Delivering Sprinkles Plus through the Integrated Child Development Services (ICDS) to reduce anemia in pre-school children in India

Iron deficiency anemia status in Iranian pregnant women and children: an umbrella systematic review and meta-analysis

BACKGROUND

Iron deficiency anemia (IDA) is a global health challenge, especially affecting females and children. We aimed to conduct an umbrella systematic review of available evidence on IDA's prevalence in Iranian pregnant women and children.

METHODS

We searched the Web of Science, Science Direct, PubMed, Scopus, and Google Scholar databases for articles published by April 2023. Meta-analyses investigating the status of IDA in Iran were included. The findings of seven meta-analyses comprising 189,627 pregnant women with a mean age of 26 and 5,890 children under six years old were included in this study. The methodological quality of each study was evaluated with the Assessment of Multiple Systematic Reviews (AMSTAR2) instrument.

RESULTS

We estimated the prevalence of IDA at 15.71% in pregnant women and 19.91% in young children. According to our subgroup analysis of pregnant women, IDA's prevalence in urban and rural regions was 16.32% and 12.75%; in the eastern, western, central, southern, and northern regions of Iran, it was estimated at 17.8%, 7.97%, 19.97%, 13.45%, and 17.82%, respectively.

CONCLUSION

IDA is common in young children and pregnant females and is a significant public health concern in Iran. The present umbrella review results estimated that Iran is in the mild level of IDA prevalence based on WHO classification. However, due to sanctions and high inflation in Iran, the prevalence of anemia is expected to increase in recent years. Multi-sectoral efforts are required to improve the iron status of these populations and reduce the burden of IDA in the country.

Barriers to and Facilitators of the Implementation of a Micronutrient Powder Program for Children: A Systematic Review Based on the Consolidated Framework for Implementation Research

BACKGROUND

As one of the most cost-effective investments for improving child nutrition, micronutrient powder (MNP) has been widely used in many countries to underpin the Sustainable Development Goals, yet challenges remain regarding its implementation on a large scale. However, few studies have explored the factors that facilitate or impede the implementation process using implementation science theories and frameworks. To address this gap, we adopted the Consolidated Framework of Implementation Research (CFIR) and conducted a systematic review of studies on the implementation barriers to and facilitators of MNP interventions.

METHOD

Five publication databases, including EMBASE, Medline, PubMed, Web of Science, and Scopus, were searched for studies on the influencing factors of MNP interventions. Based on the CFIR framework, the facilitators and barriers for the MNP program implementation reported in the included studies were extracted and synthesized by five domains: intervention characteristics, outer setting, inner setting, individual characteristics, and process.

RESULTS

A total of 50 articles were eligible for synthesis. The majority of the studies were conducted in lower-middle-income countries (52%) through the free delivery model (78%). The inner setting construct was the most prominently reported factor influencing implementation, specifically including available resources (e.g., irregular or insufficient MNP supply), structural characteristics (e.g., public-driven community-based approach), and access to information and knowledge (e.g., lack of training for primary-level workers). The facilitators of the engagement of private sectors, external guidelines, and regular program monitoring were also highlighted. On the contrary, monotonous tastes and occasional side effects impede intervention implementation. Additionally, we found that the inner setting had an interrelation with other contributing factors in the MNP program implementation.

CONCLUSION

Our results suggest that MNP program implementation was prominently influenced by the available resources, organizational structure, and knowledge of both providers and users. Mobilizing local MNP suppliers, engaging public-driven free models in conjunction with market-based channels, and strengthening the training for primary-level health workers could facilitate MNP interventions.

Conducting community-based pediatric research in rural India: Experience from vadu rural health program

This paper describes unique challenges faced during conduct of community research studies in rural population of Maharashtra at Vadu Rural Health Program, Pune, India. Some of the ethical issues faced include difficulty in comprehending the informed consent by rural families with low education levels and ensuring adequate compensation for study participation without undue inducement, ensuring large number of recruitments during early infancy, ensuring adherence to intervention by care-providers, retention of participants especially in studies having long follow-ups and regulatory compliance for serious adverse event reports are major operational challenges. The delays faced in approvals from the Health Ministry Screening Committee and lack of specific regulatory guidance on community-based conduct of studies pose challenges in terms of study timelines and operational aspect of these studies. Provision of study-related information during prestudy visits, designing patient information sheets in simple language, involving the decision-making member of the family, adequate time for families for decision-making are certain measures that have been useful for effective informed consent administration. Collaboration with accredited social health activists and auxillary nurse midwives for line-listing of pregnancies and births and regular conduction of prestudy visits or community sensitization meetings have been useful for the recruitment of large number of study participants during infancy. Strategies such as provision of universal immunization, selection of field research assistants from the local population, regular home visits, and provision of medical care has been helpful in retention of the study participants. Networking with local health facilities and local government bodies has helped in the provision of medical care to the study participants and in the management of serious adverse events. Our experience can provide important learnings to other investigators from developing countries working in the domain of child health.

A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency

BACKGROUND

Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools.

OBJECTIVES

This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity.

METHODS

We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools.

RESULTS

At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity.

CONCLUSIONS

Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.

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.

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.

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.

Prevalence of Undernutrition and Anemia among Santal Adivasi Children, Birbhum District, West Bengal, India

India’s Adivasi scheduled tribe population is disproportionately affected by undernutrition and anemia, thereby prevailing in the poorest wealth deciles denominated as socially and economically vulnerable. This study was designed to assess the extent of child undernutrition (conventional and composite index of anthropometric failure (CIAF) classification), as well as the burden of anemia in children and its independent nutrition specific and sensitive drivers, moreover to reflect the living conditions of Santal Adivasis. The research survey was conducted in 21 Santal villages, Birbhum District, West Bengal, in 2015. An overall 307 children (aged 6–39 months) and their mothers (n = 288) were assessed for their hemoglobin (Hb) levels (HemoCue Hb201+) and anthropometric indices such as height/length, weight and mid-upper arm circumference (MUAC). Moreover, socio-demographic household characteristics were surveyed. The study confirmed Adivasi children lagging behind national average with a high prevalence of undernutrition (height-for-age z-score (HAZ) 51.9%, weight-for-age z-score (WAZ) 49.2%, weight-for-height z-score WHZ 19.0% and CIAF 61.6%) and of moderate and severe anemia (Hb < 10 g/dL, 73.3% altogether). Child’s age <24 months, low WAZ scores, morbidity (any fever, diarrhea or respiratory infection) on the checkup day or during previous week, low maternal Hb level, and lack of dietary diversification were identified as predictors for anemia, thereby warrant targeted interventions to decrease the high anemia rates assessed in the study site.

Effectiveness of a home fortification programme with multiple micronutrients on infant and young child development: a cluster-randomised trial in rural Bihar, India

Research demonstrates the importance of nutrition for early brain development. Few studies have examined the effectiveness of multiple micronutrient powders (MNP) on child development. This study examined the impacts of home fortification with MNP on motor and mental development, executive function and memory of children living in Bihar. This two-arm cluster-randomised effectiveness trial selected seventy health sub-centres to receive either MNP and nutrition counselling (intervention) or nutrition counselling alone (control) for 12 months. Front-line health workers delivered the intervention to all households in study communities with a child aged 6-18 months. Data were collected using cross-sectional surveys at baseline and endline by selecting households from intervention (baseline, n 2184; endline, n 2170) and control (baseline, n 2176; endline, n 2122) communities using a two-stage cluster-randomised sampling strategy. Children in the intervention group had a significantly larger improvement from baseline to endline compared with those in the control group on scores for motor and mental development (Cohen's d, motor=0·12; 95 % CI 0·03, 0·22; mental=0·15; 95 % CI 0·06, 0·25). Greater impacts of MNP on motor and mental development were observed in children from households with higher stimulation scores at baseline compared with those with lower stimulation (Cohen's d, motor=0·20 v. 0·09; mental=0·22 v. 0·14; P interaction<0·05). No significant treatment differences were seen for executive function or memory. Home fortification with MNP through the existing health infrastructure in Bihar was effective in improving motor and mental development and should be considered in combination with other child development interventions such as stimulation.

Changes in growth, anaemia, and iron deficiency among children aged 6-23 months in two districts in Nepal that were part of the post-pilot scale-up of an integrated infant and young child feeding and micronutrient powder intervention

There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross-sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6-23 months in two districts in Nepal that were part of a post-pilot scale-up of a IYCF-MNP programme. Multivariable log-binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length-for-age z-score <-2), wasting (weight-for-length z-score <-2), underweight (weight-for-age z-score <-2), anaemia (altitude-adjusted haemoglobin <110 μg/L), moderate or severe anaemia (altitude-adjusted haemoglobin <100 g/L), iron deficiency (inflammation-adjusted ferritin <12 μg/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers' interactions with female community health volunteers (FCHVs; >1× per month or monthly vs. <1× per month) and MNP coverage (1 or ≥2 distributions vs. none among children 12-23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable-adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal-FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF-MNP programmes to improve children's nutritional status.

Multiple micronutrient status and predictors of anemia in young children aged 12-23 months living in New Delhi, India

Anemia has been identified as a severe public health concern among young children in India, however, information on the prevalence of anemia attributed to micronutrient deficiencies is lacking. We aimed to assess multiple micronutrient status (iron, zinc, selenium, vitamin A, vitamin D, folate and vitamin B12) in young Indian children and to investigate the role of these seven micronutrients and other non-nutritional factors on hemoglobin concentrations and anemia. One-hundred and twenty children aged 12 to 23 months were included in a cross-sectional nutritional assessment survey, of which 77 children provided a blood sample. Hemoglobin (Hb), serum ferritin, soluble transferrin receptor (sTfR), total body iron, zinc, selenium, retinol binding protein (RBP), folate, vitamin B12 and 25-hydroxyvitamin D (25(OH)D) were measured, and adjusted for inflammation using C-reactive protein (CRP) and α-1-acid glycoprotein (AGP), where appropriate. Predictors for hemoglobin and anemia were identified in multiple regression models. Most of the children were classified as anemic, of which 86 to 93% was associated with iron deficiency depending on the indicator applied. Deficiencies of folate (37%), and notably vitamin D (74%) were also common; fewer children were classified with deficiencies of vitamin B12 (29%), zinc (25%), and vitamin A (17%) and selenium deficiency was nearly absent. Multiple micronutrient deficiencies were common with over half (57%) deficient in three or more micronutrients, and less than 10% of children were classified with adequate status for all the micronutrients measured. Iron status was found to be the only nutritional factor statistically significantly inversely associated with anemia (P = 0.003) in multivariate analysis after controlling for sex. A coordinated multi-micronutrient program is urgently needed to combat the co-existing micronutrient deficiencies in these young children to improve micronutrient status and reduce the high burden of childhood anemia.

Designing programs to improve diets for maternal and child health: estimating costs and potential dietary impacts of nutrition-sensitive programs in Ethiopia, Nigeria, and India

Improving maternal and child nutrition in resource-poor settings requires effective use of limited resources, but priority-setting is constrained by limited information about program costs and impacts, especially for interventions designed to improve diet quality. This study utilized a mixed methods approach to identify, describe and estimate the potential costs and impacts on child dietary intake of 12 nutrition-sensitive programs in Ethiopia, Nigeria and India. These potential interventions included conditional livestock and cash transfers, media and education, complementary food processing and sales, household production and food pricing programs. Components and costs of each program were identified through a novel participatory process of expert regional consultation followed by validation and calibration from literature searches and comparison with actual budgets. Impacts on child diets were determined by estimating of the magnitude of economic mechanisms for dietary change, comprehensive reviews of evaluations and effectiveness for similar programs, and demographic data on each country. Across the 12 programs, total cost per child reached (net present value, purchasing power parity adjusted) ranged very widely: from 0.58 to 2650 USD/year among five programs in Ethiopia; 2.62 to 1919 USD/year among four programs in Nigeria; and 27 to 586 USD/year among three programs in India. When impacts were assessed, the largest dietary improvements were for iron and zinc intakes from a complementary food production program in Ethiopia (increases of 17.7 mg iron/child/day and 7.4 mg zinc/child/day), vitamin A intake from a household animal and horticulture production program in Nigeria (335 RAE/child/day), and animal protein intake from a complementary food processing program in Nigeria (20.0 g/child/day). These results add substantial value to the limited literature on the costs and dietary impacts of nutrition-sensitive interventions targeting children in resource-limited settings, informing policy discussions and serving as critical inputs to future cost-effectiveness analyses focusing on disease outcomes.

Micronutrient Fortification at Child-Care Centers Reduces Anemia in Young Children

The aim of this study was to evaluate the effectiveness of NutriSUS micronutrient fortification, in infants aged 12-36 months, for the prophylaxis and treatment of iron deficiency anemia. In this cluster-randomized clinical trial study, we evaluated infants aged 12-36 months. Length of intervention was 12 weeks. Children were cluster randomized to either NutriSUS micronutrient fortification (Group A) or control (Group B). Primary outcome variables were change in hemoglobin concentration and anemia prevalence. Two biochemical evaluations were performed to determine hemoglobin concentrations: before and after intervention. This study was conducted in eight child-care centers located within the urban perimeter of the municipality of Sobral, Ceará, in the northeast of Brazil. For Group A, baseline mean hemoglobin concentration was 11.4 ± 1.01 g/dL; after intervention it was 11.9 ± 0.90 g/dL (p = .006); 15 of 20 participants who were anemic at baseline had normal Hb levels after intervention. Number needed to treat = 2. In group B, mean baseline hemoglobin was 11.9 ± 0.89 g/dL; after intervention it was 12.2 ± 0.92 g/dL (p = .58); 4 of 5 participants who were anemic at baseline remained anemic after intervention. In our study, NutriSUS micronutrient fortification provided a beneficial effect on Hb values, reducing the prevalence of anemia. However, further studies are necessary to confirm the effectiveness of this intervention in populations on a larger scale.

Infant and Young Child Feeding (IYCF) Practices Improved in 2 Districts in Nepal during the Scale-Up of an Integrated IYCF and Micronutrient Powder Program

BACKGROUND

Three-quarters of the ≥50 programs that use micronutrient powders (MNPs) integrate MNPs into infant and young child feeding (IYCF) programs, with limited research on impacts on IYCF practices.

OBJECTIVE

This study assessed changes in IYCF practices in 2 districts in Nepal that were part of a post-pilot scale-up of an integrated IYCF-MNP program.

METHODS

This analysis used cross-sectional surveys (n = 2543 and 2578 for baseline and endline) representative of children aged 6-23 mo and their mothers in 2 districts where an IYCF program added MNP distributions through female community health volunteers (FCHVs) and health workers (HWs). Multivariable log-binomial models estimated prevalence ratios comparing reported IYCF at endline with baseline and at endline on the basis of exposure to different sources of IYCF information. Mothers who received FCHV-IYCF counseling with infrequent (≤1 time/mo) and frequent (>1 time/mo) interactions were compared with mothers who never received FCHV-IYCF counseling. The receipt of HW-IYCF counseling and receipt of MNPs from an FCHV (both yes or no) were also compared.

RESULTS

The prevalence of minimum dietary diversity (MDD) and minimum acceptable diet (MAD) was significantly higher at endline than at baseline. In analyses from endline, compared with mothers who never received FCHV counseling, only mothers in the frequent FCHV-IYCF counseling group were more likely to report feeding the minimum meal frequency (MMF) and MAD, with no difference for the infrequent FCHV-IYCF counseling group in these indicators. HW-IYCF counseling was not associated with these indicators. Mothers who received MNPs from their FCHV were more likely to report initiating solid foods at 6 mo and feeding the child the MDD, MMF, and MAD compared with mothers who did not, adjusting for HW- and FCHV-IYCF counseling and demographic covariates.

CONCLUSIONS

Incorporating MNPs into the Nepal IYCF program did not harm IYCF and may have contributed to improvements in select practices. Research that uses experimental designs should verify whether integrated IYCF-MNP programs can improve IYCF practices.

Experiences and lessons learned for delivery of micronutrient powders interventions

An effective delivery strategy coupled with relevant social and behaviour change communication (SBCC) have been identified as central to the implementation of micronutrient powders (MNP) interventions, but there has been limited documentation of what works. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," three working groups were formed to summarize experiences and lessons across countries regarding MNP interventions for young children. This paper focuses on programmatic experiences related to MNP delivery (models, platforms, and channels), SBCC, and training. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that most countries distributed MNP free of charge via the health sector, although distribution through other platforms and using subsidized fee for product or mixed payment models have also been used. Community-based distribution channels have generally shown higher coverage and when part of an infant and young child feeding approach, may provide additional benefit given their complementarity. SBCC for MNP has worked best when focused on meeting the MNP behavioural objectives (appropriate use, intake adherence, and related infant and young child feeding behaviours). Programmers have learned that reincorporating SBCC and training throughout the intervention life cycle has allowed for much needed adaptations. Diverse experiences delivering MNP exist, and although no one-size-fits-all approach emerged, well-established delivery platforms, community involvement, and SBCC-centred designs tended to have more success. Much still needs to be learned on MNP delivery, and we propose a set of implementation research questions that require further investigation.

Usual nutrient intake adequacy among young, rural Zambian children

Inadequate nutrient intakes put children at risk for impaired growth and development. We described diet, usual intakes of energy and macro- and micronutrients and prevalence of nutrient intake adequacies among 4–8-year-old Zambian children. Children not yet in school and living in Mkushi District, Central Province, Zambia were enrolled into an efficacy trial of pro-vitamin A biofortified maize. Children in the non-intervened arm were included in this analysis (n 202). Dietary intake data were collected by tablet-based 24-h recall on a monthly basis over the 6-month trial. Observed nutrient intakes were derived from reported food quantities, standard recipes and food composition tables. Usual nutrient intake distributions were modelled based on observed intakes. Prevalence of inadequacy was estimated by comparing the usual nutrient intake distribution to the nutrient requirement distribution. Frequency and quantity of consumption of commonly reported foods were described and key sources of energy and nutrients were identified. Median usual energy intake was 6422 kJ/d (1535 kcal/d). Most childrens’ macronutrient intakes fell within recommended ranges (74–98 %). Estimated prevalences of inadequate intakes of Fe, folate, vitamin B12 and Ca were 25, 57, 76 and >99 %, respectively. Estimated prevalences of inadequacy for other micronutrients were low (0·1–2·2 %). Commonly consumed foods included maize, vegetable oil, tomatoes, rape leaves and small fish (>0·6 servings/d), whereas meat, eggs or dairy were rarely eaten (<0·2 servings/d). These findings suggest that the heavily plant-based diet of rural Zambian children provides inadequate Ca, folate, vitamin B12 and Fe to meet recommended nutrient intakes.

Point-of-use fortification of foods with micronutrient powders containing iron in children of preschool and school-age

BACKGROUND

Approximately 600 million children of preschool and school age are anaemic worldwide. It is estimated that at least half of the cases are due to iron deficiency. Point-of-use fortification of foods with micronutrient powders (MNP) has been proposed as a feasible intervention to prevent and treat anaemia. It refers to the addition of iron alone or in combination with other vitamins and minerals in powder form, to energy-containing foods (excluding beverages) at home or in any other place where meals are to be consumed. MNPs can be added to foods either during or after cooking or immediately before consumption without the explicit purpose of improving the flavour or colour.

OBJECTIVES

To assess the effects of point-of-use fortification of foods with iron-containing MNP alone, or in combination with other vitamins and minerals on nutrition, health and development among children at preschool (24 to 59 months) and school (five to 12 years) age, compared with no intervention, a placebo or iron-containing supplements.

SEARCH METHODS

In December 2016, we searched the following databases: CENTRAL, MEDLINE, Embase, BIOSIS, Science Citation Index, Social Science Citation Index, CINAHL, LILACS, IBECS, Popline and SciELO. We also searched two trials registers in April 2017, and contacted relevant organisations to identify ongoing and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs trials with either individual or cluster randomisation. Participants were children aged between 24 months and 12 years at the time of intervention. For trials with children outside this age range, we included studies where we were able to disaggregate the data for children aged 24 months to 12 years, or when more than half of the participants were within the requisite age range. We included trials with apparently healthy children; however, we included studies carried out in settings where anaemia and iron deficiency are prevalent, and thus participants may have had these conditions at baseline.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 13 studies involving 5810 participants from Latin America, Africa and Asia. We excluded 38 studies and identified six ongoing/unpublished trials. All trials compared the provision of MNP for point-of-use fortification with no intervention or placebo. No trials compared the effects of MNP versus iron-containing supplements (as drops, tablets or syrup).The sample sizes in the included trials ranged from 90 to 2193 participants. Six trials included participants younger than 59 months of age only, four included only children aged 60 months or older, and three trials included children both younger and older than 59 months of age.MNPs contained from two to 18 vitamins and minerals. The iron doses varied from 2.5 mg to 30 mg of elemental iron. Four trials reported giving 10 mg of elemental iron as sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), chelated ferrous sulphate or microencapsulated ferrous fumarate. Three trials gave 12.5 mg of elemental iron as microencapsulated ferrous fumarate. Three trials gave 2.5 mg or 2.86 mg of elemental iron as NaFeEDTA. One trial gave 30 mg and one trial provided 14 mg of elemental iron as microencapsulated ferrous fumarate, while one trial gave 28 mg of iron as ferrous glycine phosphate.In comparison with receiving no intervention or a placebo, children receiving iron-containing MNP for point-of-use fortification of foods had lower risk of anaemia prevalence ratio (PR) 0.66, 95% confidence interval (CI) 0.49 to 0.88, 10 trials, 2448 children; moderate-quality evidence) and iron deficiency (PR 0.35, 95% CI 0.27 to 0.47, 5 trials, 1364 children; moderate-quality evidence) and had higher haemoglobin (mean difference (MD) 3.37 g/L, 95% CI 0.94 to 5.80, 11 trials, 2746 children; low-quality evidence).Only one trial with 115 children reported on all-cause mortality (zero cases; low-quality evidence). There was no effect on diarrhoea (risk ratio (RR) 0.97, 95% CI 0.53 to 1.78, 2 trials, 366 children; low-quality evidence).

AUTHORS' CONCLUSIONS

Point-of-use fortification of foods with MNPs containing iron reduces anaemia and iron deficiency in preschool- and school-age children. However, information on mortality, morbidity, developmental outcomes and adverse effects is still scarce.

The Impact of Integrated Infant and Young Child Feeding and Micronutrient Powder Intervention on Feeding Practices and Anemia in Children Aged 6-23 Months in Madagascar

This study assesses the impact of an integrated infant and young child feeding (IYCF) and micronutrient powder (MNP) intervention on children’s risk of anemia and IYCF practices in Madagascar. Quantitative baseline and endline surveys were conducted in representative households with children 6–23 months from two districts, where an 18-month IYCF-MNP intervention was implemented. Relative risks comparing children’s risk of anemia and maternal IYCF knowledge and practices at baseline versus endline, and also at endline among MNP-users versus non-users were estimated using log-binomial regression models. 372 and 475 children aged 6–23 months were assessed at baseline and endline respectively. Prevalence of anemia fell from 75.3% to 64.9% from baseline to endline (p = 0.002); the reduction in the risk of anemia remained significant in models adjusting for sociodemographic characteristics (ARR (95% CI): 0.86 (0.78, 0.95), p = 0.003). In endline assessments, 229 out of 474 (48.3%) of children had consumed MNPs. MNP-users had a lower risk of anemia (ARR (95% CI): 0.86 (0.74, 0.99), p = 0.04) than non-users, after controlling for child’s dietary diversity and morbidity, maternal counseling by community-health-workers, and sociodemographic characteristics. Mothers interviewed at endline also had greater nutrition knowledge and were more likely to feed their children ≥4 food groups (ARR (95% CI): 2.92 (2.24, 3.80), p < 0.001), and the minimum acceptable diet (ARR (95% CI): 2.88 (2.17, 3.82), p < 0.001) than mothers interviewed at baseline. Integration of MNP into IYCF interventions is a viable strategy for improving children’s consumption of micronutrients and reducing risk of anemia. The addition of MNP does not negatively impact, and may improve, IYCF practices.

Toward a Better Understanding of Adherence to Micronutrient Powders: Generating Theories to Guide Program Design and Evaluation Based on a Review of Published Results

Background: The Global Alliance for Improved Nutrition is conducting theory-driven process evaluations of micronutrient powder (MNP) programs. Objective: The aim was to generate preliminary theories about factors affecting adherence to recommendations with regard to point-of-use fortification of foods with MNPs. Methods: A literature search was conducted to identify documents with content related to adherence to MNPs as an intervention provided at home to children 6-59 mo of age. Thirty-five studies and 6 program descriptions were identified. We used thematic analyses to generate a comprehensive list of factors that could influence adherence, followed by content analysis to quantify the results. We developed a Program Impact Pathway to concretize the points at which the factors identified affect the process of adherence. Results: In the set of documents reviewed (n = 41), the most influential factors, measured by number of documents reporting the factor having effect, were 1) caregivers' perception of positive changes as a result of MNP use (n = 14), 2) caregivers' perceived child acceptance of food with MNPs (n = 12), and 3) caregivers' forgetfulness (n = 11). Behavior change communication channels (n = 13) and messages (n = 12) were the most frequently reported program design features influencing caregiver knowledge and subsequent adherence. Administration regimen (n = 10), which may be related to caregivers' capacity to remember to give MNPs, was also a frequently cited program design feature affecting adherence. Conclusions: The preponderance of knowledge and perception factors may reflect an underlying theoretical bias among researchers as to what they measure. To achieve programs that support greater adherence, we need to adopt a cultural-ecological perspective to inform program design in order to address a broader set of determinants. Studies that assess progress across the impact pathway, particularly from adherence to biological outcomes, would also provide guidance for evaluation studies, particularly when time or other constraints limit the potential to measure biological outcomes.

Micronutrient powder distribution through Maternal, Neonatal and Child Health Weeks in Nigeria: process evaluation of feasibility and use

OBJECTIVE

To determine the feasibility of distributing micronutrient powders (MNP) for home fortification during biannual Maternal, Neonatal and Child Health Week (MNCHW) events, as a strategy to improve young child nutrition.

DESIGN

We evaluated the coverage, delivery, use and adherence of MNP, and associated behaviour change communication (BCC) materials and social mobilization, through cross-sectional surveys of caregivers attending health-service distribution events and health workers involved in MNP distribution, facility-based observations of MNP distribution activities and a repeated survey of caregivers in their homes who received MNP for their child.

SETTING

Four Local Government Areas in Benue State, Nigeria.

SUBJECTS

Caregivers of children 6-59 months of age attending health-service distribution events.

RESULTS

The 8 million MNP delivered in this pilot during three distribution events were estimated to reach about one-third of eligible children in the area at each event. Programme fidelity was limited by shortages of MNP, BCC materials and inadequate social mobilization, with some limitations in health worker training and engagement. MNP use was consistent with the recommended two or three sachets per week among 51-69 % of caregivers surveyed at home.

CONCLUSIONS

MNP coverage was low, but consistent with that typically achieved with other services delivered through MNCHW in Benue. Among caregivers who received MNP, acceptance and use among targeted children was high. While some weaknesses in knowledge and delivery of MNP by health workers were observed, health system strengthening and more extensive social mobilization would be key to achieving higher coverage with MNP and other health services provided through MNCHW.

Process evaluation of a national school-based iron supplementation program for adolescent girls in Iran

Background

Iron deficiency anemia remains as one of the most common nutritional problems in Iran, especially in women and girls. A process evaluation study of the national iron supplementation program targeting girls attending high schools was conducted to examine degree of exposure and satisfaction of the targets with the intervention components, and to assess the delivery (quantity), fidelity (quality), and environmental mediators of the intervention.

Methods

Three assessment tools were developed and used for the process evaluation. A total of 8 schools were selected using a simple randomization method. Data were collected from students (n = 658 of 661 participants), teachers (n = 80), and school principals (n = 7 of 8). For the qualitative measures semi-structured interviews were conducted with the three study groups.

Results

Mean continuous compliance was 62.3%. Intolerance to pills and no water supply in classrooms accounted for 47.72% and 36.21% of the refusals, respectively. The refusal rate was significantly correlated (p < 0.001) with the absence of a classroom water supply, and with each student’s knowledge of iron deficiency issues (p < 0.05). The odds of refusal in the absence of a classroom water supply were 2.02 (95% CI 1 · 044 to 3 · 900) times greater than for those classrooms with a water supply. Student exposure to the program’s goal was satisfactory; however, delivery and fidelity of educational materials and training sessions were inadequate.

Conclusions

The findings suggest that the methods of delivery and the fidelity of the program components, education materials and training sessions were insufficient and need to be improved. Additionally, specific attention has to be given to contextual factors to ensure the success of the program.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-959) contains supplementary material, which is available to authorized users.