed infants compared with their mothers suggests calls for intervention targeting newborns and infants.

Effect of fortified complementary food supplementation on child growth in rural Bangladesh: a cluster-randomized trial

BACKGROUND

Growth faltering in the first 2 years of life is high in South Asia where prevalence of stunting is estimated at 40-50%. Although nutrition counselling has shown modest benefits, few intervention trials of food supplementation exist showing improvements in growth and prevention of stunting.

METHODS

A cluster-randomized controlled trial was conducted in rural Bangladesh to test the effect of two local, ready-to-use foods (chickpea and rice-lentil based) and a fortified blended food (wheat-soy-blend++, WSB++) compared with Plumpy'doz, all with nutrition counselling vs nutrition counselling alone (control) on outcomes of linear growth (length and length-for-age z-score, LAZ), stunting (LAZ < -2), weight-for-length z-score (WLZ) and wasting (WLZ < -2) in children 6-18 months of age. Children (n = 5536) were enrolled at 6 months of age and, in the food groups, provided with one of the allocated supplements daily for a year.

RESULTS

Growth deceleration occurred from 6 to 18 months of age but deceleration in LAZ was lower (by 0.02-0.04/month) in the Plumpy'doz (P = 0.02), rice-lentil (< 0.01), and chickpea (< 0.01) groups relative to control, whereas WLZ decline was lower only in Plumpy'doz and chickpea groups. WSB++ did not impact on these outcomes. The prevalence of stunting was 44% at 18 months in the control group, but lower by 5-6% (P ≤ 0.01) in those receiving Plumpy'doz and chickpea. Mean length and LAZ at 18 months were higher by 0.27-0.30 cm and 0.07-0.10 (all P < 0.05), respectively, in all four food groups relative to the control.

CONCLUSIONS

In rural Bangladesh, small amounts of daily fortified complementary foods, provided for a year in addition to nutrition counselling, modestly increased linear growth and reduced stunting at 18 months of age.

Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries

In 2011, one in every four (26%) children under 5 years of age worldwide was stunted. The realization that most stunting cannot be explained by poor diet or by diarrhoea, nor completely reversed by optimized diet and reduced diarrhoea has led to the hypothesis that a primary underlying cause of stunting is subclinical gut disease. Essentially, ingested microbes set in motion two overlapping and interacting pathways that result in linear growth impairment. Firstly, partial villous atrophy results in a reduced absorptive surface area and loss of digestive enzymes. This in turn results in maldigestion and malabsorption of much needed nutrients. Secondly, microbes and their products make the gut leaky, allowing luminal contents to translocate into systemic circulation. This creates a condition of chronic immune activation, which (i) diverts nutrient resources towards the metabolically expensive business of infection fighting rather than growth; (ii) suppresses the growth hormone‐IGF axis and inhibits bone growth, leading to growth impairment; and (iii) causes further damage to the intestinal mucosa thereby exacerbating the problem. As such, the unhygienic environments in which infants and young children live and grow must contribute to, if not be the overriding cause of, this environmental enteric dysfunction. We suggest that a package of baby‐WASH interventions (sanitation and water improvement, handwashing with soap, ensuring a clean play and infant feeding environment and food hygiene) that interrupt specific pathways through which feco‐oral transmission occurs in the first two years of a child's life may be central to global stunting reduction efforts.

Informing a Behavior Change Communication Strategy: Formative Research Findings From the Scaling Up Nutrition Movement in Mozambique

BACKGROUND

Nutrition interventions targeting the first 1000 days show promise to improve nutritional status, but they require effective implementation. Formative research is thus invaluable for developing such interventions, but there have been few detailed studies that describe this phase of work within the Scaling Up Nutrition (SUN) movement.

OBJECTIVE

To inform a stunting prevention intervention in Cabo Delgado, Mozambique, by describing the sociocultural landscape and elucidating characteristics related to young child food, illness, and health.

METHODS

This formative research utilized a rapid assessment procedures (RAP) approach with 3 iterative phases that explored local perceptions and behaviors around food and illness among the Macua, Mwani, and Maconde ethnic groups. Ethnographic methods, including in-depth interviews, direct observations, free lists, and pile sorts, were used to collect data from community leaders, caregivers, and children 6 to 23 months. Data were analyzed drawing from grounded theory and cultural domain analysis.

RESULTS

Geographic differences drive sociocultural characteristics amid 3 ethnic groups that allow for segmentation of the population into 2 distinct audiences for behavior change communications. These 2 communities have similar classification systems for children's foods but different adult dietary patterns. Small-quantity lipid-based nutrient supplement did not fall into the existing food classification systems of either community, and participants preferred its promotion through community leader channels. Community members in both groups have little recognition of and perceived severity toward nutrition-related illnesses.

CONCLUSION

Within Cabo Delgado, the cultural heterogeneity yields substantial differences related to food, illness, and health that are necessary to consider for developing an effective nutrition intervention.

Composition of Follow-Up Formula for Young Children Aged 12-36 Months: Recommendations of an International Expert Group Coordinated by the Nutrition Association of Thailand and the Early Nutrition Academy

BACKGROUND

There are no internationally agreed recommendations on compositional requirements of follow-up formula for young children (FUF-YC) aged 1-3 years.

AIM

The aim of the study is to propose international compositional recommendations for FUF-YC.

METHODS

Compositional recommendations for FUF-YC were devised by expert consensus based on a detailed literature review of nutrient intakes and unmet needs in children aged 12-36 months.

RESULTS AND CONCLUSIONS

Problematic nutrients with often inadequate intakes are the vitamins A, D, B12, C and folate, calcium, iron, iodine and zinc. If used, FUF-YC should be fed along with an age-appropriate mixed diet, usually contributing 1-2 cups (200-400 ml) of FUF-YC daily (approximately 15% of total energy intake). Protein from cow's milk-based formula should provide 1.6-2.7 g/100 kcal. Fat content should be 4.4-6.0 g/100 kcal. Carbohydrate should contribute 9-14 g/100 kcal with >50% from lactose. If other sugars are added, they should not exceed 10% of total carbohydrates. Calcium should provide 200 mg/100 kcal. Other micronutrient contents/100 kcal should reach 15% of the World Health Organization/Food and Agriculture Organization recommended nutrient intake values. A guidance upper level that was 3-5 times of the minimum level was established. Countries may adapt compositional requirements, considering recommended nutrient intakes, habitual diets, nutritional status and existence of micronutrient programs to ensure adequacy while preventing excessive intakes.

Inclusion of Small Indigenous Fish Improves Nutritional Quality During the First 1000 Days

BACKGROUND

Within food-based approaches to improve nutrition during the first 1000 days of life, improved formulations of food products and the use of animal source foods, such as fish, are 2 widely cited strategies; however, there are few examples where the 2 strategies are combined. Furthermore, although small indigenous fish are highly nutritious and available to the poor in many regions of the world, their importance is often overlooked.

OBJECTIVE

To document the development of 2 nutritious fish-based food products in Bangladesh: a chutney for pregnant and lactating women (PLW) and a complementary food (CF) for infants and young children (6-23 months), including potential contributions to recommended or desirable nutrient intakes in the first 1000 days, processing methods, and nutrient composition.

METHODS

Local nutrient-rich ingredients and simple processing methods based on traditional knowledge (for the chutney), and a literature review (for the CF), were selected and trial batches produced. Products were analyzed for nutrient composition using standard analytical procedures and results compared with recommended or desirable nutrient intakes for women and children.

RESULTS

Both products could contribute significantly to micronutrient intakes of PLW (24% of iron and 35% of calcium recommended intakes) and macro- and micronutrient intake of infants and young children (≥ 65% of vitamin A, ≥ 61% of zinc, and 41% of iron desirable intakes) when consumed in the proposed serving size.

CONCLUSION

Inclusion of small indigenous fish as an underutilized animal source food in combination with other local nutrient-rich ingredients in food products represents a promising food-based strategy to improve nutrition, with many additional potential benefits for communities involved in production, and therefore warrants further investigation.

Provision of 10-40 g/d Lipid-Based Nutrient Supplements from 6 to 18 Months of Age Does Not Prevent Linear Growth Faltering in Malawi

BACKGROUND

Complementing infant diets with lipid-based nutrient supplements (LNSs) has been suggested to improve growth and reduce morbidity, but the daily quantity and the milk content of LNSs affect their cost.

OBJECTIVE

We tested the hypotheses that the change in mean length-for-age z score (LAZ) for infants provided with 10-40 g LNSs/d from ages 6 to 18 mo would be greater than that for infants receiving no dietary intervention at the same age and that provision of LNSs that did not contain milk would be as good as milk-containing LNSs in promoting linear growth.

METHODS

We enrolled in a randomized single-blind trial 6-mo-old infants who were allocated to 1 of 6 groups to receive 10, 20, or 40 g LNSs/d containing milk powder; 20 or 40 g milk-free LNSs/d; or no supplement until 18 mo of age. The primary outcome was change in LAZ.

RESULTS

Of the 1932 enrolled infants, 78 (4.0%) died and 319 (16.5%) dropped out during the trial. The overall reported supplement consumption was 71.6% of days, with no difference between the groups (P = 0.26). The overall mean ± SD length and LAZ changes were 13.0 ± 2.1 cm and -0.45 ± 0.77 z score units, respectively, which did not differ between the groups (P = 0.66 for length and P = 0.74 for LAZ). The difference in mean LAZ change in the no-milk LNS group compared with the milk LNS group was -0.02 (95% CI: -0.10, 0.06; P = 0.72).

CONCLUSION

Our results do not support the hypothesis that LNS supplementation during infancy and childhood promotes length gain or prevents stunting between 6 and 18 mo of age in Malawi. This trial was registered at clinicaltrials.gov as NCT00945698.

High protein intake from meat as complementary food increases growth but not adiposity in breastfed infants: a randomized trial

BACKGROUND

High intake of cow-milk protein in formula-fed infants is associated with higher weight gain and increased adiposity, which have led to recommendations to limit protein intake in later infancy. The impact of protein from meats for breastfed infants during complementary feeding may be different.

OBJECTIVE

We examined the effect of protein from meat as complementary foods on growth and metabolic profiles of breastfed infants.

DESIGN

This was a secondary analysis from a trial in which exclusively breastfed infants (5-6 mo old from the Denver, CO, metro area) were randomly assigned to receive commercially available pureed meats (Meat group; n = 14) or infant cereal (Cereal group; n = 28) as their primary complementary feedings for ∼ 5 mo. Anthropometric measures and diet records were collected monthly from 5 to 9 mo of age; intakes from complementary feeding and breast milk were assessed at 9 mo of age.

RESULTS

The Meat group had significantly higher protein intake, whereas energy, carbohydrate, and fat intakes from complementary feeding did not differ by group over time. At 9 mo of age, mean (± SEM) intakes of total (complementary feeding plus breast milk) protein were 2.9 ± 0.6 and 1.4 ± 0.4 g · kg(-1) · d(-1), ∼ 17% and ∼ 9% of daily energy intake, for Meat and Cereal groups, respectively (P < 0.001). From 5 to 9 mo of age, the weight-for-age z score (WAZ) and length-for-age z score (LAZ) increased in the Meat group (ΔWAZ: 0.24 ± 0.19; ΔLAZ: 0.14 ± 0.12) and decreased in the Cereal group (ΔWAZ: -0.07 ± 0.17; ΔLAZ: -0.27 ± 0.24) (P-group by time < 0.05). The change in weight-for-length z score did not differ between groups. Total protein intake at 9 mo of age and baseline WAZ were important predictors of changes in the WAZ (R(2) = 0.23, P = 0.01).

CONCLUSION

In breastfed infants, higher protein intake from meats was associated with greater linear growth and weight gain but without excessive gain in adiposity, suggesting that potential risks of high protein intake may differ between breastfed and formula-fed infants and by the source of protein.

Dietary diversity at 6 months of age is associated with subsequent growth and mediates the effect of maternal education on infant growth in urban Zambia

BACKGROUND

Although numerous cross-sectional studies have shown an association between WHO infant and young child feeding (IYCF) indicators and child anthropometric measures, limited longitudinal evidence exists linking these indicators with subsequent growth.

OBJECTIVES

The purpose of this study was to investigate whether meeting WHO IYCF indicators at 6 and 12 mo of age was associated with growth to 18 mo of age and if dietary diversity mediated the relation between household wealth, maternal education, and child growth.

METHODS

We used longitudinal data on 811 infants in the CIGNIS (Chilenje Infant Growth, Nutrition, Infection Study), a randomized controlled trial comparing the effect of micronutrient-fortified porridges on infant growth in Lusaka, Zambia. Twenty-four-h diet recalls were conducted at 6 and 12 mo of age, and length and weight measurements at ages 6 and 18 mo were used to produce height-for-age Z-scores (HAZs) and weight-for-height Z-scores (WHZs). Information on household assets was used to generate a household wealth index, and level of maternal education was collected.

RESULTS

In fully adjusted analyses, iron-rich food intake at 6 mo and greater household wealth and maternal education were positively associated with HAZ at 18 mo (all P ≤ 0.016). Iron-rich food intake at 6 and 12 mo, achieving a "minimum acceptable diet" at 12 mo, and higher maternal education were associated with greater WHZ at 18 mo (all P ≤ 0.044). Dietary diversity at 6 mo of age was positively associated with both HAZ and WHZ at 18 mo (both P ≤ 0.001) and mediated 13.4% and 25.9% of the total effect of maternal education on HAZ and WHZ, respectively, at 18 mo.

CONCLUSIONS

Our findings indicate that IYCF programs should be targeted toward the early period of complementary food introduction and that policies aimed at increasing formal maternal education may benefit child growth through improved feeding practices. This trial was registered at www.controlled-trials.com as ISRCTN37460449.

Preventing acute malnutrition among young children in crises: a prospective intervention study in Niger

BACKGROUND

Finding the most appropriate strategy for the prevention of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) in young children is essential in countries like Niger with annual "hunger gaps." Options for large-scale prevention include distribution of supplementary foods, such as fortified-blended foods or lipid-based nutrient supplements (LNSs) with or without household support (cash or food transfer). To date, there has been no direct controlled comparison between these strategies leading to debate concerning their effectiveness. We compared the effectiveness of seven preventive strategies-including distribution of nutritious supplementary foods, with or without additional household support (family food ration or cash transfer), and cash transfer only-on the incidence of SAM and MAM among children aged 6-23 months over a 5-month period, partly overlapping the hunger gap, in Maradi region, Niger. We hypothesized that distributions of supplementary foods would more effectively reduce the incidence of acute malnutrition than distributions of household support by cash transfer.

METHODS AND FINDINGS

We conducted a prospective intervention study in 48 rural villages located within 15 km of a health center supported by Forum Santé Niger (FORSANI)/Médecins Sans Frontières in Madarounfa. Seven groups of villages (five to 11 villages) were allocated to different strategies of monthly distributions targeting households including at least one child measuring 60 cm-80 cm (at any time during the study period whatever their nutritional status): three groups received high-quantity LNS (HQ-LNS) or medium-quantity LNS (MQ-LNS) or Super Cereal Plus (SC+) with cash (€38/month [US$52/month]); one group received SC+ and family food ration; two groups received HQ-LNS or SC+ only; one group received cash only (€43/month [US$59/month]). Children 60 cm-80 cm of participating households were assessed at each monthly distribution from August to December 2011. Primary endpoints were SAM (weight-for-length Z-score [WLZ]<-3 and/or mid-upper arm circumference [MUAC]<11.5 cm and/or bipedal edema) and MAM (-3≤WLZ<-2 and/or 11.5≤MUAC<12.5 cm). A total of 5,395 children were included in the analysis (615 to 1,054 per group). Incidence of MAM was twice lower in the strategies receiving a food supplement combined with cash compared with the cash-only strategy (cash versus HQ-LNS/cash adjusted hazard ratio [HR]=2.30, 95% CI 1.60-3.29; cash versus SC+/cash HR=2.42, 95% CI 1.39-4.21; cash versus MQ-LNS/cash HR=2.07, 95% CI 1.52-2.83) or with the supplementary food only groups (HQ-LNS versus HQ-LNS/cash HR=1.84, 95% CI 1.35-2.51; SC+ versus SC+/cash HR=2.53, 95% CI 1.47-4.35). In addition, the incidence of SAM was three times lower in the SC+/cash group compared with the SC+ only group (SC+ only versus SC+/cash HR=3.13, 95% CI 1.65-5.94). However, non-quantified differences between groups, may limit the interpretation of the impact of the strategies.

CONCLUSIONS

Preventive distributions combining a supplementary food and cash transfer had a better preventive effect on MAM and SAM than strategies relying on cash transfer or supplementary food alone. As a result, distribution of nutritious supplementary foods to young children in conjunction with household support should remain a pillar of emergency nutritional interventions. Additional rigorous research is vital to evaluate the effectiveness of these and other nutritional interventions in diverse settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01828814 Please see later in the article for the Editors' Summary.

Poor dietary diversity and low nutrient density of the complementary diet for 6- to 24-month-old children in urban and rural KwaZulu-Natal, South Africa

Infants and toddlers have high nutritional requirements relative to body size but consume small amounts of food and therefore need nutrient-dense complementary foods. A cross-sectional study included children aged 6-24 months, stratified in three age categories (6-11 months, 12-17 months and 18-24 months) and randomly selected from an urban (n = 158) and a rural (n = 158) area, both of low socio-economic status, in the KwaZulu-Natal Province of South Africa. Dietary diversity and nutrient density of the complementary diet (excluding breast milk and formula milk) based on a repeated 24-h dietary recall was assessed. For breastfeeding children, nutrient density of the complementary diet was adequate for protein, vitamin A and vitamin C; and inadequate for 100% of children for zinc, for >80% of children for calcium, iron and niacin; and between 60% and 80% of children for vitamin B6 and riboflavin. Urban/rural differences in density for animal and plant protein, cholesterol and fibre occurred in 18-24-month-old children. Fewer than 25% of children consumed ≥4 food groups, with no urban/rural differences. Higher dietary diversity was associated with higher nutrient density for protein and several of the micronutrients including calcium, iron and zinc. The poor nutrient density for key micronutrients can probably be ascribed to lack of dietary variety, and little impact of mandatory fortification of maize meal/wheat flour on infants/toddlers' diet. Targeted strategies are needed to enable mothers to feed their children a more varied diet.