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

The medium-term impact of a micronutrient powder intervention on anemia among young children in Rural China

BACKGROUND

Poor development of young children is a common issue in developing countries and it is well established that iron deficiency anemia is one of the risk factors. Research has shown that iron deficiency is a common micronutrient deficiency among children in rural China and can result in anemia. A previous paper using data from the same trial as those used in the current study, but conducted when sample children were younger, found that after 6 months of providing caregivers of children 6-11 months of age free access to iron-rich micronutrient powder (MNP) increased the hemoglobin concentrations (Hb) of their children. However, no effects were found 12 and 18 months after the intervention. The current study followed up the children four years after the start of the original intervention (when the children were 4-5 years old) and aims to assess the medium-term impacts of the MNP program on the nutritional status of the sample pre-school-aged children, including their levels of Hb, the prevalence of anemia, and the dietary diversity of the diets of the children.

METHODS

At baseline, this study sampled 1,802 children aged 6-11 months in rural Western China. The intervention lasted 18 months. In this medium-term follow-up study that successfully followed 81% (n = 1,464) of children (aged 49-65 months) from the original study population 4 years after the start of the intervention, we used both intention-to-treat (ITT) effect and average treatment on the treated effect (ATT) analyses to assess the medium-term impacts of the MNP distribution program on the nutritional status of sample children.

RESULTS

The ITT analysis shows that the MNP intervention decreased the prevalence of anemia of young children in the medium run by 8% (4 percentage points, p < 0.1). The ATT analysis shows that consuming 100 (out of 540) MNP sachets during the initial intervention led to a decrease in anemia of 4% (2 percentage points, p < 0.1). Among children with moderate anemia at baseline (Hb < 100 g/L), the intervention reduced the probability of anemia by 45% (9 percentage points, p < 0.1), and, for those families that complied by consuming 100 (out of 540) sachets, a 25% (5 percentage points, p < 0.05) reduction in the anemia rate was found. The MNP intervention also led to a persistent increase in dietary diversity among children that were moderately anemic at baseline. The results from the quantile treatment effect analysis demonstrated that children with lower Hb levels at baseline benefited relatively more from the MNP intervention.

CONCLUSIONS

The findings of the current study reveal that the MNP intervention has medium-term effects on the nutritional status of children in rural China. The impacts of the MNP program were relatively higher for children that initially had more severe anemia levels. Hence, the implications of this study are that programs that aim to increase caregiver knowledge of nutrition and improve their feeding practices should be encouraged across rural China. Families, policymakers, and China's society overall need to continue to pay more attention to problems of childhood anemia in rural areas. This is particularly crucial for families with moderately anemic children at an early age as it can significantly contribute to improving the anemia status of children across rural areas of China.

TRIAL REGISTRATION

ISRCTN44149146 (15/04/2013).

Comparative prebiotic potential of galacto- and fructo-oligosaccharides, native inulin, and acacia gum in Kenyan infant gut microbiota during iron supplementation

Iron fortification to prevent anemia in African infants increases colonic iron levels, favoring the growth of enteropathogens. The use of prebiotics may be an effective strategy to reduce these detrimental effects. Using the African infant PolyFermS gut model, we compared the effect of the prebiotics short-chain galacto- with long-chain fructo-oligosaccharides (scGOS/lcFOS) and native inulin, and the emerging prebiotic acacia gum, a branched-polysaccharide-protein complex consisting of arabinose and galactose, during iron supplementation on four Kenyan infant gut microbiota. Iron supplementation did not alter the microbiota but promoted Clostridioides difficile in one microbiota. The prebiotic effect of scGOS/lcFOS and inulin was confirmed during iron supplementation in all investigated Kenyan infant gut microbiota, leading to higher abundance of bifidobacteria, increased production of acetate, propionate, and butyrate, and a significant shift in microbiota composition compared to non-supplemented microbiota. The abundance of the pathogens Clostridium difficile and Clostridium perfringens was also inhibited upon addition of the prebiotic fibers. Acacia gum had no effect on any of the microbiota. In conclusion, scGOS/lcFOS and inulin, but not acacia gum, showed a donor-independent strong prebiotic potential in Kenyan infant gut microbiota. This study demonstrates the relevance of comparing fibers in vitro prior to clinical studies.

Vitamin E deficiency in childhood: a narrative review

Vitamin E is an important nutrient from the earliest stages of life. It plays key roles as an antioxidant and in the maintenance of the immune system, among others. Vitamin E deficiency (VED), which occurs more frequently in children, is rarely addressed in the literature. This narrative review aims to summarise the chemistry, biology, serum indicators and clinical trials that have evaluated the impact of fortification and other relevant aspects of vitamin E, in addition to the prevalence of its deficiency, in children worldwide. Vitamin E intake in recommended amounts is essential for this nutrient to perform its functions in the body. Serum α-tocopherol is the most widely used biochemical indicator to assess the prevalence of VED. VED has been associated with symptoms secondary to fat malabsorption and may lead to peripheral neuropathy and increased erythrocyte haemolysis. Reduced concentrations of α-tocopherol may be caused by the combination of diets with low amounts of vitamin E and inadequate consumption of fats, proteins and calories. The lowest prevalence of VED was found in Asia and the highest in North America and Brazil. High proportions of VED provide evidence that this nutritional deficiency is a public health problem in children and still little addressed in the international scientific literature. The planning, evaluation and implementation of health policies aimed at combatting VED in the paediatric population are extremely important.

The effect of interventions distributing home fortification products on infant and young child feeding (IYCF) practices: A systematic narrative review

Interventions distributing micronutrient powders (MNPs) and small-quantity lipid-based nutrient supplements (SQ-LNS), or home fortification products (HFPs), have the potential to improve infant and young child feeding (IYCF) practices and children's nutrition. We systematically searched for studies on the effect of interventions distributing HFP on IYCF practices. We identified 12 (8 MNP, 4 SQ-LNS) studies: seven programmes with IYCF behaviour change communications (BCC) and MNP (IYCF-MNP) and one provided MNP without IYCF BCC (MNP only). Three SQ-LNS studies came from randomised trials without an IYCF component (SQ-LNS only) and one from a programme with both IYCF BCC and SfQ-LNS (IYCF-SQ-LNS). Five IYCF-MNP programmes reported positive associations with some IYCF practices-four with minimum dietary diversity, two with minimum meal frequency, four with minimum acceptable diet, and three with the initiation of complementary foods at 6 months. Two reported no association between MNP and IYCF indicators, and one reported a decline in IYCF practices during the intervention, although it also reported significant changes to the IYCF programme during the evaluation period. Two studies from interventions that distributed SQ-LNS (one from a related set of randomised controlled trials and the sole IYCF-SQ-LNS programme) reported a positive association with IYCF practices; one trial reported no change in breast milk intake with the provision of SQ-LNS and one found no association with IYCF practices. SQ-LNS and MNP can address nutrient gaps for young children in low-resource settings; our findings indicate that programmes that combine HFP with IYCF interventions may also contribute to improved IYCF practices in some settings.

Anemia among Syrian Refugee Children Aged 6 to 23 Months Living in Greater Beirut, Lebanon, including the Voices of Mothers' and Local Healthcare Staff: A Mixed-Methods Study

Globally, the prevalence of anemia among children during the period of complementary feeding is high. A cross-sectional, mixed-methods study was conducted to examine the main determinants of anemia among Syrian refugee children aged 6 to 23 months (n = 215) and to illuminate the knowledge, attitudes and perceptions of their mothers and Lebanese healthcare staff on its causes and available treatment options. 42% of the children and 20% of their mothers were anemic. Determinants of child anemia were the mother having anemia or not knowing that fish/seafood is a source of iron; the child having been acutely ill the last two weeks or receiving cow's milk, but not consuming iron-rich infant formula, added fats/oils, or fruits in the previous 24 hours. Several Syrian mothers knew some causes of anemia and named dizziness as a leading symptom but did not mention flesh foods as a key source of heme iron. They reported financial constraints in accessing iron-rich foods and supplements. Lebanese doctors largely gave appropriate dietary advice and prescribed iron supplements as treatment. Multisectoral interventions are needed that combine medical and financial support with nutrition counseling for mothers to reduce the high burden of anemia among young children living in a multiple crises situation.

Adherence to micronutrient powder for home fortification of foods among infants and toddlers in rural China: a structural equation modeling approach

Background

The WHO recommends daily use of micronutrient powder for infants and toddlers at risk of micronutrient deficiencies in low-and-middle-income countries. China has established a micronutrient powder distribution program in many rural townships and villages, yet adherence to micronutrient powder remains suboptimal; a little is known about the behavioral inputs that may influence adherence. This study examines direct and indirect behavioral inputs in micronutrient powder adherence among caregivers in rural western China following the Integrated Behavioral Model (IBM) framework.

Methods

Cross-sectional data were collected from April to May 2019 among 958 caregivers of children aged 6 to 24 months in six counties. Data were collected on micronutrient powder adherence behavior, direct behavioral inputs (knowledge and skills, intention, salience, environmental constraints, and habits), and indirect behavioral inputs (attitudes, perceived social norms, and personal agency). Structural equation modeling (SEM) adjusted for sociodemographic covariates was used to evaluate the IBM framework.

Results

Mean micronutrient powder adherence in the previous seven days was 53.02%, and only 22.86% of caregivers consistently fed micronutrient powder from the start of micronutrient powder distribution at six months of age. The SEM model revealed small- to medium-sized effects of salience (β = 0.440, P < 0.001), intention (β = 0.374, P < 0.001), knowledge and skills (β = 0.214, P < 0.001), personal agency (st. effect = 0.172, P < 0.001), environmental constraints (β=-0.142, P < 0.001), and caregiver generation (β = 0.119, P < 0.05) on micronutrient powder adherence. Overall, 54.7% of the variance in micronutrient powder adherence was explained by the IBM framework. Salience had the largest impact on micronutrient powder adherence (Cohen’s f2 = 0.227). Compared to parent caregivers, grandparents had a higher degree of micronutrient powder adherence on average (P < 0.001), and behavioral inputs were consistent among both parent and grandparent caregivers.

Conclusion

There is a need to improve micronutrient powder adherence among rural caregivers. The IBM framework showed a high degree of explanatory power in predicting micronutrient powder adherence behavior. The findings suggest that increased reminders from doctors regarding micronutrient powder and coaching to improve personal agency in micronutrient powder feeding may increase adherence.

The association between micronutrient powder delivery patterns and caregiver feeding behaviors in rural China

Background

High adherence and proper usage of micronutrient powder (MNP) influence child nutritional outcomes, yet few studies explore the role of delivery patterns. This study explores the association between MNP delivery patterns and MNP feeding behaviors among Han and minority caregivers in rural Western China.

Methods

In August 2019, a total of 1021 caregiver-child pairs were selected through a four-stage cluster sampling process. A cross-sectional survey collected information on caregiver demographics, MNP delivery patterns (channel and frequency), and MNP feeding behaviors (proper usage and adherence). Using logistic regression, we examined which delivery channels and delivery frequencies were associated with proper usage and high adherence.

Results

The results indicated that minority caregivers had lower levels of proper MNP usage than did Han caregivers (89.2%), with Tibetan caregivers’ reporting the lowest rates of adherence (32.6%). Logistic regression revealed that that township-based channel was significantly correlated with proper usage among Tibetan and Yi caregivers (Odds Ratio, OR = 2.0, p < 0.01; and OR = 3.5, p < 0.001). Overall, the township-based and home-visit channels were significantly correlated with high adherence (OR = 1.7 and OR = 2.3, respectively; p < 0.001); delivery frequency was significantly correlated with high adherence (2 months: OR = 2.2, p < 0.001 and ≤ 1 month: OR = 3.5, p < 0.001) but not correlated with proper usage among the whole sample and individual ethnic groups.

Conclusions

In conclusion, the study finds evidence of a correlation between MNP delivery channel and both proper usage and high adherence as well as a correlation between MNP delivery frequency and high adherence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13726-4.

Serum Ferritin Threshold for Iron Deficiency Screening in One-Year-Old Children

The American Academy of Pediatrics recommends universal hemoglobin screening for iron deficiency anemia using hemoglobin <110 g/L at the 1-year-old well child visit. Our retrospective study suggests the need for combined hemoglobin and serum ferritin iron deficiency screening and raising the diagnostic serum ferritin threshold to 24-25 μg/L.

High adherence and its influencing factors on multiple micronutrient powders (MNPs)

Adherence to home fortification of foods with multiple micronutrient powders (MNPs) is an essential indicator of effective implementation of MNP programmes. A meta‐analysis was conducted to evaluate the high adherence rate (HAR) to MNPs and further investigate the factors that influence HAR. We searched PubMed, Web of Science, Embase, CAB Abstracts, MEDLINE (OVID), Cochrane Library, China National Knowledge Infrastructure, Wanfang and VP, from the date of database inception to 9 November 2020. We included peer‐reviewed observational studies that investigated adherence to MNPs. Data on the HAR to MNPs and influencing factors on HAR were extracted and then pooled together. A total of 10 studies were included. The pooled HAR to MNPs was 63.28% (51.12%–74.64%). Among HARs, rates were higher in middle‐income countries (65.21%) than low‐income countries (55.23%). Parental age over 30 years (maternal age OR = 1.25, 95% CI: 1.08–1.44; paternal age OR = 1.17, 95% CI: 1.04–1.32), children aged 18–36 months (OR = 1.45, 95% CI: 1.12–1.88), maternal educational attainment of college or above (OR = 1.38, 95% CI:1.10–1.73), caregiver with the perception that other mothers use MNPs (OR = 1.52, 95% CI:1.19–1.95), caregiver being aware of the importance of iron (OR = 1.42, 95% CI: 1.18–1.71), caregiver having correct knowledge of MNPs (OR = 1.36, 95% CI:1.19–1.57) and caregiver reporting children have no side effects from MNPs (OR = 2.77, 95% CI: 2.46–3.11) were contributing factors to high adherence to MNPs. The overall HAR to MNPs was relatively low; hence, effective and trusted communication channels need to be established, along with more thorough dissemination of the knowledge of MNPs to caregivers, to improve MNPs adherence rates, especially in low‐income countries.

Geographical variation and temporal trend in anemia among children aged 6-59 months in low- and middle-income countries during 2000-2018: forecasting the 2030 SDG target

OBJECTIVE

To examine geographical variations, trends and projections in the prevalence of childhood anemia at national and subpopulation levels.

DESIGN

Repeated cross-sectional Demographic and Health Survey (DHS) conducted during 2000-2018.

SETTING

Fifty-three low- and middle-income countries (LMIC).

PARTICIPANTS

Totally, 776 689 children aged 6-59 months.

RESULTS

During the latest DHS rounds between 2005 and 2018, the prevalence of child anemia was > 20 % in fifty-two out of fifty-three countries and ranged from 15·9 % in Armenia in 2016 to 87·8 % in Burkina Faso in 2010. Out of thirty-six countries with at least two surveys during 2000-2018, the prevalence of child anemia decreased in twenty-two countries, highest in Zimbabwe (-4·2 %) and increased in fourteen countries, highest in Burundi (5·0 %). Based on the trend, eleven and twenty-two out of thirty-six countries are projected to experience, respectively, moderate and severe public health problem according to the WHO criteria (moderate problem: 20-39·9 % and severe problem: ≥ 40 %) due to child anemia in 2030, with the highest prevalence in Liberia (87·5 %, 95 % credible interval 52·0-98·8 %). The prevalence of child anemia varied across the mother's education and age, child sex, wealth quintiles, and place of residence, with the highest rate of child anemia among the poorest, rural and low-educated mothers. These scenarios are projected to continue. The probability of reducing child anemia at < 0·5 % by 2030 is 0 % for all study countries.

CONCLUSIONS

The prevalence of child anemia varied between and within countries. None of the thirty-six LMIC is likely to eradicate child anemia by 2030.

Exploring behavioural factors affecting nutritional supplement use among children in Honduras

OBJECTIVE

This study explored social and behavioural factors associated with a home fortification of complementary foods program among families of undernourished children in 14 rural communities in Honduras.

DESIGN

We collected and analysed survey data from a convenience sample of 196 households participating in a nutritional program using home fortification of complementary foods in 2017. The program supplied families with a soy-based atole powder fortified with micronutrients. A research team completed a face-to-face survey exploring social and behavioural factors associated with nutritional supplement use. Anthropometric measurements for participating children were abstracted from health clinic records of previous quarterly appointments.

SETTING

The study took place in San Jose del Negrito, Honduras.

PARTICIPANTS

Participants were parents or guardians of children enrolled in the nutrition program.

RESULTS

Nearly half of participant families shared the nutritional supplement with other family members besides the index child, while 10 % reported using the supplement as a meal replacement for the child. Low education level of mothers was associated with improper use of the supplement (P = 0·005). Poorer families were more likely to share the supplement (P = 0·013).

CONCLUSIONS

These results highlight the challenges of programs using home fortification of complementary foods in the context of food scarcity. Findings highlight the importance of increasing rural children's overall caloric intake, perhaps by increasing access to locally available protein sources. Results also suggest transitioning nutritional programs to family-based interventions to increase overall intended compliance to nutrition programming.

Experience of using home-based fortified diet in rehabilitation of malnourished children at Indus Hospital, Karachi, Pakistan: an institution based retrospective chart review study

Background

Globally, it is estimated that 50 million children under five are wasted. National nutrition survey-2018 has shown that 23.3 and 45.5% of children are wasted and stunted in Pakistan. Many studies have shown that hospital-based management of malnutrition is not practical due to high cost and iatrogenic infections and currently WHO recommends community-based management of malnutrition with provision of therapeutic food. There is limited evidence of community rehabilitation of malnourished children by using home fortified diet in Pakistan. This study explores use of energy dense, home fortified diet in achieving weight gain of malnourished children in Karachi.

Methods

A descriptive, retrospective chart review of pediatric patients (aged 6 month–5 years) seen in Indus Hospital between January 2017 to June 2018 was conducted. A pre-designed data abstraction form was used to record detailed information about demographic characteristics, feeding, anthropometric, micronutrient, and nutritional details at enrollment and on follow-up.

Results

A total of 361 patients were included in the final analysis. The median age (IQR) of children was 15 (14) months. Forty eight percent (n = 172) children had diarrhea and 54% (n = 195) children had respiratory tract infection. The median length of stay in the program was 28 days. The median (IQR) for average weight gain was 4.8 (0–10.3) g/Kg/day, 64.6% (n = 226) children defaulted, 29% (n = 102) were cured and 3% (n = 10) died.

Conclusion

This study showed adequate weight gain and recovery in malnourished children by using home fortified diet in real life situations without using therapeutic food or monetary support. Home fortified diets may serve as effective strategy in community-based rehabilitation of malnourished children.

Thiamine fortification strategies in low- and middle-income settings: a review

Thiamine (vitamin B1 ) is an essential micronutrient in energy metabolism and cognitive and neurological health. Thiamine deficiency disorders (TDDs) have a range of clinical presentations that result in various morbidities and can be fatal if not promptly recognized and treated, especially in infants. To intervene, thiamine intakes by breastfeeding mothers and others at risk of thiamine deficiency should be increased to ensure adequate thiamine intake. Although thiamine fortification programs have a long history in high-income countries, there are few mandatory fortification programs to address TDDs in low- and middle-income countries (LMICs), particularly in the regions of greatest concern, South and Southeast Asia. This review highlights essential aspects for consideration in the development of a mandatory fortification program in LMICs, including an overview of the data required to model fortification dosing schemes, available thiamine fortificants, and potential fortification vehicles, as well as identifies current knowledge gaps.

A Mixed-Methods Study of Factors Influencing Access to and Use of Micronutrient Powders in Rwanda

Gaps in complementary feeding practices hinder the use of multiple micronutrients powder (MNP) in Rutsiro district in Rwanda. Successful MNP program implementation requires uninterrupted availability and accessibility to the product, as well as greater understanding of health benefits of the MNP.

The World Health Organization recommends point-of-use fortification with multiple micronutrients powder (MNP) for foods consumed by children aged 6–23 months in populations where anemia prevalence among children under 2 years or under 5 years of age is 20% or higher. In Rwanda, anemia affects 37% of children under 5 years. The MNP program was implemented to address anemia, but research on factors affecting the implementation of the MNP program is limited. We conducted a mixed-methods study to examine the factors influencing access to and use of MNP among mothers (N=379) in Rutsiro district, northwest Rwanda. Inductive content analysis was used for qualitative data. Logistic regression analysis was used to determine factors associated with the use of MNP. Qualitative results indicated that the unavailability of MNP supplies and distribution issues were major barriers to accessing MNP. Factors influencing the use of MNP included mothers' perceptions of side effects and health benefits of MNP, as well as inappropriate complementary feeding practices. Mothers of older children (aged 12–23 months) were more likely to use MNP than those of younger children (aged 6–11 months) (adjusted odds ratio [aOR]=3.63, P<.001). Mothers whose children participated in the supplementary food program were nearly 3 times more likely to use MNP than those whose children had never participated in the program (aOR=2.84, P=.001). Increasing household hunger score was significantly associated with lower odds of using MNP (aOR=0.80, P=.038). Mechanisms to monitor MNP supply and program implementation need to be strengthened to ensure mothers have access to the product. MNP program implementers should address gaps in complementary feeding practices and ensure mothers have access to adequate complementary foods.

Effectiveness of various methods of home fortification in under-5 children: where they work, where they do not. A systematic review and meta-analysis

CONTEXT

The common approaches of home fortification (HF) for prevention and/or treatment of micronutrient deficiencies are micronutrient powders (MNPs), foodlets, and lipid-based nutrient supplements (LNSs). There are mixed results for the impact of HF on growth and nutritional status of young children.

OBJECTIVE

This systematic review was prepared in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate current evidence from randomized controlled trials including children younger than 5 years to assess the effect of strategies of HF on growth and micronutrient status.

METHODS

The MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar databases were searched to July 2018. A total of 1301 studies were found in a preliminary search. After screening of titles and abstracts, 30 studies were selected.

RESULTS

Treatment with MNPs, foodlets, and LNSs effectively increased hemoglobin concentrations by at least 2.52 g/L, 4.59 g/L, and 4.4 g/dL, respectively, as compared with a control. There was a significant decrease in risk of anemia development after foodlet intervention compared with a control or iron drops (odds ratio, 0.27; 95%CI, 0.10-0.74; P = 0.01). However, these interventions did not result in any significant improvement in z-scores for changes of height for age, weight for age, and weight for height. The results indicated that MNP (7.16; 95%CI, 0.31-14.01; P = 0.04) and foodlet treatment (4.92; 95%CI, 0.28-9.57; P = 0.04) could increase serum zinc levels. However, none of the home fortification methods improved vitamin A status in the target group.

CONCLUSION

Home fortification can be used as an effective method to improve hemoglobin, iron, and zinc status, although in this study it had no effect on vitamin A or anthropometric indicators of the target population. More investigations are warranted for newer approaches of HF to improve a broader range of micronutrients as well as child growth indices and for evaluation of the coverage, compliance, and consistency of such interventions at the population level.

PROSPERO REGISTRATION NO

CRD42018109279.

Consumption of a Single Dose of Prebiotic Galacto-Oligosaccharides Does Not Enhance Iron Absorption from Micronutrient Powders in Kenyan Infants: A Stable Iron Isotope Study

BACKGROUND

Long-term feeding of prebiotic galacto-oligosaccharides (GOS) increases iron absorption in African infants, but the underlying mechanism and how long GOS need to be fed to infants to achieve an increase in absorption is uncertain.

OBJECTIVES

In Kenyan infants, we tested whether the addition of GOS to a single test meal would affect iron absorption from a micronutrient powder (MNP) containing ferrous sulfate (FeSO4) and another MNP containing ferrous fumarate (FeFum) and sodium iron ethylenediaminetetraacetate (NaFeEDTA).

METHODS

In a randomized-entry, prospective crossover study, iron deficient (87%) and anemic (70%) Kenyan infants (n  = 23; mean ± SD age, 9.9 ± 2.1 months) consumed 4 stable iron isotope-labeled maize porridge meals fortified with MNPs containing 5 mg iron as FeFum + NaFeEDTA, or FeSO4, either without or with 7.5 g GOS. The primary outcome, fractional iron absorption (FIA), was assessed by erythrocyte incorporation of isotopic labels. Data were analyzed using a 2-way repeated-measures ANOVA.

RESULTS

There was no significant interaction between GOS and the iron compounds on FIA, and the addition of GOS did not have a significant effect on FIA. There was a statistically significant difference in FIA between the meals fortified with FeSO4 and with FeFum + NaFeEDTA (P  < 0.001).Given with GOS, FIA from FeSO4 was 40% higher than from FeFum + NaFeEDTA (P  < 0.001); given without GOS, it was 51% higher (P  < 0.01).

CONCLUSIONS

The addition of GOS to a single iron-fortified maize porridge test meal in Kenyan infants did not significantly increase iron absorption, suggesting long-term feeding of GOS may be needed to enhance iron absorption at this age. This study was registered at clinicaltrials.gov as NCT02666417.

Successful delivery of nutrition programs and the sustainable development goals

Malnutrition affects millions of people globally, especially women, children, and other vulnerable populations. Sustainable Development Goals (SDGs) were set in 2015 to end poverty, protect the planet, and improve the lives and prospects of everyone by 2030. To achieve the SDG goals effective nutrition interventions and programs need to be efficiently delivered to those most in need. Nutrition directly affects 2 SDGs (2 and 3) and indirectly influences five others. In addition, almost all SDGs influence nutrition and thus attaining the SDG goals is also a pre-requisite to achieving the Global Nutrition targets set in 2012. Evidence-based nutrition interventions, for which there is strong evidence of their biological impact, have the potential to directly influence SDGs 2 and 3 if successfully delivered at scale in high-burden countries. Nevertheless, delivery of nutrition programs is a complex process, where policy, government commitment, adequate budget allocation, supplies and delivery systems, training of service providers, informed beneficiaries and program monitoring and evaluation all need to be in place and aligned with each other. Although in the past decade there has been progress in the SDGs that nutrition directly affects, many goals are still off-track, likely due to several pending gaps at policy-level, program-level, and intervention-level. To accelerate the progress toward reaching the SDG goals that are directly influenced by nutrition, countries need to be supported to successfully and sustainably deliver proven interventions and to scale-up and deliver new interventions in new and innovative ways, and the evidence base should be built in promising areas especially integrating (rather than prioritizing over each other) nutrition-specific and sensitive approaches.

Food Fortification: The Advantages, Disadvantages and Lessons from Sight and Life Programs

Deficiencies in one or more micronutrients such as iron, zinc, and vitamin A are widespread in low- and middle-income countries and compromise the physical and cognitive capacity of millions of people. Food fortification is a cost-effective strategy with demonstrated health, economic and social benefits. Despite ongoing debates globally and in some countries regarding the performance and safety of food fortification, the practice offers significant benefits across each of the main vehicles for food fortification (large-scale food fortification, biofortification and point-of-use or home fortification) ranging from reducing the prevalence of nutritional deficiencies and economic benefits to societies and economies. Using Sight and Life's global and national experiences in implementing food fortification efforts, we demonstrate how different programs in LMICs have successfully addressed challenges with food fortification and in doing so, find that these efforts are most successful when partnerships are formed that include the public and private sector as well as other parties that can provide support in key areas such as advocacy, management, capacity building, implementation and regulatory monitoring.

Potential of pumpkin to combat vitamin A deficiency during complementary feeding in low and middle income countries: variety, provitamin A carotenoid content and retention, and dietary reference intakes

The risk of child vitamin A deficiency (VAD) in low and middle income countries (LMICs) begins during the age range of complementary feeding (6-24 months), when children are fed complementary foods (CFs) deficient in vitamin A. However, pumpkin, a source of provitamin A carotenoids (PVACs) is widely cultivated in LMICs, but underutilized as a complementary food. Moreover, when consumed by humans, PVACs are bioconverted to retinol, the active form of vitamin A used by the body. This study evaluated the potential of pumpkin toward combating VAD by reviewing varieties of pumpkin cultivated in LMICs and their provitamin A carotenoid (PVAC) content; retention of PVACs in pumpkin during processing it as a CF; and the extent to which a CF prepared from pumpkin may meet the dietary reference intakes (DRIs) for vitamin A for children aged 6-24 months old. Pumpkin may combat VAD because the varieties cultivated have high β-carotene content, it is a provitamin A biofortifiable food crop, and 100% retention of PVACs was observed when processed using home cooking methods. Feeding less than 50 g of cooked pumpkin per day meets 100% of the recommended dietary allowance (RDA) and adequate intake (AI) of vitamin A for children 6 to 24 months old. Consumption of pumpkin may be used to complement vitamin A supplementation, fortification, and diversification of CFs with animal source foods. For better yield of pumpkin in LMICs, nutrition sensitive agricultural programmes such as biofortification and agronomic management of pumpkin need to be promoted and supported.

The nutritional characteristics and acceptability of Baobab (Adansonia digitata L) pulp as nutrient concentrate substitute in custard powder

Micronutrient deficiency in the human diet is of serious concern in developing nations. The utilization potential of Baobab pulp (BP) as a micronutrient source in custard formulation was evaluated. Custard powder was formulated from corn-starch, salt, flavor, colorant, and a commercial nutrient concentrate (NC) using a standard recipe, as a control sample. The nutrient concentrate was substituted by 20 – 50% of Baobab pulp in custard formulation. Custard powder was characterized by chemical, physicochemical, pasting, and sensory properties, using standard procedures. Substitution of Baobab pulp for nutrient concentrate in custard formulation resulted in a significant (p ≤0.05) increase in the crude protein (2.23 – 3.67%), fat (1.49 – 2.40%), fiber (2.95 – 4.85%), and ash (2.21 – 3.63%) contents of custard powder. The vitamins A, C, and Beta-carotene contents of Baobab pulp-fortified custard varied (p ≤0.05) significantly. Substitution of Baobab pulp for nutrient concentrate increased the mineral composition (Calcium (1.16 – 5.75 ppm), Magnesium (1.09 – 1.83 ppm), Potassium (0.81 – 2.68 ppm), and Iron (0.12 – 0.39 ppm)) of custard samples significantly (p ≤0.05). The addition of Baobab pulp in the custard powder formulation enhanced its chemical composition and sensory attributes. The enhancement level increases with an increase in the proportion of baobab pulp.

Effect of low-iron micronutrient powder (MNP) on the composition of gut microbiota of Bangladeshi children in a high-iron groundwater setting: a randomized controlled trial

Purpose

Adverse effects of iron fortification/supplements such as Micronutrient Powder (MNP) on gut microbiota have previously been found in infection-prone African settings. This study examined the adversaries of a low-iron MNP compared with the standard MNP on the composition of gut microbiota in Bangladeshi children exposed to a high concentration of iron from potable groundwater.

Methods

A randomized controlled trial was conducted in 2- to 5-year-old children, drinking groundwater with a high concentration of iron (≥ 2 mg/L). Children were randomized to receive one sachet per day of either standard MNP (12.5 mg iron) or low-iron MNP (5 mg iron), for 2 months. A sub-sample of 53 children was considered for paired assessment of the gut microbiome by 16S rRNA amplicon sequencing.

Results

At baseline, the gut microbiota consisted of Bifidobacteriaceae (15.6%), Prevotellaceae (12.2%), Lactobacillaceae (3.6%), Clostridiaceae (4.1%) and Enterobacteriaceae (2.8%). Overall, there was no significant treatment effect of the low-iron MNP compared to the standard MNP. However, an apparent treatment effect was observed in children with a relative adult-like microbiota, with a higher relative abundance of potentially pathogenic Enterobacteriaceae after receiving the standard MNP compared to the low-iron MNP. This effect, however, was statistically non-significant (p = 0.07).

Conclusion

In Bangladeshi children drinking iron-rich groundwater, a low-iron MNP supplementation did not have a significant impact on their gut microbiota profile/composition compared to the standard MNP.

The trial registration number is ISRCTN60058115; Date of registration 03/07/2019; retrospectively registered.

Supplementary Information

The online version of this article (10.1007/s00394-021-02523-1) contains supplementary material, which is available to authorized users.

Interventions for Addressing Anemia Among Children and Adolescents: An Overview of Systematic Reviews

Context: Anemia is a public health problem that can lead to growth, cognitive, and motor impairments. Objective: To collate evidence on interventions for addressing childhood and adolescent anemia. Methods: In this overview of systematic reviews, we included Cochrane as well as non-Cochrane systematic reviews (SRs) irrespective of language and publication status. Two sets of review authors independently screened articles for eligibility and extracted data from relevant SRs. We present data in a tabular format and summarize results based on outcome reported, age of participants, and type of interventions. We also adopt a "measurement for change" approach to assess the utility of measurement for development of interventions in childhood and adolescent anemia. Results: Our search yielded 2,601 records of which 31 SRs were found eligible for inclusion. Results were favorable for fortification and supplementation with clear reduction in the risk of anemia and increase in hemoglobin levels across all age groups. Other interventions reported by the SRs were inconclusive and suggest further research. Conclusions: Current evidence suggests that fortification or supplementation with iron and micronutrients leads to better reduction in the risk of anemia and improvements in hemoglobin levels among children and adolescents. Results of this overview can help decision makers in informing selection of interventions to address childhood and adolescent anemia. Review Registration: PROSPERO CRD42016053687.

Can Double Fortification of Salt with Iron and Iodine Reduce Anemia, Iron Deficiency Anemia, Iron Deficiency, Iodine Deficiency, and Functional Outcomes? Evidence of Efficacy, Effectiveness, and Safety

BACKGROUND

Anemia, iron deficiency, and iodine deficiency are problems of important public health concern in many parts of the world, with consequences for the health, development, and work capacity of populations. Several countries are beginning to implement double fortified salt (DFS) programs to simultaneously address iodine and iron deficiencies.

OBJECTIVE

Our objective was to summarize the evidence for efficacy and effectiveness of DFS on the full range of status and functional outcomes and across different implementation and evaluation designs essential to successful interventions.

METHODS

We conducted a systematic review and meta-analysis of published and gray literature examining the effects of DFS on nutritional status, cognition, work productivity, development, and morbidity of all population groups. We searched for articles in Medline, Embase, CINAHL, Cochrane Central Register, and ProQuest for randomized trials, quasi-randomized trials, and program effectiveness evaluations.

RESULTS

A total of 22 studies (N individuals = 52,758) were included. Efficacy studies indicated a significant overall positive effect on hemoglobin concentration [standardized mean difference (95% CI): 0.33 (0.18, 0.48)], ferritin [0.42 (0.08, 0.76)], anemia [risk ratio (95% CI): 0.80 (0.70, 0.92)], and iron deficiency anemia [0.36 (0.24, 0.55)]. Effects on urinary iodine concentration were not significantly different between DFS and iodized salt. The impact on functional outcomes was mixed. Only 2 effectiveness studies were identified. They reported programmatic challenges including low coverage, suboptimal DFS quality, and storage constraints.

CONCLUSIONS

Given the biological benefits of DFS across several populations in efficacy research, additional evaluations of robust DFS programs delivered at scale, which consider effective implementation and measure appropriate biomarkers, are needed.

Impact of iron fortification on anaemia and iron deficiency among pre-school children living in Rural Ghana

Anaemia in young sub-Saharan African children may be due to the double burden of malaria and iron deficiency. Primary analysis of a double-blind, cluster randomized trial of iron containing micronutrient powder supplementation in Ghanaian children aged 6 to 35 months found no difference in malaria risk between intervention and placebo groups. Here, we performed a secondary analysis of the trial data to assess the impact of long-term prophylactic iron fortificant on the risk of iron deficiency and anaemia in trial subjects. This population-based randomized-cluster trial involved 1958 children aged between 6 to 35 months, identified at home and able to eat semi-solid foods. The intervention group (n = 967) received a daily dose containing 12.5 mg elemental iron (as ferrous fumarate), vitamin A (400 μg), ascorbic acid (30 mg) and zinc (5 mg). The placebo group (n = 991) received a similar micronutrient powder but without iron. Micronutrient powder was provided daily to both groups for 5 months. At baseline and endline, health assessment questionnaires were administered and blood samples collected for analysis. The two groups had similar baseline anthropometry, anaemia, iron status, demographic characteristics, and dietary intakes (p > 0.05). Of the 1904 (97.2%) children who remained at the end of the intervention, the intervention group had significantly higher haemoglobin (p = 0.0001) and serum ferritin (p = 0.0002) levels than the placebo group. Soluble transferrin receptor levels were more saturated among children from the iron group compared to non-iron group (p = 0.012). Anaemia status in the iron group improved compared to the placebo group (p = 0.03). Continued long-term routine use of micronutrient powder containing prophylactic iron reduced anaemia, iron deficiency and iron deficiency anaemia among pre-school children living in rural Ghana's malaria endemic area.

Multiple micronutrient supplementation improves growth and reduces the risk of anemia among infants in Gaza Strip, Palestine: a prospective randomized community trial

BACKGROUND

Infants and young children 6-24 months of age are the most nutritionally vulnerable groups, as their needs for vitamins and minerals are high relative to the amount of food they consume. This study determines the effect of Micronutrient Powder Supplementation (MNP) on growth and hemoglobin of infants in Gaza Strip, Palestine.

METHOD

This was a two-arm parallel-group randomized controlled trial conducted in two health care clinics of the United Nations Relief and Work Agency (UNRWA) at the Middle Area governorate of Gaza Strip, Palestine. A total of 200 healthy infants aged 6-month-old were recruited and randomized to receive 3 sachets/week of MNP for 12 months alongside with the National Micronutrient Supplement (NMS) (n = 100) or NMS alone (n = 100). Weight, length, blood hemoglobin, and dietary intakes were measured at 6, 9, 12, 15, 18, and 21 (3 months after the end of intervention) months of age. Analysis was by intention to treat.

RESULTS

The experimental group had a higher concentration of hemoglobin at 12 and 15 months than did the control group, and a significant difference (p <  0.05) was observed at 15 months only. Significantly greater weight, length, weight-for-age, length-for-age, and weight-for-length z-scores were observed in the experimental group than that in the control group at 12 and 15 months (p <  0.05). The prevalence of anemia (18% vs. 52%) and stunting (1% vs. 11%) were higher in the control than the experimental group, respectively. After controlling for sex, similar findings were reported.

CONCLUSIONS

Addition of MNP to the existing NMS program improved the nutritional status of young children. The potential benefits of MNP supplementation on physical growth and hemoglobin should be considered in the existing NMS program.

TRIAL REGISTRATION

ISRCTN57594793 ; Date of registration: 20-03-2018 (Retrospectively registered).

Impact of nutrient supplementation on maternal nutrition and child growth and development in Sub-Saharan Africa: the case of small-quantity lipid-based nutrient supplements

Micronutrient deficiencies remain common among women and children in Sub-Saharan Africa (SSA); in pregnant/lactating women, the intakes of essential fatty acids may also be low. Enriching home-prepared foods with small-quantity lipid-based nutrient supplements (SQ-LNSs) is a promising new strategy of delivering additional micronutrients, essential fatty acids and good quality protein to women and children. This narrative review aimed to examine the impact of SQ-LNSs supplementation among women and infants and young children in SSA, and to discuss the differential impact of SQ-LNS consumption across different settings. Papers reporting randomized trials conducted in SSA in which apparently healthy women and/or ≥6-mo-old children received SQ-LNSs were identified through electronic and manual searches. Prenatal SQ-LNS consumption reduced the prevalence of low gestational weight gain in Ghana when compared with multiple micronutrients supplementation, and was associated with poorer iron/hemoglobin status when compared with iron-plus-folic acid supplementation. SQ-LNSs received alone or as intervention package improved infant/child growth in two trials in Ghana and one trial each in Burkina Faso, Kenya, Zimbabwe and South Africa, but had no impact on growth in two trials in Malawi. SQ-LNSs supplementation improved motor development in Ghana, Burkina Faso, Malawi, Kenya, and South Africa, but had no impact on language, socio-emotional, and executive functions in Ghana and Malawi and on Griffiths' developmental scores in Malawi. SQ-LNSs may contribute to improving child growth in SSA. More research is needed to determine the iron level in SQ-LNSs effective for improving both maternal hemoglobin/iron status and birth outcomes.

Opportunities for plant-derived enhancers for iron, zinc, and calcium bioavailability: A review

Understanding of the mechanism of interactions between dietary elements, their salts, and complexing/binding ligands is vital to manage both deficiency and toxicity associated with essential element bioavailability. Numerous mineral ligands are found in both animal and plant foods and are known to exert bioactivity via element chelation resulting in modulation of antioxidant capacity or micobiome metabolism among other physiological outcomes. However, little is explored in the context of dietary mineral ligands and element bioavailability enhancement, particularly with respect to ligands from plant-derived food sources. This review highlights a novel perspective to consider various plant macro/micronutrients as prospective bioavailability enhancing ligands of three essential elements (Fe, Zn, and Ca). We also delineate the molecular mechanisms of the ligand-binding interactions underlying mineral bioaccessibility at the luminal level. We conclude that despite current understandings of some of the structure-activity relationships associated with strong mineral-ligand binding, the physiological links between ligands as element carriers and uptake at targeted sites throughout the gastrointestinal (GI) tract still require more research. The binding behavior of potential ligands in the human diet should be further elucidated and validated using pharmacokinetic approaches and GI models.

Ending malnutrition in all its forms requires scaling up proven nutrition interventions and much more: a 129-country analysis

BACKGROUND

Sustainable Development Goal (SDG) 2.2 calls for an end to all forms of malnutrition, with 2025 targets of a 40% reduction in stunting (relative to 2012), for wasting to occur in less than 5% of children, and for a 50% reduction in anaemia in women (15-49 years). We assessed the likelihood of countries reaching these targets by scaling up proven interventions and identified priority interventions, based on cost-effectiveness.

METHODS

For 129 countries, the Optima Nutrition model was used to compare 2019-2030 nutrition outcomes between a status quo (maintained intervention coverage) scenario and a scenario where outcome-specific interventions were scaled up to 95% coverage over 5 years. The average cost-effectiveness of each intervention was calculated as it was added to an expanding package of interventions.

RESULTS

Of the 129 countries modelled, 46 (36%), 66 (51%) and 0 (0%) were on track to achieve the stunting, wasting and anaemia targets respectively. Scaling up 18 nutrition interventions increased the number of countries reaching the SDG 2.2 targets to 50 (39%), 83 (64%) and 7 (5%) respectively. Intermittent preventative treatment of malaria during pregnancy (IPTp), infant and young child feeding education, vitamin A supplementation and lipid-based nutrition supplements for children produced 88% of the total impact on stunting, with average costs per case averted of US$103, US$267, US$556 and US$1795 when interventions were consecutively scaled up, respectively. Vitamin A supplementation and cash transfers produced 100% of the total global impact on prevention of wasting, with average costs per case averted of US$1989 and US$19,427, respectively. IPTp, iron and folic acid supplementation for non-pregnant women, and multiple micronutrient supplementation for pregnant women produced 85% of the total impact on anaemia prevalence, with average costs per case averted of US$9, US$35 and US$47, respectively.

CONCLUSIONS

Prioritising nutrition investment to the most cost-effective interventions within the country context can maximise the impact of funding. A greater focus on complementing nutrition-specific interventions with nutrition-sensitive ones that address the social determinants of health is critical to reach the SDG targets.

Determinants of adherence to micronutrient powder use among young children in Ethiopia

In Ethiopia, home fortification of complementary foods with micronutrient powders (MNPs) was introduced in 2015 as a new approach to improve micronutrient intakes. The objective of this study was to assess factors associated with intake adherence and drivers for correct MNP use over time to inform scale‐up of MNP interventions. Mixed methods including questionnaires, interviews and focus group discussions were used. Participants, 1,185 children (6–11 months), received bimonthly 30 MNP sachets for 8 months, with instruction to consume 15 sachets/month, that is, a sachet every other day and maximum of one sachet per day. Adherence to distribution (if child receives ≥14 sachets/month) and adherence to instruction (if child receives exactly 15[±1] sachets/month) were assessed monthly by counting used sachets. Factors associated with adherence were examined using generalized estimating equations. Adherence fluctuated over time, an average of 58% adherence to distribution and 28% for adherence to instruction. Average MNP consumption was 79% out of the total sachets provided. Factors positively associated with adherence included ease of use (instruction), child liking MNP and support from community (distribution and instruction) and mother's age >25 years (distribution). Distance to health post, knowledge of correct use (OR = 0.74, 95% CI = 0.66–0.81), perceived negative effects (OR = 0.73, 95% CI = 0.54–0.99) and living in Southern Nations, Nationalities and People Region (OR = 0.59, 95% CI = 0.52–0.67) were inversely associated with adherence to distribution. Free MNP provision, trust in the government and field staff played a role in successful implementation. MNP is promising to be scaled‐up, by taking into account factors that positively and negatively determine adherence.

The effect of iron dosing schedules on plasma hepcidin and iron absorption in Kenyan infants

BACKGROUND

In adults, oral iron doses increase plasma hepcidin (PHep) for 24 h, but not for 48 h, and there is a circadian increase in PHep over the day. Because high PHep decreases fractional iron absorption (FIA), alternate day iron dosing in the morning may be preferable to consecutive day dosing. Whether these effects occur in infants is uncertain.

OBJECTIVE

Using stable iron isotopes in Kenyan infants, we compared FIA from morning and afternoon doses and from consecutive, alternate (every second day) and every third day iron doses.

METHODS

In prospective studies, we measured and compared FIA and the PHep response from 1) meals fortified with a 12-mg iron micronutrient powder given in the morning or afternoon (n = 22); 2) the same given on consecutive or alternate days (n = 21); and 3) a 12-mg iron supplement given on alternate days or every third day (n = 24).

RESULTS

In total, 65.7% of infants were anemic. In study 1, PHep did not differ between morning and afternoon (P = 0.072), and geometric mean FIA[-SD, +SD](%) did not differ between the morning and afternoon doses [15.9 (8.9, 28.6) and 16.1 (8.7, 29.8), P = 0.877]. In study 2, PHep was increased 24 h after oral iron (P = 0.014), and mean FIA [±SD](%) from the baseline dose [23.3 (10.9)] was greater than that from the consecutive day dose (at 24 h) [20.1 (10.4); P = 0.042] but did not differ from the alternate day dose (at 48 h) [20.9 (13.4); P = 0.145]. In study 3, PHep was not increased 48 and 72 h after oral iron (P = 0.384), and the geometric mean FIA[-SD, +SD](%) from doses given at baseline, alternate days, and every third day did not differ [12.7 (7.3, 21.9), 13.8 (7.8, 24.2), and 14.8 (8.8, 24.8), respectively; P = 0.080].

CONCLUSIONS

In Kenyan infants given 12 mg oral iron, morning and afternoon doses are comparably absorbed, dosing on consecutive days increases PHep and modestly decreases iron absorption compared with alternate day dosing, and dosing on alternate days or every third day does not increase PHep or decrease absorption. This trial was registered at clinicaltrials.gov as NCT02989311 and NCT03617575.

Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) is critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness are currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.

The Central Role of Iron in Human Nutrition: From Folk to Contemporary Medicine

Iron is a fundamental element in human history, from the dawn of civilization to contemporary days. The ancients used the metal to shape tools, to forge weapons, and even as a dietary supplement. This last indication has been handed down until today, when martial therapy is considered fundamental to correct deficiency states of anemia. The improvement of the martial status is mainly targeted with dietary supplements that often couple diverse co-factors, but other methods are available, such as parenteral preparations, dietary interventions, or real-world approaches. The oral absorption of this metal occurs in the duodenum and is highly dependent upon its oxidation state, with many absorption influencers possibly interfering with the intestinal uptake. Bone marrow and spleen represent the initial and ultimate step of iron metabolism, respectively, and the most part of body iron circulates bound to specific proteins and mainly serves to synthesize hemoglobin for new red blood cells. Whatever the martial status is, today’s knowledge about iron biochemistry allows us to embrace exceedingly personalized interventions, which however owe their success to the mythical and historical events that always accompanied this metal.

Facility- and community-based delivery of micronutrient powders in Uganda: Opening the black box of implementation using mixed methods

Micronutrient powders (MNP) have the potential to increase micronutrient intake, yet documentation of implementation lessons remains a gap. This paper presents results of a pilot in Uganda comparing community- and facility-based delivery of MNP and documenting experiences of caregivers and distributors. The pilot's mixed method evaluation included a cross-sectional endline survey, monthly household visits, and midline and endline interviews. Primary outcomes were ever-covered (received ≥1 MNP packet), repeat-coverage (received ≥2 MNP packets), and adherence (consumed no more than 1 MNP sachet per day, consumed MNP with food, and consumed MNP 3+ days in past week). An adjusted Wald chi-square test compared differences in programme outcomes between arms, and logit regression identified predictors to adherence. Key informant interviews were coded thematically. Most programme outcomes in the endline survey were statistically significantly higher in the community arm, although in both arms, adherence was lower than other outcomes (adherence 31.4% in facility vs. 58.3% in community arm). Counselling, receipt of communication materials, perceived positive effects, MNP knowledge, and child liking MNP were consistent predictors of adherence in both arms. Qualitative findings corroborated survey results, revealing that social encouragement and advocacy facilitated use and that forgetting to give MNP was a barrier. Facility arm caregivers also cited distance, time, and transportation cost as barriers. Distributors had positive experiences with training and supervision but experienced increased workloads in both arms. MNP programme design is context-specific but could benefit from strengthened community sensitization, continued and more effective counselling for caregivers, and increased support for distributors.

Mixed methods evaluation explains bypassing of vouchers in micronutrient powder trial in Mozambique

Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross-sectional survey among caregivers of children 6-23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one-fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.

Adherence and acceptability of community-based distribution of micronutrient powders in Southern Mali

Home fortification with micronutrient powders (MNP) has been shown to reduce anaemia, with high overall acceptability and adherence, but there is limited evidence from West Africa. Around 80% of children younger than 5 years are anaemic in Mali, and new interventions are needed. This paper reports on the adherence and acceptability of a community‐led MNP intervention targeting children aged 6–59 months in Southern Mali. The MNP were delivered by a multidisciplinary group of community volunteers using community‐based preschools, cooking demonstrations, and traditional communication networks to promote MNP, nutrition, hygiene, and child stimulation. The MNP were delivered alongside early childhood development interventions and seasonal malaria chemoprevention. Adherence and acceptability were evaluated through two cross‐sectional surveys in 2014 and 2016 and a qualitative evaluation in 2015. Over 80% of parents reported ever having given MNP to their child, with 65% having given MNP for four or more days in the last week. Likely contributors to uptake include: perceived positive changes in the children following MNP use, the selection of a food vehicle that was already commonly given to children (morning porridge or bouillie) and the community driven, decentralized and integrated delivery approach. These findings support recommendations from recent reviews of MNP implementation to use community‐based delivery approaches and behaviour change components.

Predictors of micronutrient powder (MNP) knowledge, coverage, and consumption during the scale-up of an integrated infant and young child feeding (IYCF-MNP) programme in Nepal

Large-scale programmes using micronutrient powders (MNPs) may not achieve maximum impact due to limited/inappropriate MNP coverage, consumption, and use. We identify predictors of MNP coverage, maternal knowledge of appropriate use, and child MNP consumption in Nepal. A cross-sectional survey was conducted in 2,578 mother-child pairs representative of children 6-23 months in two districts that were part of the post-pilot, scale-up of an integrated infant and young child feeding-MNP (IYCF-MNP) programme. Children aged 6-23 months were expected to receive 60 MNP sachets every 6 months from a female community health volunteer (FCHV) or health centre. Outcomes of interest were MNP coverage (ever received), maternal knowledge of appropriate use (correct response to seven questions), repeat coverage (receipt ≥ twice; among children 12-23 months who had received MNP at least once, n = 1342), and high intake (child consumed ≥75% of last distribution, excluding those with recent receipt/insufficient time to use 75% at recommended one-sachet-per-day dose, n = 1422). Multivariable log-binomial regression models were used to identify predictors of the four outcomes. Coverage, knowledge of appropriate use, and repeat coverage were 61.3%, 33.5%, and 45.9%, respectively. Among MNP receivers, 97.9% consumed MNP at least once and 38.9% of eligible children consumed ≥75% of last distribution. FCHV IYCF-MNP counselling was positively associated with knowledge, coverage, repeat coverage, and high intake; health worker counselling with knowledge and coverage indicators; and radio messages with coverage indicators only. FCHV counselling had the strongest association with knowledge, coverage, and high intake. Community-based counselling may play a vital role in improving coverage and intake in MNP programmes.

An Integrated Infant and Young Child Feeding and Micronutrient Powder Intervention Does Not Affect Anemia, Iron Status, or Vitamin A Status among Children Aged 12-23 Months in Eastern Uganda

BACKGROUND

Micronutrient powders (MNP) can reduce iron deficiency and anemia in children.

OBJECTIVE

We evaluated the impact of an integrated infant and young child feeding (IYCF)-MNP intervention on anemia and micronutrient status among children aged 12-23 mo in Eastern Uganda. The intervention focused on MNP distribution, IYCF education, and caregiver behavior change.

METHODS

Population-based cross-sectional surveys representative of children aged 12-23 mo in Amuria (intervention) and Soroti (nonintervention) districts were collected in June/July 2015 at baseline (n = 1260) and 12 mo after implementation at endline in 2016 (n = 1490). From pooled capillary blood, we assessed hemoglobin, malaria, ferritin, retinol binding protein (RBP), C-reactive protein, and ɑ1-acid glycoprotein. Ferritin and RBP were regression-adjusted to correct for inflammation. Caregivers reported sociodemographic characteristics and MNP knowledge and practices. Linear regression estimated the difference-in-difference (DiD) effect of MNP on hemoglobin, ferritin, and RBP, and logistic regression estimated DiD effect of MNP on anemia (hemoglobin <11.0 g/dL), iron deficiency (ferritin <12.0 µg/L), iron deficiency anemia (hemoglobin <11.0 g/dL and ferritin <12.0 µg/L), and vitamin A deficiency (VAD; RBP equivalent to <0.70 µmol/L retinol: <0.79 µmol/L at baseline and RBP <0.67 µmol/L at endline).

RESULTS

In Amuria, 96% of children had ever consumed MNP versus <1% of children in Soroti. Fifty-four percent of caregivers reported organoleptic changes when MNP were added to foods cooked with soda ash. Adjusting for age, sex, malaria, recent morbidity, and household-level factors, the intervention was associated with -0.83 g/dL lower hemoglobin (95% CI, -1.36, -0.30 g/dL; P = 0.003) but not with anemia, ferritin, iron deficiency, iron deficiency anemia, RBP, or VAD.

CONCLUSIONS

Despite high program fidelity, the intervention was associated with reduced hemoglobin concentrations but not with change in anemia or micronutrient status among children aged 12-23 mo in Eastern Uganda. Contextual factors, such as cooking with soda ash, might explain the lack of effectiveness.

Role of home visits by volunteer community health workers: to improve the coverage of micronutrient powders in rural Bangladesh

OBJECTIVE

We assessed the role of home visits by Shasthya Shebika (SS) - female volunteer community health workers (CHWs) - in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver-provider interaction on coverage variables.

DESIGN

We used data from three cross-sectional surveys undertaken at baseline (n 1927), midline (n 1924) and endline (n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver's household in the 12 months preceding the survey considering three outcome variables - message (ever heard), contact (ever used) and effective coverage (regular used) of MNP. We performed multiple logistic regressions to explore the determinants of coverage, employed an 'interaction term' and calculated an odds ratio (OR) to assess the modifying effect of SS's home visits on coverage.

SETTINGS

Sixty-eight sub-districts from ten districts of Bangladesh.

PARTICIPANTS

Children aged 6-59 months and their caregivers.

RESULTS

A home visit from an SS positively impacts message coverage at both midline (ratio of OR 1·70; 95 % CI 1·25, 2·32; P < 0·01) and endline (ratio of OR 3·58; 95 % CI 2·22, 5·78; P < 0·001), and contact coverage both at midline (ratio of OR 1·48; 95 % CI 1·06, 2·07; P = 0·021) and endline (ratio of OR 1·74; 95 % CI 1·23, 2·47; P = 0·002). There was no significant effect of a SS's home visit on effective coverage.

CONCLUSIONS

The households visited by BRAC's volunteer CHWs have better message and contact coverage among the children aged 6-59 months.

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. Multiple micronutrient powders (MNPs) are single-dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi-solid food for children six months of age or older. The use of MNPs 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. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out-of-date.

OBJECTIVES

To assess the effects and safety of home (point-of-use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi-solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point-of-use fortification.

SEARCH METHODS

We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs with individual randomisation or cluster-randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron-containing supplements, which is 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 included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 29 studies (33,147 children) conducted in low- and middle-income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty-six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron-only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate-certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high-certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low-certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate-certainty evidence) at follow-up compared with children receiving the control intervention. We did not find an effect on weight-for-age (MD 0.02, 95% CI -0.03 to 0.07; 10 studies; 9287 children; moderate-certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all-cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low-certainty evidence) and haemoglobin concentrations (MD -2.81 g/L, 95% CI -10.84 to 5.22; 2 studies; 278 children; very low-certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low-certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

AUTHORS' CONCLUSIONS

Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

Daily Supplementation With Egg, Cow Milk, and Multiple Micronutrients Increases Linear Growth of Young Children with Short Stature

BACKGROUND

Childhood stunting is the most prevalent public health nutrition problem in low- and middle-income countries.

OBJECTIVE

This study aimed to determine whether daily supplementation in 12-18-mo-old undernourished Bangladeshi children with egg, cow milk, and multiple micronutrients improves linear growth.

METHODS

In the Bangladesh Environmental Enteric Dysfunction (BEED) study, a community-based intervention study, 12-18-mo-old children with length-for-age z score (LAZ) <1 were supplemented daily with an egg and 150 mL of milk for 90 feeding days, and 1 sachet of multiple micronutrient powder was provided daily for 60 feeding days. The change in LAZ over this period was compared with that in children of the same age and same baseline LAZ who were enrolled in the recently completed Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health (MAL-ED) Dhaka birth cohort study conducted in the same community where no nutrition intervention was provided. Difference-in-difference (DID) analysis was done and the effect size was adjusted for other possible covariates using a generalized estimating equation in a regression model.

RESULTS

A total of 472 children with LAZ <1 completed the intervention and data were available for 174 children in the comparison group. Compared with the comparison group, adjusted DID analysis revealed a change in LAZ in the intervention group of +0.23 (95% CI: 0.18, 0.29; P < 0.05). In a subgroup analysis, the changes were +0.27 (95% CI: 0.18, 0.35; P < 0.05) in stunted (LAZ <2) children and +0.19 (95% CI: 0.12, 0.27; P < 0.05) in children at risk of stunting (LAZ -1 to -2). No allergic reactions or other adverse events related to milk and egg consumption were observed.

CONCLUSIONS

Daily directly observed milk, egg, and multiple micronutrient supplementation may improve linear growth of stunted children. A randomized controlled trial with longer duration of supplementation coupled with an additional intervention aimed at reducing pathogen burden is warranted to confirm these results. This trial was registered at clinicaltrials.gov as NCT02812615.

Interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low- and middle-income countries: a systematic review and network meta-analysis

Background: Optimizing linear growth in children during complementary feeding period (CFP) (6-24 months) are critical for their development. Several interventions, such as micronutrient and food supplements, deworming, maternal education, and water, sanitation and hygiene (WASH), could potentially be provided to prevent stunting, but their comparative effectiveness is currently unclear. In this study, we evaluated comparative effectiveness of interventions under these domains on child linear growth outcomes of height-for-age z-score (HAZ) and stunting (HAZ <-2SD) Methods: For this study, we searched for low- and middle-income country (LMIC)-based randomized clinical trials (RCTs) of aforementioned interventions provided to children during CFP. We searched for reports published until September 17, 2019 and hand-searched bibliographies of existing reviews. We performed random-effects network meta-analysis (NMA) for HAZ and stunting. Results: The evidence base for our NMA was based on 79 RCTs (96 papers) involving 81,786 children. Among the micronutrients, compared to standard-of-care, iron + folic acid (IFA) (mean difference =0.08; 95% credible interval [CrI]: 0.01, 0.15) and multiple micronutrients (MMN) (mean difference =0.06; 95%CrI: 0.01, 0.11) showed improvements for HAZ; MMN also reduced the risks for stunting (RR=0.86; 95%Crl: 0.73, 0.98), whereas IFA did not (RR=0.92; 95%Crl: 0.64, 1.23). For food supplements, flour in the caloric range of 270-340 kcal (RR=0.73; 95%Crl: 0.51, 1.00) and fortified lipid-based nutrient supplements (LNS) containing 220-285 kcal (RR=0.80; 95%Crl: 0.66, 0.97) decreased the risk of stunting compared to standard-of-care, but these interventions and other food supplements did not show improvements for HAZ. Deworming, maternal education, and WASH interventions did not show improvements for HAZ nor stunting. Conclusion: While we found micronutrient and food supplements to be effective for HAZ and/or stunting, the evidence base for other domains in this life stage was limited, highlighting the need for more investigation. Registration: PROSPERO CRD42018110449; registered on 17 October 2018.

Maternal Human Milk Oligosaccharide Profile Modulates the Impact of an Intervention with Iron and Galacto-Oligosaccharides in Kenyan Infants

There is little data on human milk oligosaccharide (HMO) composition in Sub-Saharan Africa. Iron fortificants adversely affect the infant gut microbiota, while co-provision of prebiotic galacto-oligosaccharides (GOS) mitigates most of the adverse effects. Whether variations in maternal HMO profile can influence the infant response to iron and/or GOS fortificants is unknown. The aim of this study was to determine HMO profiles and the secretor/non-secretor phenotype of lactating Kenyan mothers and investigate their effects on the maternal and infant gut microbiota, and on the infant response to a fortification intervention with 5 mg iron (2.5 mg as sodium iron ethylenediaminetetraacetate and 2.5 mg as ferrous fumarate) and 7.5 g GOS. We studied mother–infant pairs (n = 80) participating in a 4-month intervention trial in which the infants (aged 6.5–9.5 months) received daily a micronutrient powder without iron, with iron or with iron and GOS. We assessed: (1) maternal secretor status and HMO composition; (2) effects of secretor status on the maternal and infant gut microbiota in a cross-sectional analysis at baseline of the intervention trial; and (3) interactions between secretor status and intervention groups during the intervention trial on the infant gut microbiota, gut inflammation, iron status, growth and infectious morbidity. Secretor prevalence was 72% and HMOs differed between secretors and non-secretors and over time of lactation. Secretor status did not predict the baseline composition of the maternal and infant gut microbiota. There was a secretor-status-by-intervention-group interaction on Bifidobacterium (p = 0.021), Z-scores for length-for-age (p = 0.022) and weight-for-age (p = 0.018), and soluble transferrin receptor (p = 0.041). In the no iron group, longitudinal prevalence of diarrhea was higher among infants of non-secretors (23.8%) than of secretors (10.4%) (p = 0.001). In conclusion, HMO profile may modulate the infant gut microbiota response to fortificant iron; compared to infants of secretor mothers, infants of non-secretor mothers may be more vulnerable to the adverse effect of iron but also benefit more from the co-provision of GOS.

The Effect of the Yingyangbao Complementary Food Supplement on the Nutritional Status of Infants and Children: A Systematic Review and Meta-Analysis

Yingyangbao (YYB) is a nutrient-dense complementary food supplement for infants and young children in China. There has been considerable interest and research on the potential effects of YYB on hematological and anthropometric outcomes in China, but limited effort has been made to consolidate and synthesize the evidence to inform the research and policy agendas. Eight English databases and three Chinese databases were searched from January 2001 to June 2019 to identify YYB intervention studies. A total of 32 quasi-experimental, post-only, concurrent-control studies or pre-post studies were identified, and 26 were included in the meta-analyses. A pooled analysis of post-only studies with concurrent-control determined that YYB was associated with an increase of 4.43 g/L (95% confidence interval (CI) 1.55, 7.30) hemoglobin concentration, 2.46 cm (CI 0.96, 3.97) in height, and 0.79 kg (CI 0.25, 1.32) weight in infants and young children. YYB was also associated with reductions in the prevalence of anemia (risk ratio (RR) = 0.55; 95% CI: 0.45, 0.67), stunting (RR = 0.60; 95% CI: 0.44, 0.81), and underweight (RR = 0.51; 95% CI: 0.39, 0.65). Overall, YYB was found to be associated with improved hematological and anthropometric indicators among infants and young children in China; however, randomized trials are needed to causally assess the efficacy of YYB due to the inherent risk of bias in existing quasi-experimental studies; rigorous implementation and cost-effectiveness evaluations are also needed.

Bottlenecks and predictors of coverage and adherence outcomes for a micronutrient powder program in Ethiopia

A theory-driven evaluation was conducted to assess performance of a trial to deliver micronutrient powder (MNP) through the Ethiopian Ministry of Health. We adapted an approach to coverage assessment, originally developed to identify bottlenecks in health service delivery, to examine sequential program outcomes and their correlates using cross-sectional survey data of caregivers of children 6-23 months (N = 1915). Separate multivariable Poisson regression models were used to estimate adjusted risk ratios of conceptually relevant determinants of coverage and adherence. Caregivers of children >11 months were more likely to have received MNP than caregivers of younger infants, yet children 12-17 months were 32% (P < 0.001) and children 18-23 months 38% (P < 0.001) less likely to have been fed MNP in the 14 days preceding the survey than children 6-11 months. Among caregivers who initiated feeding MNP, the most frequently reported reasons for discontinuing use were not obtaining additional supply (36.1%) and perceived child rejection of food with MNP (22.9%). For each additional time a caregiver met with frontline workers in the 3 months preceding the survey, they were 13% more likely to have recently fed MNP (P < 0.001). Caregivers' perception that MNP produced positive changes in children was associated with a 14% increase in the likelihood of having recently fed it (P < 0.001). These results emphasize the importance of counselling for MNP and infant and young child feeding for initial use and the importance of multiple contacts with frontline workers for continued use.

Micronutrient powder supplements combined with nutrition education marginally improve growth amongst children aged 6-23 months in rural Burkina Faso: A cluster randomized controlled trial

Micronutrients powder (MNP) can prevent anaemia amongst children 6-23 months old. However, evidence of an effect on growth is limited and concerns about the safety of iron-containing MNP interventions limits their applicability. In a cluster randomized controlled intervention, we evaluated the effectiveness of a nutritional package including counselling and provision of MNP to improve the nutritional status of children aged 6-23 months and the effect of sustained use of MNP on morbidity in a malaria-endemic area. Child feeding practises and nutritional status were assessed through cross-sectional surveys. Biweekly morbidity surveillance and anthropometry measurements were carried out in a nested cohort study. No significant differences in the prevalence of wasting (-0.7% [-6.8, 5.3] points; p = .805), stunting (+4.6% [-2.9, 12.0] points; p = .201), or mean length-for-age z-score and weight-for-length z-score scores were found between study groups. The proportion of children with a minimum dietary diversity score and those with a minimum acceptable diet significantly increased in the intervention group compared with the control by 6.5% points (p = .043) and 5.8% points (p = .037), respectively. There were no significant differences in the risk of diarrhoea (RR: 1.68, 95% CI [0.94, 3.08]), fever (RR: 1.20 [0.82, 1.77]), and malaria (RR: 0.68 [0.37, 1.26]) between study groups. In the nested study, the rate of linear growth was higher in the intervention than in the control group by 0.013 SD/month (p = .027). In a programmatic intervention, MNP and nutrition education marginally improved child feeding practises and growth, without increasing morbidity from malaria or fever.

Prevalence and causes of anaemia in children aged 6-23 months in rural Qinghai, China: findings from a cross-sectional study

OBJECTIVE

To investigate the current situation of anaemia among children aged 6-23 months in a rural county in China, and to explore the influencing factors and the main causes of anaemia.

DESIGN

A cross-sectional study.

SETTING

Huzhu County in Qinghai Province, China PARTICIPANTS: We selected 38 sampled villages using Proportional to Population Size sampling method. We obtained the name list of children aged 6-23 months in each sampled village and planned to survey all the eligible children aged 6-23 months and their caregivers.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The prevalence of anaemia, the influencing factors of anaemia, the laboratory tests for biological causes of anaemia, including serum ferritin, soluble transferrin receptor, folic acid, homocysteine and vitamin B12.

RESULTS

A total of 754 children aged 6-23 months and their caregivers were surveyed, and 183 anaemic children aged 12-23 months were collected venous blood sample. The anaemia prevalence of children aged 6-23 months in Huzhu County was 59.1%. Children of younger age (OR=0.968, 95% CI 0.940 to 0.998), Tibetan nationality (OR=3.123, 95% CI 1.473 to 6.623) and not introducing meat (OR=0.698, 95% CI 0.499 to 0.976) were more likely to be anaemic. More than 80% of children with anaemia were due to iron deficiency (ID), and 20.2% of them had both iron and folic acid deficiencies.

CONCLUSIONS

The anaemia prevalence of children aged 6-23 months in Huzhu County was high and children of younger age, Tibetan nationality and not introducing meat were more likely to be anaemic. The main cause of anaemia was nutritional anaemia, with the vast majority being ID. Interventions of feeding counselling and nutrients supplements are appropriate and should be further strengthened.

TRIAL REGISTRATION NUMBER

ChiCTRPRC12002444.