Growth and micronutrient status in children receiving a fortified complementary food

The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review

BACKGROUND

Low-income and middle-income countries (LMICs) experiencing nutrition transition face an increasing double burden of malnutrition (DBM). WHO has urged the identification of risks and opportunities in nutrition interventions to mitigate the DBM, but robust evidence is missing. This review summarises the effect of nutrition-specific and nutrition-sensitive interventions on undernutrition and overnutrition in LMICs.

METHODS

We searched four major databases and grey literature for publications in English, French, Portuguese, and Spanish from Jan 1, 2000, to Aug 14, 2023. Eligible studies evaluated nutrition-specific or nutrition-sensitive interventions on both undernutrition and overnutrition, employing robust study designs (individually randomised, cluster randomised, and non-randomised trials; interrupted time series; controlled before-after; and prospective cohort studies). Studies were synthesised narratively, and classified as DBM-beneficial, potentially DBM-beneficial, DBM-neutral, potentially DBM-harmful, and DBM-harmful, using vote counting. This review is registered with PROSPERO (CRD42022320131).

FINDINGS

We identified 26 studies evaluating 20 nutrition-specific (maternal and child health [MCH] and school-based programmes) and six nutrition-sensitive (conditional cash transfers and other social policies) interventions. Seven of eight MCH interventions providing food-based or nutritional supplements indicated possible DBM-harmful effects, associated with increased maternal or child overweight. Most school-based programmes and MCH interventions that target behavioural change were considered potentially DBM-beneficial. Two studies of conditional cash transfers suggested DBM-beneficial effects in children, whereas one indicated potentially harmful effects on maternal overweight. A study on a family planning service and one on an education reform revealed possible long-term harmful effects on obesity.

INTERPRETATION

There is considerable scope to repurpose existing nutrition interventions to reduce the growing burden of the DBM in LMICs. In settings undergoing rapid nutrition transition, specific policy attention is required to ensure that food-based or supplement-based MCH programmes do not unintentionally increase maternal or child overweight. Consistent reporting of undernutrition and overnutrition outcomes in all nutrition interventions is essential to expand the evidence base to identify and promote interventions maximising benefits and minimising harms on the DBM.

FUNDING

President's Scholarship (Imperial College London) and National Institute for Health and Care Research.

TRANSLATIONS

For the Portuguese, Spanish and French translations of the abstract see Supplementary Materials section.

Global Trends in the Availability of Dietary Data in Low and Middle-Income Countries

Individual-level quantitative dietary data can provide suitably disaggregated information to identify the needs of all population sub-groups, which can in turn inform agricultural, nutrition, food safety, and environmental policies and programs. The purpose of this discussion paper is to provide an overview of dietary surveys conducted in low- and middle-income countries (LMICs) from 1980 to 2019, analyzing their key characteristics to understand the trends in dietary data collection across time. The present study analyzes the information gathered by the Food and Agriculture Organization of the United Nations/World Health Organization Global Individual Food consumption data Tool (FAO/WHO GIFT). FAO/WHO GIFT is a growing repository of individual-level dietary data and contains information about dietary surveys from around the world, collected through published survey results, literature reviews, and direct contact with data owners. The analysis indicates an important increase in the number of dietary surveys conducted in LMICs in the past four decades and a notable increase in the number of national dietary surveys. It is hoped that this trend continues, together with associated efforts to validate and standardize the dietary methods used. The regular implementation of dietary surveys in LMICs is key to support evidence-based policies for improved nutrition.

Identifying Targets for the Prevention of Childhood Undernutrition in a Resource-Limited Peri-Urban Ecuadorian Community

BACKGROUND

In middle-income countries, malnutrition concentrates in marginalized populations with a lack of effective preventive strategies.

OBJECTIVE

Identify risk factors for undernutrition in a peri-urban Ecuadorian community of children aged 12 to 59 months.

METHODS

Data from a cross-sectional survey in 2011 of children 1 to 5 years were analyzed including demographic data, medical history and examination, food frequency questionnaire (FFQ), anthropometric measurements, and blood for complete blood count, C-reactive protein, vitamin A, iron, and zinc levels. Dietary Diversity Score (DDS) was calculated from FFQ. Bivariate and multivariate analysis assessed effects on primary outcome of undernutrition by DDS, vitamin deficiencies, and demographic and nutritional data.

RESULTS

N = 67, 52.2% undernourished: 49.3% stunted, 25.4% underweight, and 3% wasted; 74.6% (n = 50) were anemic and 95.1% (n = 39) had low serum zinc. Dietary Diversity Score was universally low (mean 4.91 ± 1.36, max 12). Undernutrition was associated with lower vitamin A levels (20 306, IQR: 16605.25-23973.75 vs 23665, IQR: 19292-26474 ng/mL, P = .04); underweight was associated with less parental report of illness (43.8%, n = 7 vs 80% n = 40, P = .005) and higher white blood count (13.7, IQR: 11.95-15.8 vs 10.9, IQR: 7.8-14.23 × 10⁹/L, P = .02). In multiple regression, risk of undernutrition decreased by 4% for every $10 monthly income increase (95 CI%: 0.5%-7.4%, P = .02, n = 23); risk of underweight decreased by 0.06 for every increased DDS point (adjusted odds ratio: 0.06; 95 CI%: 0.004-0.91, P = .04, n = 23).

CONCLUSIONS

In this peri-urban limited-resource, mostly Indigenous Ecuadorian community, stunting exceeds national prevalence, lower monthly income is the strongest predictor of undernutrition, lower DDS can predict some forms of undernutrition, and vitamin deficiencies are associated with but not predictive of undernutrition.

Low prevalence of anemia among Shuar communities of Amazonian Ecuador

OBJECTIVE

Anemia is an important global health challenge. We investigate anemia prevalence among Indigenous Shuar of Ecuador to expand our understanding of population-level variation, and to test hypotheses about how anemia variation is related to age, sex, and market integration.

METHODS

Hemoglobin levels were measured in a total sample of 1650 Shuar participants (ages 6 months to 86 years) from 46 communities between 2008 and 2017 to compare anemia prevalence across regions characterized by different levels of market integration.

RESULTS

Shuar anemia rates among children under 15 years (12.2%), adult women (10.5%), and adult men (5.3%) were less than half of those previously documented in other neo-tropical Indigenous populations. Anemia prevalence did not vary between more traditional and market integrated communities (OR = 0.47, p = .52). However, anemia was negatively associated with body mass index (OR = 0.47, p = .002).

CONCLUSIONS

Compared to other South American Indigenous populations, anemia prevalence is relatively low among Shuar of Ecuador and invariant with market integration. Understanding this pattern can provide valuable insights into anemia prevention among at-risk populations.

Impact of Infant and Young Child Feeding (IYCF) Nutrition Interventions on Breastfeeding Practices, Growth and Mortality in Low- and Middle-Income Countries: Systematic Review

Undernutrition is associated with 45% of total infant deaths, totalling 2.7 million globally per year. The vast majority of the burden is felt in low- and middle-income countries (LMICs). This review aims to assess the effectiveness of infant and young child feeding (IYCF) interventions. We searched multiple databases including Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE. Title/abstract screening and full-text screening and data extraction filtered 77 studies for inclusion. Breastfeeding education interventions (n = 38) showed 20% increase in rates of early initiation of breastfeeding, 102% increase in exclusive breastfeeding (EBF) at 3 months and 53% increase in EBF at 6 months and 24% decreases in diarrheal diseases. Complementary feeding education intervention (n=12) showed a 0.41 standard deviation (SD) increase in WAZ, and 0.25 SD in HAZ in food secure setting. Complementary food provision with or without education (n=17) showed a 0.14 SD increase in HAZ and 36% decrease in stunting. Supplementary food interventions (n=12) showed a significant 0.15 SD increase in WHZ. Subgroup analyses showed healthcare professional led interventions were largely more effective, especially on breastfeeding outcomes. We believe this is a comprehensive review of the existing literature on IYCF studies in LMICs. Though breastfeeding education is well supported in its effectiveness on breastfeeding practices, limited evidence exists for growth outcomes. Supplementation interventions seem to have better effects at improving growth. However, more research is required to reach more substantial conclusions.

Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming.

Effectiveness of a locally produced ready-to-use supplementary food in preventing growth faltering for children under 2 years in Cambodia: a cluster randomised controlled trial

This cluster randomised controlled trial tested the effectiveness of a locally produced, fish-based, ready-to-use supplementary food (RUSF) to prevent growth faltering (decline in z-scores). Cambodian infants (n= 485), aged 6 to 11 months, were randomised by site to receive the RUSF, Corn-Soy Blend++ (CSB++), micronutrient powders (MNP), or no supplement (control). The intervention was for 6 months. In unadjusted analysis, the control group had statistically significantly decreased weight-for-age z-scores (WAZ; -0.02, 95%CI = -0.03 - -0.01, P= 0.001) and height-for-age z-scores (HAZ; -0.07, 95%CI = -0.09 - -0.05, P < 0.001), and increased mid-upper arm-circumference (MUAC; 0.02cm, 95%CI = 0.01 - 0.04, P = 0.010), but no statistically significant change in weight-for-height z-scores (WHZ). The RUSF group did not differ significantly from the control for WAZ, HAZ or WHZ (in other words, WAZ and HAZ decreased and WHZ did not change), but had increased MUAC in comparison to the control (0.04cm, 95%CI = 0.01 - 0.06, P = 0.008). There were no statistically significant differences between the RUSF group and the CSB++ or MNP groups with respect to WAZ, HAZ, WHZ or MUAC. Interestingly, in adjusted analysis, low consumers of RUSF had increased WAZ, WHZ and MUAC (0.03, 95%CI = 0.01-0.06, P = 0.006; 0.04, 95%CI = 0.01-0.08, P = 0.026; and 0.05cm, 95%CI = 0.02-0.09, P = 0.004, respectively) compared with the control. The novel RUSF, particularly in small quantities, protected against ponderal growth faltering, but the improvements were of limited clinical significance.

Food fortification with multiple micronutrients: impact on health outcomes in general population

BACKGROUND

Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

OBJECTIVES

To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

SEARCH METHODS

We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

MAIN RESULTS

We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

AUTHORS' CONCLUSIONS

The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

Multi-Micronutrient Fortified Rice Improved Serum Zinc and Folate Concentrations of Cambodian School Children. A Double-Blinded Cluster-Randomized Controlled Trial

BACKGROUND

Within Cambodia, micronutrient deficiencies continue to be prevalent in vulnerable groups, such as women and children. Fortification of staple foods such as rice could be a promising strategy for Cambodia to improve micronutrient status.

OBJECTIVE

Our objective was to investigate the impact of multiple-micronutrient fortified rice (MMFR), distributed through a World Food Program school-meals program (WFP-SMP) on serum zinc concentrations and folate status in a double-blind, cluster-randomized, placebo-controlled trial.

METHODS

Sixteen schools were randomly assigned to receive one of three different types of extruded-fortified rice (UltraRice Original (URO), UltraRice New (URN), or NutriRice) or unfortified rice (placebo) six days a week for six months. A total of 1950 schoolchildren (6-16 years old) participated in the study. Serum zinc (all groups) and folate (only in NutriRice and placebo group) concentrations were assessed from morning non-fasting antecubital blood samples and were measured at three time points (baseline and after three and six months).

RESULTS

After six months of intervention, serum zinc concentrations were significantly increased in all fortified rice group compared to placebo and baseline (0.98, 0.85 and 1.40 µmol/L for URO, URN and NutriRice, respectively) (interaction effect: p < 0.001 for all). Children in the intervention groups had a risk of zinc deficiencies of around one third (0.35, 039, and 0.28 for URO, URN, and NutriRice, respectively) compared to the placebo (p < 0.001 for all). The children receiving NutriRice had higher serum folate concentrations at endline compared to children receiving normal rice (+ 2.25 ng/mL, p = 0.007).

CONCLUSIONS

This study showed that the high prevalence of zinc and folate deficiency in Cambodia can be improved through the provision of MMFR. As rice is the staple diet for Cambodia, MMFR should be considered to be included in the school meal program and possibilities should be explored to introduce MMFR to the general population.

Assessing the dietary intake of calcium, magnesium, iron, zinc and copper in institutionalised children and adolescents from Guatemala. Contribution of nutritional supplements

In childhood and adolescence an adequate mineral intake is essential for normal growth and immune function, and to prevent chronic diseases in adulthood. The aim of this study was to analyse the dietary intake of Ca, Mg, Fe, Zn and Cu in children and adolescents from an orphanage-school in Guatemala and to assess the mineral contribution of nutritional supplements used by this population. Mineral content was analysed in nutritional supplements, bioaccesible fractions obtained after an in vitro gastrointestinal method, and diets sampled by a 7-day duplicate diet study. The average mineral content in the duplicate diets, including supplements, was (mg/d): Ca 452, Mg 230, Fe 25, Zn 8 and Cu 0.22. Especially Ca and Cu values were below recommended daily intakes. The content of these minerals in the nutritional supplements (mg/serving) was 49-112 for Ca, 1.2-3.8 for Fe, 24-47 for Mg, 0.7-4.16 for Zn and 0.08-0.23 for Cu. A great proportion of dietary minerals was provided by supplements, the contribution of which was: Ca 53.1%, Mg 58.4%, Fe 27.6%. Zn 82.2% and Cu 98.5%. Mineral bioaccessibility in supplements was particularly low for Ca and, to a lesser extent, for Fe and Zn. In spite of the high supplement consumption (up to 4 servings/d) important mineral deficiencies were detected in the diet of institutionalised children. Findings suggest that formulation and nutritional values of supplements used in Latin America should be carefully reviewed, in order to be a useful tool in the prevention and treatment of hidden hunger.

Development of Acute Malnutrition Despite Nutritional Supplementation in Malawi

Malnutrition in children is most often attributed to inadequate nutrient intake. Utilizing data from 2 prospective, randomized controlled trials of complimentary feeding with supplemental legumes (n = 693, ages 6-24 months) in 2 Malawian villages, Masenjere, and Limera, we document a high rate 70/693 (10.1%) of acute malnutrition (AM). Risks for AM in this setting, as determined by Cox regression analysis, include study village (hazard ratio [HR] 3.0), prior malnutrition (HR 4.12), stunting (HR 2.87), and a marker of food insecurity (HR 1.89). Comparison of Masenjere to Limera demonstrate adequate and similar nutritional intake yet an increased rate of AM in Masenjere, 56 of 400 (14.0%) versus 14 of 293 (4.8%), and stunting, 140 of 400 (35%) versus 80 of 293 (27%), environmental enteric dysfunction 246 of 400 (71%) versus 181/293 (67%), and infectious symptoms (cough and diarrhea). Masenjere did have cleaner water and less food insecurity 200 of 399 (50.5%) versus 204 of 293 (69.6%). These findings suggest adequate complementary nutrient intake does not protect young children against AM.

Effects of complementary feeding on attained height among lower primary school-aged children in Eastern Uganda: A nested prospective cohort study

BACKGROUND

Despite the fact that Uganda has been a signatory to the global strategy for Infant and Young Children Feeding practices (IYCF) for nearly a decade, the prevalence of stunting among children under five years of age remains tragically high at 17% in Eastern Uganda and twofold higher countrywide. Only 6% of all children aged 6-23 months feed adequately. This study aimed to establish the covariates of complementary feeding (CF) and its effect on attained height among primary school-aged children in Mbale district (Eastern Uganda).

METHODS

This was a community-based prospective cohort study using data from the PROMISE EBF trial. The main exposure variable was adequate complementary feeding (CF) measured in a parent questionnaire at 18-24 months of age. We defined adequate CF as having received animal food, cereals and fruit, juice and/or vegetables during the 24 hours preceding the interview. An adapted minimum acceptable diet was defined as having been given milk or milk products at least twice a day, an adapted meal frequency of two and solid or semi-solid food from at least four food groups on a 24-hour dietary recall based on modified IYCF criteria. The main outcome variable was attained height [(height-for-age Z score (HAZ)] measured between five and eight years of age using the WHO growth standards. Effects of CF on HAZ were estimated using linear regression analyses with cluster-robust standard errors.

RESULTS

A total of 506 children were studied. The majority (85%) were from rural areas and the average age at the end of the study was 6.9 (standard deviation: 0.63) years. Of these, 23.9% were adequately fed and 2.3% received the adapted minimum acceptable diet. Adequate CF was not associated with HAZ (adjusted β = -0.111; 95% CI: -0.363, 0.141; p = 0.374). Factors significantly associated with attained height were baseline HAZ (0.262; 0.152, 0.374; p<0.001) and WHZ (-0.147; -0.243, -0.051; p = 0.004), child's age (0.454; -0.592, -0.315; p<0.001) and maternal education (0.030; 95% CI: 0.003, 0.057; p = 0.034).

CONCLUSION

Adequate CF at age 18-24 months was worryingly insufficient and not associated with attained HAZ at age 5-8 years. Further strategies need to be considered to improve child nutrition and linear growth in resource-constrained settings.

Prevalence of Anemia in Children from Latin America and the Caribbean and Effectiveness of Nutritional Interventions: Systematic Review and Meta⁻Analysis

Anemia affects 1.62 billion people worldwide. Latin America and the Caribbean (LAC) comprise several developing countries where children are a population at risk. This systematic review and meta-analysis aimed to estimate the prevalence of anemia in this population. Electronic databases, reference lists, and websites of health ministries were searched until December 2018. Stratified analyses were performed using RevMan5.3 to estimate the overall prevalence of anemia in preschool and school-age children. The effectiveness of nutritional interventions was also evaluated. We included 61 studies from the 917 reviewed, which included 128,311 preschool- and 38,028 school-age children from 21 LAC countries. The number of anemic children was 32.93% and 17.49%, respectively, demonstrating a significant difference according to age (p < 0.01). No difference was observed by gender and only school-age children from low/very low socioeconomic status (SES) (25.75%) were more prone to anemia than those from middle SES (7.90%). It was not a concern in the Southern Cone but constituted a serious public health problem in the Latin Caribbean. Nutritional interventions reduced the prevalence from 45% to 25% (p < 0.01). Anemia is still a public health problem for children in LAC countries. National surveys should include school-age children. Further nutritional interventions are required to control anemia.

Community-based supplementary feeding for food insecure, vulnerable and malnourished populations - an overview of systematic reviews

BACKGROUND

Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low- and middle-income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated.

OBJECTIVES

1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school-aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations.2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups.

METHODS

In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community-based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically.

MAIN RESULTS

This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non-Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC.The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow-up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease-related outcomes, neurocognitive development and psychosocial outcomes, and adverse events.Mortality data were limited and underpowered in meta-analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long-term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer-term outcomes. In one study (505 participants), high-protein supplementation was associated with increased risk of small-for-gestational age babies.Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well-nourished. In children with MAM, the provision of specially formulated food improved their weight, weight-for-height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower-income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance.Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long-term benefit.In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis.The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group.There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.

AUTHORS' CONCLUSIONS

Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short-term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised.

Attitudes toward Supplemental Nutrition Assistance Programs in Caregivers of Children with Moderate-Acute Malnutrition Younger than 5 Years in Denpasar, Bali: A Qualitative Study

BACKGROUND

Providing additional nutriment represents one strategy for overcoming moderate-acute malnutrition (MAM) in children younger than 5 years. However, it is important to examine how well received such Supplemental Nutrition Assistance Programs (SNAP) are by caregivers in order to ensure optimal results.

OBJECTIVE

This study explores SNAP's reception by caregivers of MAM children younger than 5 years.

METHODS

Qualitative research was conducted through semi-structured, in-depth interviews with 16 selected caregivers and 5 Nutritional Executives from October to November, 2016 at 4 health centers in Denpasar, Bali, Indonesia. The results are presented to highlight the underlying patterns of SNAP's acceptance.

RESULTS

Overall, the informants responded negatively to SNAP, reporting that it was of limited usefulness. The results show 4 main themes relating to the receipt of SNAP. The first relates to the caregiver's preferences in terms of the types of supplementary food on offer. Second, caregiver's perceptions that the child was not, in fact, in a state of illness or disease due to a medical issue. Third, that the caregiver does not require supplementary food as they maintain that they are able to buy it independently. Fourth, factors related to the lack of support for health-care workers working with malnourished children.

CONCLUSION

The study finds that strengthening the role of health workers in terms of enabling them to effectively communicate the benefits of supplementary food to caregivers as well as adjusting the range of foods available according to the recipient's preferences is critical in overcoming malnutrition in children younger than 5 years.

Tools to improve planning, implementation, monitoring, and evaluation of complementary feeding programmes

Adequate nutrient intake is a prerequisite for achieving good nutrition status. Suboptimal complementary feeding practices are a main risk factor for stunting. The need for systematic and user-friendly tools to guide the planning, implementation, monitoring, and evaluation of dietary interventions for children aged 6-23 months has been recognized. This paper describes five tools, namely, ProPAN, Optifood, Cost of the Diet, Fill the Nutrient Gap, and Monitoring Results for Equity System that can be used in different combinations to improve situation analysis, planning, implementation, monitoring, or evaluation approaches for complementary feeding in a particular context. ProPAN helps with development of strategies and activities designed to change the behaviours of the target population. Optifood provides guidance for developing food-based recommendations. The Cost of the Diet can provide insight on economic barriers to accessing a nutritious and balanced diet. The Fill the Nutrient Gap facilitates formulation of context-specific policies and programmatic approaches to improve nutrient intake, through a multistakeholder process that uses insights from linear programming and secondary data. The Monitoring Results for Equity System helps with analysis of gaps, constraints, and determinants of complementary feeding interventions and adoption of recommended practices especially in the most vulnerable and deprived populations. These tools, and support for their use, are readily available and can be used either alone and/or complementarily throughout the programme cycle to improve infant and young child-feeding programmes at subnational and national levels.

Cracking the Egg Potential: Traditional Knowledge, Attitudes, and Practices in a Food-Based Nutrition Intervention in Highland Ecuador

BACKGROUND

Food-based interventions can reduce the prevalence of undernutrition and improve household food security, but nutritious and accessible foods may be underutilized. In Ecuador, eggs are inexpensive and widely available, but while they are a valuable source of essential nutrients for infants and young children, medical advice and community-based information have limited their inclusion in infants' diets.

OBJECTIVE

A qualitative component was conducted to understand local perceptions, knowledge, and practices to complement a randomized control trial that studied the effect of introducing eggs on nutritional status and growth in infants from 6 to 9 months in rural communities in the highland province of Cotopaxi, Ecuador.

METHODS

The qualitative inquiry consisted of key informant interviews, focus group discussions (FGDs), and structured observations in order to understand perceptions, knowledge, and practices related to household egg consumption and to the introduction of eggs in infants' diets.

RESULTS

The two principal findings were that: (i) eggs are an available and culturally acceptable food source although they are not always a part of the diet; and (ii) perceptions and practices related to household consumption and the introduction of eggs into the diet of infants are shaped by local knowledge and practices, which are shaped by biomedical information and advice provided by public health professionals.

CONCLUSION

Through an effective food-based intervention that includes qualitative research and a social marketing component, the behaviors of mothers and other caregivers can be modified, enabling children to realize the nutritional advantages of early introduction of eggs into their diet.

Complementary Feeding Interventions Have a Small but Significant Impact on Linear and Ponderal Growth of Children in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Background: World Health Assembly member states have committed to ambitious global targets for reductions in stunting and wasting by 2025. Improving complementary diets of children aged 6-23 mo is a recommended approach for reducing stunting in children <5 y old. Less is known about the potential of these interventions to prevent wasting.Objective: The aim of this article was to review and synthesize the current literature for the impact of complementary feeding interventions on linear [length-for-age z score (LAZ)] and ponderal [weight-for-length z score (WLZ)] growth of children aged 6-23 mo, with the specific goal of updating intervention-outcome linkages in the Lives Saved Tool (LiST).Methods: We started our review with studies included in the previous LiST review and searched for articles published since January 2012. We identified longitudinal trials that compared children aged 6-23 mo who received 1 of 2 types of complementary feeding interventions (nutrition education or counseling alone or complementary food supplementation with or without nutrition education or counseling) with a no-intervention control. We assessed study quality and generated pooled estimates of LAZ and WLZ change, as well as length and weight gain, for each category of intervention.Results: Interventions that provided nutrition education or counseling had a small but significant impact on linear growth in food-secure populations [LAZ standardized mean difference (SMD): 0.11; 95% CI: 0.01, 0.22] but not on ponderal growth. Complementary food supplementation interventions with or without nutrition education also had a small, significant effect in food-insecure settings on both LAZ (SMD: 0.08; 95% CI: 0.04, 0.13) and WLZ (SMD: 0.05; 95% CI: 0.01, 0.08).Conclusions: Nutrition education and complementary feeding interventions both had a small but significant impact on linear growth, and complementary feeding interventions also had an impact on ponderal growth of children aged 6-23 mo in low- and middle-income countries. The updated LiST model will support nutrition program planning and evaluation efforts by allowing users to model changes in intervention coverage on both stunting and wasting.

Nutrient composition of premixed and packaged complementary foods for sale in low- and middle-income countries: Lack of standards threatens infant growth

Premixed flours for infant porridge are increasingly produced and sold in developing countries to complement continued breastfeeding. Such complementary food (CF) products have known efficacy against malnutrition in children from 6 to 24 months of age, but ingredient ratios and production processes may vary. This study provides the first systematic measurement of their actual nutrient composition. We purchased samples of 108 premixed CF products in 22 low- and middle-income countries, and commissioned blind laboratory measurement of each product's macronutrients and micronutrients. We compared measured contents to nutrient claims on their packaging and to CF standards from the Codex Alimentarius, the Super Cereal Plus product used in nutrition assistance programs, and the Lutter and Dewey (2003) recommendations, as well as our own modeled nutrient requirements for a healthy breastfed child. Actual densities are significantly different from nutrient claims for protein (p = .013) and fat (p = .000). Only 15% of samples met two of the three benchmarks for fat, 32% met the most stringent protein standard, while only 22% met them for iron, and 21% for zinc. The median healthy child consuming breast milk plus enough of these solid foods to meet energy needs would experience deficits of zinc at 6 months, iron at 6 and 9 months, and dietary fat from 12 months of age. In summary, premixed CF products can provide adequate nutrient density but usually do not, revealing the need and opportunity for independent monitoring and quality assurance to help grain millers making premixed foods maintain uniform ingredient ratios and production practices.

Growth patterns in early childhood: Better trajectories in Afro-Ecuadorians independent of sex and socioeconomic factors

The first years of life are the most dynamic period for childhood growth. There are limited data available on growth patterns of infants and children living in rural Latin America. The aim of this study was to describe the growth patterns from birth to 5years in children living in a rural District of tropical coastal Ecuador using data from a birth cohort of 2404 neonates. We hypothesize that there would be growth differences according to ethnicity and sex. Evaluations were conducted at birth or until 2weeks of age and at 7, 13, 24, 36 and 60months during clinic and home visits. Individual growth trajectories for weight-for-age, height-for-age and weight/height-for-age Z-scores were estimated using multilevel models. Girls were lighter and shorter than boys at birth. However, Afro-Ecuadorian children (versus mestizo or indigenous) were longer/taller and heavier throughout the first 5years of life and had greater mean trajectories for HAZ and WAZ independent of sex and socioeconomic factors. Our data indicate that ethnicity is a determinant of growth trajectories during the first 5years of life independent of socioeconomic factors in a birth cohort conducted in a rural region of Latin America.

High consumption of commercial food products among children less than 24 months of age and product promotion in Kathmandu Valley, Nepal

Commercially produced complementary foods can help improve nutritional status of young children if they are appropriately fortified and of optimal nutrient composition. However, other commercially produced snack food products may be nutritionally detrimental, potentially increasing consumption of foods high in salt or sugar and displacing consumption of other more nutritious options. Helen Keller International, in collaboration with the Nepal government, implemented a study to assess mothers' utilization of commercial food products for child feeding and exposure to commercial promotions for these products. A cross‐sectional survey was conducted among 309 mothers of children less than 24 months of age across 15 health facilities. Utilization of breastmilk substitutes was low, having been consumed by 6.2% of children 0–5 months of age and 7.5% of children 6–23 months of age. Approximately one‐fourth (24.6%) of children 6–23 months age had consumed a commercially produced complementary food in the prior day. Twenty‐eight percent of mothers reported observing a promotion for breastmilk substitutes, and 20.1% reported promotions for commercially produced complementary foods. Consumption of commercially produced snack food products was high at 74.1% of children 6–23 months. Promotions for these same commercially produced snack food products were highly prevalent in Kathmandu Valley, reported by 85.4% of mothers. In order to improve diets during the complementary feeding period, development of national standards for complementary food products is recommended. Nutritious snack options should be promoted for the complementary feeding period; consumption of commercially produced snack food products high in sugar and salt and low in nutrients should be discouraged.

Infant and young child feeding practices and stunting in two highland provinces in Ecuador

The first two years of life are critical for growth and development. Little is known about infant and young child feeding (IYCF) practices in the Ecuadorian highlands and how they contribute to stunting. With the objective of understanding nutritional status and the influencing factors to design an intervention, we assessed the nutritional status of 293 infants and children between 0 and 24 months of age, living in 14 communities in the provinces of Tungurahua and Chimborazo using a cross-sectional study design. We used the WHO IYCF indicators to assess feeding practices; estimated dietary intake with 24-h recalls; and identified nutritious local foods by food frequency questionnaires. Multiple regression modelling was performed to identify correlates of nutritional status. Stunting was found in 56.2% of children. Mean protein, vitamin A and vitamin C intakes were above recommendations for all ages. Only infants 6.0 to 8.9 months of age and non-breastfed children 12-23.9 months of age consumed energy intakes below recommendations. Younger age groups had below recommended intakes for iron and calcium. While mean complementary food densities met recommendations for protein, vitamin A, vitamin C and energy, those for zinc, iron and calcium were lower than recommended. Older age, respiratory infections and being male were predictors of lower HAZ, whereas early initiation of breastfeeding, higher socioeconomic status, consumption of iron-rich foods and higher dietary protein density were protective. Interventions that promote and support optimal breastfeeding practices and enable increased consumption of nutritious local foods have potential to contribute to reducing stunting in this vulnerable population. © 2016 John Wiley & Sons Ltd.

Oral protein calorie supplementation for children with chronic disease

BACKGROUND

Poor growth and nutritional status are common in children with chronic diseases. Oral protein calorie supplements are used to improve nutritional status in these children. These expensive products may be associated with some adverse effects, e.g. the development of inappropriate eating behaviour patterns. This is a new update of a Cochrane review last updated in 2009.

OBJECTIVES

To examine evidence that in children with chronic disease, oral protein calorie supplements alter daily nutrient intake, nutritional indices, survival and quality of life and are associated with adverse effects, e.g. diarrhoea, vomiting, reduced appetite, glucose intolerance, bloating and eating behaviour problems.

SEARCH METHODS

Trials of oral protein calorie supplements in children with chronic diseases were identified through comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Companies marketing these products were also contacted.Most recent search of the Group's Trials Register: 24 February 2015.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing oral protein calorie supplements for at least one month to increase calorie intake with existing conventional therapy (including advice on improving nutritional intake from food or no specific intervention) in children with chronic disease.

DATA COLLECTION AND ANALYSIS

We independently assessed the outcomes: indices of nutrition and growth; anthropometric measures of body composition; calorie and nutrient intake (total from oral protein calorie supplements and food); eating behaviour; compliance; quality of life; specific adverse effects; disease severity scores; and mortality; we also assessed the risk of bias in the included trials.

MAIN RESULTS

Four studies (187 children) met the inclusion criteria. Three studies were carried out in children with cystic fibrosis and one study included children with paediatric malignant disease. Overall there was a low risk of bias for blinding and incomplete outcome data.Two studies had a high risk of bias for allocation concealment. Few statistical differences were found in the outcomes we assessed between treatment and control groups, except change in total energy intake at six and 12 months, mean difference 304.86 kcal per day (95% confidence interval 5.62 to 604.10) and mean difference 265.70 kcal per day (95% confidence interval 42.94 to 485.46), respectively. However, these were based on the analysis of just 58 children in only one study. Only two chronic diseases were included in these analyses, cystic fibrosis and paediatric malignant disease. No other studies were identified which assessed the effectiveness of oral protein calorie supplements in children with other chronic diseases.

AUTHORS' CONCLUSIONS

Oral protein calorie supplements are widely used to improve the nutritional status of children with a number of chronic diseases. We identified a small number of studies assessing these products in children with cystic fibrosis and paediatric malignant disease, but were unable to draw any conclusions based on the limited data extracted. We recommend a series of large, randomised controlled trials be undertaken investigating the use of these products in children with different chronic diseases. Until further data are available, we suggest these products are used with caution.

Effects of animal source food and micronutrient fortification in complementary food products on body composition, iron status, and linear growth: a randomized trial in Cambodia

BACKGROUND

Poor nutritional quality of complementary foods often limits growth. Animal source foods, such as milk or meat, are often unaffordable. Local affordable alternatives are needed.

OBJECTIVE

We evaluate the efficacy of 2 newly developed, rice-based complementary food products: WinFood (WF) with small fish and edible spiders and WinFood-Lite (WF-L) fortified with small fish, against 2 existing fortified corn-soy blend products, CSB+ (purely plant based) and CSB++ (8% dried skimmed milk).

DESIGN

In total, 419 infants aged 6 mo were enrolled in this randomized, single-blinded study for 9 mo, designed primarily to assess increments in fat-free mass by a deuterium dilution technique and change in plasma ferritin and soluble transferrin receptor. Secondary endpoints were changes in anthropometric variables, including knee-heel length. Data were analyzed by the intention-to-treat approach.

RESULTS

There was no difference in fat-free mass increment in WF or WF-L compared with CSB+ [WF: +0.04 kg (95% CI: -0.20, 0.28 kg); WF-L: +0.14 kg (95% CI: -0.10, 0.38 kg)] or CSB++ [WF: -0.03 kg (95% CI: -0.27, 0.21 kg); WF-L: +0.07 kg (95% CI: -0.18, 0.31 kg)] and no effect on iron status. The 1.7-mm (95% CI: -0.1, 3.5 mm) greater increase in knee-heel length in WF-L than in CSB+ was not significant.

CONCLUSIONS

No difference was found between the locally produced products (WF and WF-L) and the CSBs. Micronutrient fortification may be necessary, and small fish may be an affordable alternative to milk to improve complementary foods. The dietary role of edible spiders needs to be further explored. This trial was registered at controlled-trials.com as ISRCTN19918531.

Food supplementation for improving the physical and psychosocial health of socio-economically disadvantaged children aged three months to five years

BACKGROUND

Undernutrition contributes to five million deaths of children under five each year. Furthermore, throughout the life cycle, undernutrition contributes to increased risk of infection, poor cognitive functioning, chronic disease, and mortality. It is thus important for decision-makers to have evidence about the effectiveness of nutrition interventions for young children.

OBJECTIVES

Primary objective1. To assess the effectiveness of supplementary feeding interventions, alone or with co-intervention, for improving the physical and psychosocial health of disadvantaged children aged three months to five years.Secondary objectives1. To assess the potential of such programmes to reduce socio-economic inequalities in undernutrition.2. To evaluate implementation and to understand how this may impact on outcomes.3. To determine whether there are any adverse effects of supplementary feeding.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, PsycINFO, and seven other databases for all available years up to January 2014. We also searched ClinicalTrials.gov and several sources of grey literature. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that provided supplementary food (with or without co-intervention) to children aged three months to five years, from all countries. Adjunctive treatments, such as nutrition education, were allowed. Controls had to be untreated.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data, and assessed risk of bias. We conducted meta-analyses for continuous data using the mean difference (MD) or the standardised mean difference (SMD) with a 95% confidence interval (CI), correcting for clustering if necessary. We analysed studies from low- and middle-income countries and from high-income countries separately, and RCTs separately from CBAs. We conducted a process evaluation to understand which factors impact on effectiveness.

MAIN RESULTS

We included 32 studies (21 RCTs and 11 CBAs); 26 of these (16 RCTs and 10 CBAs) were in meta-analyses. More than 50% of the RCTs were judged to have low risk of bias for random selection and incomplete outcome assessment. We judged most RCTS to be unclear for allocation concealment, blinding of outcome assessment, and selective outcome reporting. Because children and parents knew that they were given food, we judged blinding of participants and personnel to be at high risk for all studies.Growth. Supplementary feeding had positive effects on growth in low- and middle-income countries. Meta-analysis of the RCTs showed that supplemented children gained an average of 0.12 kg more than controls over six months (95% confidence interval (CI) 0.05 to 0.18, 9 trials, 1057 participants, moderate quality evidence). In the CBAs, the effect was similar; 0.24 kg over a year (95% CI 0.09 to 0.39, 1784 participants, very low quality evidence). In high-income countries, one RCT found no difference in weight, but in a CBA with 116 Aboriginal children in Australia, the effect on weight was 0.95 kg (95% CI 0.58 to 1.33). For height, meta-analysis of nine RCTs revealed that supplemented children grew an average of 0.27 cm more over six months than those who were not supplemented (95% CI 0.07 to 0.48, 1463 participants, moderate quality evidence). Meta-analysis of seven CBAs showed no evidence of an effect (mean difference (MD) 0.52 cm, 95% CI -0.07 to 1.10, 7 trials, 1782 participants, very low quality evidence). Meta-analyses of the RCTs demonstrated benefits for weight-for-age z-scores (WAZ) (MD 0.15, 95% CI 0.05 to 0.24, 8 trials, 1565 participants, moderate quality evidence), and height-for-age z-scores (HAZ) (MD 0.15, 95% CI 0.06 to 0.24, 9 trials, 4638 participants, moderate quality evidence), but not for weight-for-height z-scores MD 0.10 (95% CI -0.02 to 0.22, 7 trials, 4176 participants, moderate quality evidence). Meta-analyses of the CBAs showed no effects on WAZ, HAZ, or WHZ (very low quality evidence). We found moderate positive effects for haemoglobin (SMD 0.49, 95% CI 0.07 to 0.91, 5 trials, 300 participants) in a meta-analysis of the RCTs.Psychosocial outcomes. Eight RCTs in low- and middle-income countries assessed psychosocial outcomes. Our meta-analysis of two studies showed moderate positive effects of feeding on psychomotor development (SMD 0.41, 95% CI 0.10 to 0.72, 178 participants). The evidence of effects on cognitive development was sparse and mixed.We found evidence of substantial leakage. When feeding was given at home, children benefited from only 36% of the energy in the supplement. However, when the supplementary food was given in day cares or feeding centres, there was less leakage; children took in 85% of the energy provided in the supplement. Supplementary food was generally more effective for younger children (less than two years of age) and for those who were poorer/ less well-nourished. Results for sex were equivocal. Our results also suggested that feeding programmes which were given in day-care/feeding centres and those which provided a moderate-to-high proportion of the recommended daily intake (% RDI) for energy were more effective.

AUTHORS' CONCLUSIONS

Feeding programmes for young children in low- and middle-income countries can work, but good implementation is key.

Identifying determinants of effective complementary feeding behaviour change interventions in developing countries

As stunting moves to the forefront of the global agenda, there is substantial evidence that behaviour change interventions (BCI) can improve infant feeding practices and growth. However, this evidence has not been translated into improved outcomes on a national level because we do not know enough about what makes these interventions work, for whom, when, why, at what cost and for how long. Our objective was to examine the design and implementation of complementary feeding BCI, from the peer-reviewed literature, to identify generalisable key determinants. We identified 29 studies that evaluated BCI efficacy or effectiveness, were conducted in developing countries, and reported outcomes on infant and young children aged 6-24 months. Two potential determinants emerged: (1) effective studies used formative research to identify cultural barriers and enablers to optimal feeding practices, to shape the intervention strategy, and to formulate appropriate messages and mediums for delivery; (2) effective studies delineated the programme impact pathway to the target behaviour change and assessed intermediary behaviour changes to learn what worked. We found that BCI that used these developmental and implementation processes could be effective despite heterogeneous approaches and design components. Our analysis was constrained, however, by the limited published data on how design and implementation were carried out, perhaps because of publishing space limits. Information on cost-effectiveness, sustainability and scalability was also very limited. We suggest a more comprehensive reporting process and a more strategic research agenda to enable generalisable evidence to accumulate.

Is the inclusion of animal source foods in fortified blended foods justified?

Fortified blended foods (FBF) are used for the prevention and treatment of moderate acute malnutrition (MAM) in nutritionally vulnerable individuals, particularly children. A recent review of FBF recommended the addition of animal source food (ASF) in the form of whey protein concentrate (WPC), especially to corn-soy blends. The justification for this recommendation includes the potential of ASF to increase length, weight, muscle mass accretion and recovery from wasting, as well as to improve protein quality and provide essential growth factors. Evidence was collected from the following four different types of studies: (1) epidemiological; (2) ASF versus no intervention or a low-calorie control; (3) ASF versus an isocaloric non-ASF; and (4) ASF versus an isocaloric, isonitrogenous non-ASF. Epidemiological studies consistently associated improved growth outcomes with ASF consumption; however, little evidence from isocaloric and isocaloric, isonitrogenous interventions was found to support the inclusion of meat or milk in FBF. Evidence suggests that whey may benefit muscle mass accretion, but not linear growth. Overall, little evidence supports the costly addition of WPC to FBFs. Further, randomized isocaloric, isonitrogenous ASF interventions with nutritionally vulnerable children are needed.

Protecting child health and nutrition status with ready-to-use food in addition to food assistance in urban Chad: a cost-effectiveness analysis

Background

Despite growing interest in use of lipid nutrient supplements for preventing child malnutrition and morbidity, there is inconclusive evidence on the effectiveness, and no evidence on the cost-effectiveness of this strategy.

Methods

A cost effectiveness analysis was conducted comparing costs and outcomes of two arms of a cluster randomized controlled trial implemented in eastern Chad during the 2010 hunger gap by Action contre la Faim France and Ghent University. This trial assessed the effect on child malnutrition and morbidity of a 5-month general distribution of staple rations, or staple rations plus a ready-to-use supplementary food (RUSF). RUSF was distributed to households with a child aged 6–36 months who was not acutely malnourished (weight-for-height > = 80% of the NCHS reference median, and absence of bilateral pitting edema), to prevent acute malnutrition in these children. While the addition of RUSF to a staple ration did not result in significant reduction in wasting rates, cost-effectiveness was assessed using successful secondary outcomes of cases of diarrhea and anemia (hemoglobin <110 g/L) averted among children receiving RUSF.

Total costs of the program and incremental costs of RUSF and related management and logistics were estimated using accounting records and key informant interviews, and include costs to institutions and communities. An activity-based costing methodology was applied and incremental costs were calculated per episode of diarrhea and case of anemia averted.

Results

Adding RUSF to a general food distribution increased total costs by 23%, resulting in an additional cost per child of 374 EUR, and an incremental cost per episode of diarrhea averted of 1,083 EUR and per case of anemia averted of 3,627 EUR.

Conclusions

Adding RUSF to a staple ration was less cost-effective than other standard intervention options for averting diarrhea and anemia. This strategy holds potential to address a broad array of health and nutrition outcomes in emergency settings where infrastructure is weak and other intervention options are infeasible in the short-term. However, further research is needed to establish the contexts in which RUSF is most effective and cost-effective in preventing acute malnutrition and morbidity among vulnerable children, compared to other options.

Impact of education and provision of complementary feeding on growth and morbidity in children less than 2 years of age in developing countries: a systematic review

BACKGROUND

About one third of deaths in children less than 5 years of age are due to underlying undernutrition. According to an estimate, 19.4% of children <5 years of age in developing countries were underweight (weight-for-age Z score <-2) and about 29.9% were stunted in the year 2011 (height-for-age Z score <-2). It is well recognized that the period of 6-24 months of age is one of the most critical time for the growth of the infant.

METHODS

We included randomized, non-randomized trials and programs on the effect of complementary feeding (CF) (fortified or unfortified, but not micronutrients alone) and education on CF on children less than 2 years of age in low and middle income countries (LMIC). Studies that delivered intervention for at least 6 months were included; however, studies in which intervention was given for supplementary and therapeutic purposes were excluded. Recommendations are made for input to the Lives Saved Tool (LiST) model by following standardized guidelines developed by Child Health Epidemiology Reference Group (CHERG).

RESULTS

We included 16 studies in this review. Amongst these, 9 studies provided education on complementary feeding, 6 provided complementary feeding (with our without education) and 1 provided both as separate arms. Overall, education on CF alone significantly improved HAZ (SMD: 0.23; 95% CI: 0.09, 0.36), WAZ (SMD 0.16, 95% CI: 0.05, 0.27), and significantly reduced the rates of stunting (RR 0.71; 95% CI: 0.56, 0.91). While no significant impact were observed for height and weight gain. Based on the subgroup analysis; ten studies from food secure populations indicated education on CF had a significant impact on height gain, HAZ scores, and weight gain, however, stunting reduced non-significantly. In food insecure population, CF education alone significantly improved HAZ scores, WAZ scores and significantly reduced the rates of stunting, while CF provision with or without education improved HAZ and WAZ scores significantly.

CONCLUSION

Complementary feeding interventions have a potential to improve the nutritional status of children in developing countries. However, large scale high quality randomized controlled trials are required to assess the actual impact of this intervention on growth and morbidity in children 6-24 months of age. Education should be combined with provision of complementary foods that are affordable, particularly for children in food insecure countries.

Designing appropriate complementary feeding recommendations: tools for programmatic action

Suboptimal complementary feeding practices contribute to a rapid increase in the prevalence of stunting in young children from age 6 months. The design of effective programmes to improve infant and young child feeding requires a sound understanding of the local situation and a systematic process for prioritizing interventions, integrating them into existing delivery platforms and monitoring their implementation and impact. The identification of adequate food-based feeding recommendations that respect locally available foods and address gaps in nutrient availability is particularly challenging. We describe two tools that are now available to strengthen infant and young child-feeding programming at national and subnational levels. ProPAN is a set of research tools that guide users through a step-by-step process for identifying problems related to young child nutrition; defining the context in which these problems occur; formulating, testing, and selecting behaviour-change recommendations and nutritional recipes; developing the interventions to promote them; and designing a monitoring and evaluation system to measure progress towards intervention goals. Optifood is a computer-based platform based on linear programming analysis to develop nutrient-adequate feeding recommendations at lowest cost, based on locally available foods with the addition of fortified products or supplements when needed, or best recommendations when the latter are not available. The tools complement each other and a case study from Peru illustrates how they have been used. The readiness of both instruments will enable partners to invest in capacity development for their use in countries and strengthen programmes to address infant and young child feeding and prevent malnutrition.

Micronutrient fortification of food and its impact on woman and child health: a systematic review

BACKGROUND

Vitamins and minerals are essential for growth and metabolism. The World Health Organization estimates that more than 2 billion people are deficient in key vitamins and minerals. Groups most vulnerable to these micronutrient deficiencies are pregnant and lactating women and young children, given their increased demands. Food fortification is one of the strategies that has been used safely and effectively to prevent vitamin and mineral deficiencies.

METHODS

A comprehensive search was done to identify all available evidence for the impact of fortification interventions. Studies were included if food was fortified with a single, dual or multiple micronutrients and impact of fortification was analyzed on the health outcomes and relevant biochemical indicators of women and children. We performed a meta-analysis of outcomes using Review Manager Software version 5.1.

RESULTS

Our systematic review identified 201 studies that we reviewed for outcomes of relevance. Fortification for children showed significant impacts on increasing serum micronutrient concentrations. Hematologic markers also improved, including hemoglobin concentrations, which showed a significant rise when food was fortified with vitamin A, iron and multiple micronutrients. Fortification with zinc had no significant adverse impact on hemoglobin levels. Multiple micronutrient fortification showed non-significant impacts on height for age, weight for age and weight for height Z-scores, although they showed positive trends. The results for fortification in women showed that calcium and vitamin D fortification had significant impacts in the post-menopausal age group. Iron fortification led to a significant increase in serum ferritin and hemoglobin levels in women of reproductive age and pregnant women. Folate fortification significantly reduced the incidence of congenital abnormalities like neural tube defects without increasing the incidence of twinning. The number of studies pooled for zinc and multiple micronutrients for women were few, though the evidence suggested benefit. There was a dearth of evidence for the impact of fortification strategies on morbidity and mortality outcomes in women and children.

CONCLUSION

Fortification is potentially an effective strategy but evidence from the developing world is scarce. Programs need to assess the direct impact of fortification on morbidity and mortality.

Specially formulated foods for treating children with moderate acute malnutrition in low- and middle-income countries

BACKGROUND

Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low- and middle-income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid-based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition.

OBJECTIVES

To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low- and middle-income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective.

SEARCH METHODS

In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition-related organisations and researchers in this field.    

SELECTION CRITERIA

We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses using the random-effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods.

MAIN RESULTS

Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care - the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight-for-height (MD 0.20 z-score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid-based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses - there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid-based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non-recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight-for-height, and mid-upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid-based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses - no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid-based nutrient supplements versus specific types of blended foods - a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods - in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet - no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content.

AUTHORS' CONCLUSIONS

In conclusion, there is moderate to high quality evidence that both lipid-based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid-based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short-term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.

Extruded rice grains fortified with zinc, iron, and vitamin A increase zinc status of Thai school children when incorporated into a school lunch program

Iron (Fe), zinc (Zn), and vitamin A (VA) deficiencies are common among children in developing countries and often occur in the same individual. Rice is widely consumed in the developing countries of Asia and the low phytate in polished rice makes it ideal for Zn and Fe fortification. Triple-fortified rice grains with Zn, Fe, and VA were produced using hot extrusion technology. The main objective of the present study was to determine the impact of triple-fortified extruded rice on Zn status in school children in Southern Thailand. Although serum zinc was the main outcome indicator, Fe and VA status were also assessed. School children with low serum zinc (n = 203) were randomized to receive either triple-fortified rice (n = 101) or natural control rice (n = 102) as a component of school lunch meals for 5 mo. Serum Zn, hemoglobin, serum ferritin, serum retinol, and C-reactive protein were measured at baseline and at the end of the study. After the intervention, serum Zn increased (P < 0.05) in both the fortification (11.3 ± 1.3 μmol/L) and control (10.6 ± 1.4 μmol/L) groups, most likely due to the proper implementation of the school lunch and school milk programs, with the increase greater in the group receiving the triple-fortified rice (P < 0.05). Because the children were not Fe or VA deficient at baseline, there was no change in Fe or VA status. We conclude that Zn fortification of extruded rice grains is efficacious and can be used to improve Zn status in school children.

Establishing desirable fortificant levels for calcium, iron and zinc in foods for infant and young child feeding: examples from three Asian countries

We used the World Health Organization's recommended procedures to establish desirable fortificant levels for three problem micronutrients in children's diets, based on dietary data collected earlier from Filipino (n = 1374; 6-36 months), Mongolian (n = 179; 12-36 months) and Cambodian (n = 177; 12-36 months) children. Prevalence of inadequate and excessive intakes of calcium and zinc (via cut-point method) and iron (via full-probability approach) was assessed after adjusting usual intake distributions with pc-side using internal or external within-person variances from Filipino (calcium and iron) and US National Health And Nutrition Examination Survey III (zinc) national surveys. Fortificant levels were determined by repositioning usual intake distributions so that the 2.5th percentile of the targeted populations equalled the estimated average requirement (calcium, zinc) or so that full-probability prevalence was no larger than 2.5% (iron). Prevalence of inadequate intakes was ≥70% for calcium and iron, except Filipino infants (30% for Ca) and Cambodian toddlers (41% for Fe); but <1% for zinc for toddlers in Mongolia and 20% in Cambodia. Prevalence of excessive intakes was <1% for zinc, calcium and iron, except for Mongolian toddlers (11% for Zn). Desirable fortificant levels, although apparently negligible for zinc, were 530-783 mg for calcium and 10.8-22.8 mg for iron (per 100 g). Fortificant levels can be estimated from 24-h recalls, preferably by applying internal within-person variances. Fortification with calcium and iron was necessary, but seemingly not for zinc, despite a high prevalence of low serum zinc, suggesting the need for better defined cut-offs for population risk of zinc deficiency based on dietary zinc intake and/or serum zinc.

Oral iron supplements for children in malaria-endemic areas

BACKGROUND

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

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Plasma zinc concentration responds to short-term zinc supplementation, but not zinc fortification, in young children in Senegal1,2

BACKGROUND

Simple, low-cost methods are needed to evaluate the effect of zinc-fortification programs. Plasma zinc concentration is a useful biomarker of zinc intake from supplementation, but responses to zinc fortification are inconsistent.

OBJECTIVE

The objective was to compare the change in plasma zinc concentrations in young children who received zinc from either a liquid supplement or a zinc-fortified complementary food.

DESIGN

A double-blind intervention trial was conducted in 137 young Senegalese children aged 9-17 mo who were randomly assigned to receive one of the following treatments for 15 d: 1) 30 g dry weight of an iron-fortified cereal porridge and a liquid multivitamin supplement without zinc (control group), 2) the same porridge and multivitamin supplement with 6 mg Zn added to the supplement dose (ZnSuppl group), or 3) the same porridge with added zinc to provide 6 mg Zn per 25 g dry weight of porridge and multivitamin without zinc (ZnFort group).

RESULTS

Mean (±SD) plasma zinc concentration (μg/dL) increased by 4.7 ± 1.6 (P = 0.004) in the ZnSuppl group, which was significantly greater (P = 0.009) than the mean change in the control group (-1.0 ± 1.6; P = 0.51) and in the ZnFort group (-1.8 ± 1.7; P = 0.29). The latter 2 groups did not differ from each other (P = 0.99).

CONCLUSIONS

Plasma zinc concentration increased in children who received daily zinc supplementation for 15 d but not in those who received a zinc-fortified complementary food containing a similar amount of zinc. Additional longer-term studies are needed to assess the effect of zinc-fortification programs on zinc-related functional outcomes and the usefulness of plasma zinc as a biomarker of program effect. This trial was registered at www.clinicaltrials.gov as study NCT0094398.

A micronutrient-fortified food enhances iron and selenium status of Zambian infants but has limited efficacy on zinc

Micronutrient-fortified, cereal-based infant foods are recommended for reducing multiple micronutrient deficiencies in low-income countries, but their nutritional quality is not always optimal. In a double-blind randomized trial, we compared the efficacy of a locally produced porridge based on maize, beans, bambaranuts, and groundnuts fortified with 19 (rich) or 9 (basal) micronutrients. Infants aged 6 mo from Lusaka, Zambia were randomized to receive the richly fortified (n = 373) or basal (n = 370) porridge daily for 12 mo along with routine vitamin A supplements. Baseline and final micronutrient status and inflammation (based on α-1-glycoprotein) were assessed using nonfasting blood samples. Baseline prevalence of anemia (39%) and zinc deficiency (51%) were a public health concern. There were overall treatment effects on hemoglobin (Hb) (P = 0.001), serum transferrin receptor (P < 0.001), serum ferritin (P < 0.001), and serum selenium (P = 0.009); biomarker responses for iron and zinc were modified by baseline concentrations, and for Hb and iron by socioeconomic status. At 18 mo, the adjusted odds of anemia, iron deficiency anemia (Hb <105 g/L and transferrin receptor > 11.0 mg/L), and iron deficiency were 0.37 (95% CI = 0.25, 0.55), 0.18 (0.09, 0.35), and 0.30 (0.18, 0.50) times those in the basal group, respectively. The rich level of fortification had no overall treatment effect on serum zinc (1.09; 0.66, 1.80) but improved serum zinc in children with lower Hb concentrations at baseline (P = 0.024). A locally produced cereal- and legume-based infant food richly fortified with micronutrients reduced anemia and improved iron and selenium status but may require reformulation to improve the biochemical zinc status of urban Zambian infants.

vProtein: identifying optimal amino acid complements from plant-based foods

BACKGROUND

Indispensible amino acids (IAAs) are used by the body in different proportions. Most animal-based foods provide these IAAs in roughly the needed proportions, but many plant-based foods provide different proportions of IAAs. To explore how these plant-based foods can be better used in human nutrition, we have created the computational tool vProtein to identify optimal food complements to satisfy human protein needs.

METHODS

vProtein uses 1251 plant-based foods listed in the United States Department of Agriculture standard release 22 database to determine the quantity of each food or pair of foods required to satisfy human IAA needs as determined by the 2005 daily recommended intake. The quantity of food in a pair is found using a linear programming approach that minimizes total calories, total excess IAAs, or the total weight of the combination.

RESULTS

For single foods, vProtein identifies foods with particularly balanced IAA patterns such as wheat germ, quinoa, and cauliflower. vProtein also identifies foods with particularly unbalanced IAA patterns such as macadamia nuts, degermed corn products, and wakame seaweed. Although less useful alone, some unbalanced foods provide unusually good complements, such as Brazil nuts to legumes. Interestingly, vProtein finds no statistically significant bias toward grain/legume pairings for protein complementation. These analyses suggest that pairings of plant-based foods should be based on the individual foods themselves instead of based on broader food group-food group pairings. Overall, the most efficient pairings include sweet corn/tomatoes, apple/coconut, and sweet corn/cherry. The top pairings also highlight the utility of less common protein sources such as the seaweeds laver and spirulina, pumpkin leaves, and lambsquarters. From a public health perspective, many of the food pairings represent novel, low cost food sources to combat malnutrition. Full analysis results are available online at http://www.foodwiki.com/vprotein.

Impact of maternal education about complementary feeding and provision of complementary foods on child growth in developing countries

Background

Childhood undernutrition is prevalent in low and middle income countries. It is an important indirect cause of child mortality in these countries. According to an estimate, stunting (height for age Z score < -2) and wasting (weight for height Z score < -2) along with intrauterine growth restriction are responsible for about 2.1 million deaths worldwide in children < 5 years of age. This comprises 21 % of all deaths in this age group worldwide. The incidence of stunting is the highest in the first two years of life especially after six months of life when exclusive breastfeeding alone cannot fulfill the energy needs of a rapidly growing child. Complementary feeding for an infant refers to timely introduction of safe and nutritional foods in addition to breast-feeding (BF) i.e. clean and nutritionally rich additional foods introduced at about six months of infant age. Complementary feeding strategies encompass a wide variety of interventions designed to improve not only the quality and quantity of these foods but also improve the feeding behaviors. In this review, we evaluated the effectiveness of two most commonly applied strategies of complementary feeding i.e. timely provision of appropriate complementary foods (± nutritional counseling) and education to mothers about practices of complementary feeding on growth. Recommendations have been made for input to the Lives Saved Tool (LiST) model by following standardized guidelines developed by Child Health Epidemiology Reference Group (CHERG).

Methods

We conducted a systematic review of published randomized and quasi-randomized trials on PubMed, Cochrane Library and WHO regional databases. The included studies were abstracted and graded according to study design, limitations, intervention details and outcome effects. The primary outcomes were change in weight and height during the study period among children 6-24 months of age. We hypothesized that provision of complementary food and education of mother about complementary food would significantly improve the nutritional status of the children in the intervention group compared to control. Meta-analyses were generated for change in weight and height by two methods. In the first instance, we pooled the results to get weighted mean difference (WMD) which helps to pool studies with different units of measurement and that of different duration. A second meta-analysis was conducted to get a pooled estimate in terms of actual increase in weight (kg) and length (cm) in relation to the intervention, for input into the LiST model.

Results

After screening 3795 titles, we selected 17 studies for inclusion in the review. The included studies evaluated the impact of provision of complementary foods (±nutritional counseling) and of nutritional counseling alone. Both these interventions were found to result in a significant increase in weight [WMD 0.34 SD, 95% CI 0.11 – 0.56 and 0.30 SD, 95 % CI 0.05-0.54 respectively) and linear growth [WMD 0.26 SD, 95 % CI 0.08-0.43 and 0.21 SD, 95 % CI 0.01-0.41 respectively]. Pooled results for actual increase in weight in kilograms and length in centimeters showed that provision of appropriate complementary foods (±nutritional counseling) resulted in an extra gain of 0.25kg (±0.18) in weight and 0.54 cm (±0.38) in height in children aged 6-24 months. The overall quality grades for these estimates were that of ‘moderate’ level. These estimates have been recommended for inclusion in the Lives Saved Tool (LiST) model. Education of mother about complementary feeding led to an extra weight gain of 0.30 kg (±0.26) and a gain of 0.49 cm (±0.50) in height in the intervention group compared to control. These estimates had been recommended for inclusion in the LiST model with an overall quality grade assessment of ‘moderate’ level.

Conclusion

Provision of appropriate complementary food, with or without nutritional education, and maternal nutritional counseling alone lead to significant increase in weight and height in children 6-24 months of age. These interventions can significantly reduce the risk of stunting in developing countries and are recommended for inclusion in the LiST tool.

Enhancements to nutrition program in Indian integrated child development services increased growth and energy intake of children

The Indian Integrated Child Development Services (ICDS) provides supplemental food to children aged 6 mo to 6 y. This study assessed the impact of enhancements to the existing Supplemental Nutrition Program of local production of supplemental food, home fortification with a micronutrient powder, and improved program monitoring. A quasi-experimental longitudinal design was used. Data were collected from 15 Anganwadi centers randomly selected from the enhanced program and 15 from the usual program. Multilevel linear regression was used to examine changes over time between the 2 groups accounting for village-level variation in intent-to-treat analysis. Children in the enhanced program initially aged 12-18 mo gained 0.72 (P = 0.02) greater height-for-age Z-score. Significant differences were observed in gain in weight-for-age Z-score among those initially aged 9-11 (2.48; P = 0.01), 12-18 (0.76; P = 0.01), and 19-24 mo old (0.73; P = 0.01), and gain in weight-for-height Z-score among 9-11 (2.66; P = 0.04) and 19-24 mo old (0.99; P = 0.01). For these age groups, the prevalence of stunting, underweight, or wasting averted ranged from 20.3 to 33.4%. Energy intake in the enhanced program was significantly greater for boys initially aged 12-18 mo (575.1 kJ/d; P = 0.03). Results from a qualitative substudy supported the plausibility of observed outcomes. ICDS would be more effective in improving child nutrition if it included these enhancements. The enhancements studied may be useful in improving program delivery and uptake of other similar programs.

Impact of flooding on feeding practices of infants and young children in Dhaka, Bangladesh Slums: what are the coping strategies?

Previous research has shown that urban slums are hostile environments for the growth of infants and young children (IYC). Flooding is a hazard commonly found in Dhaka slums (Bangladesh) which negatively impacts IYC's nutritional and health status. This paper aims 1) to identify the impact of flooding on IYC's feeding practices, and 2) to explore the coping strategies developed by caregivers. Qualitative data (participant observation and semi-structured interviews) and quantitative data (household questionnaire and anthropometric measurements) collected in slums in Dhaka (n=18 mothers, n=5 community health workers, and n=55 children) were analysed. The subjects of the interviews were mothers and Bangladesh Rural Advancement Committee (BRAC) community health workers living and working in the slums. Research findings showed that breastfeeding and complementary feeding practices for IYC were poor and inappropriate due to lack of knowledge, time, and resources in normal times and worse during flooding. One coping strategy developed by mothers purposely to protect their IYC's nutritional status was to decrease their personal food intake. Our research findings suggest that mothers perceived the negative impact of flooding on their IYC's nutritional health but did not have the means to prevent it. They could only maintain their health through coping strategies which had other negative consequences. The results suggests a holistic approach combining 1) provision of relief for nutritionally vulnerable groups during flooding, 2) support to mothers in their working role, 3) breastfeeding counseling and support to lactating mothers with difficulties, and 4) preventing malnutrition in under 2 year old children.

Growing Children's Bodies and Minds: Maximizing Child Nutrition and Development

For their optimal growth, and for greater long-term human capital development, children profit not only from improved nutrition but also from improved learning opportunities in the earliest years of life. This paper describes how actions to enhance optimal infant and young child nutrition can be linked with child development interventions for children under 3 years of age. In countries with high rates of malnutrition, linking these two components will result in synergies of program activities, and will bring about a greater impact at reduced cost than either activity conducted separately. New understanding of social marketing and communication strategies can increase effectiveness of linked interventions. Public–private partnerships to improve both child development and nutrition offer promise for sustainable interventions.

Effect of an improved local ingredient-based complementary food fortified or not with iron and selected multiple micronutrients on Hb concentration

OBJECTIVE

To assess the effect of an improved local ingredient-based gruel fortified or not with selected multiple micronutrients (MM) on Hb concentration of young children.

DESIGN

In a nutrition centre that we opened in their villages, children received either MM supplement (containing iron, zinc, vitamin A, vitamin C and iodine) with the improved gruel (MMGG) or the improved gruel only (GG), twice daily, 6 d/week, for 6 months. We assessed baseline and endpoint Hb concentration and anthropometric indices.

SETTING

Kongoussi, a rural and poor district of Burkina Faso.

SUBJECTS

In a community-based trial, we randomly assigned 131 children aged 6-23 months with Hb concentrations in the range of 80-109 g/l into two groups.

RESULTS

The groups did not differ significantly at baseline. Mean baseline Hb concentration was 89·2 (sd 6·5) g/l and 90·3 (sd 8·4) g/l in the GG and the MMGG, respectively (P = 0·42). It increased to 104·1 (sd 11·4) g/l in the GG (P < 0·001) and 107·6 (sd 14·7) g/l in the MMGG (P < 0·001). The between-group difference of 3·5 (95 % CI -1·0, 8·1) g/l in mean (sd) endpoint Hb concentration was not significant (P = 0·13). The endpoint anthropometric indices were not different between the groups.

CONCLUSIONS

This MM supplement had no additional effect on Hb concentration. Thorough studies are needed to evaluate the actual efficacy of the gruel before its introduction into household routine.

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

BACKGROUND

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

OBJECTIVES

To assess the effect of iron on malaria and deaths.

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Zinc Fortification on Zinc Nutrition

Food fortification is increasingly recognized as an effective approach to improve a population's micronutrient status. The present report provides a critical review of the scientific evidence currently available on the impact of zinc fortification on zinc nutrition.

The available studies clearly show that zinc fortification can increase dietary zinc intake and total daily zinc absorption. Most absorption studies also indicate that adding zinc to food does not adversely affect the absorption of other minerals, such as iron. Despite the positive effect of zinc fortification on total zinc absorption, only a few studies have found positive impacts of zinc fortification on serum zinc concentrations or functional indicators of zinc status. The reasons for these inconsistent results are uncertain but may relate to the choice of food vehicles, the age group and zinc status of the study populations, or particular aspects of the study design. Thus, additional research is needed to determine the impact of zinc fortification, with or without other micronutrients, in populations at risk for zinc deficiency.

Because of the benefits of increasing intake in populations at high risk for zinc deficiency, the documented increase in total zinc absorption that occurs following zinc fortification, the absence of any adverse effects, and the relatively low cost of adding zinc, public health planners should consider including zinc in mass and targeted fortification programs in such populations. Because of the limited available information on program impact, it will be important to evaluate the outcomes of such programs.