Effect of preventive zinc supplementation on linear growth in children under 5 years of age in developing countries: a meta-analysis of studies for input to the lives saved tool

An Ex-Ante Analysis of the Impact of Biofortified Zinc Rice on Dietary Zinc Inadequacy: Evidence from Bangladesh, Indonesia, and the Philippines

BACKGROUND

South, East, and Southeast Asia are among the regions of the world with the highest estimated prevalence of inadequate zinc intake. Because populations in those regions eat rice as their main staple, zinc biofortification of rice can potentially improve zinc intake, especially among the most vulnerable.

OBJECTIVES

We modeled the impact of the consumption of zinc-biofortified rice on zinc intake and inadequacy among women of childbearing age and young children nationally in Indonesia, the Philippines, and at a subnational level in Bangladesh.

METHODS

We conducted an ex-ante analysis by applying increments of zinc content in rice, from a baseline level of 16 parts per million (ppm) to 100 ppm, and based on rice consumption data to substitute levels of conventional rice with zinc-biofortified rice varying between 10% and 70%.

RESULTS

Among all datasets evaluated from these 3 countries, the prevalence of dietary zinc inadequacy at baseline was 94%-99% among women of childbearing age, 77%-100% among children 4-5 y old, and 27%-78% among children 1-3 y old. At the current breeding target of 28 ppm, zinc-biofortified rice has the potential to decrease zinc inadequacy by ≤50% among women and children in rural Bangladesh and among children in the Philippines where consumption of rice is higher compared with Indonesia.

CONCLUSIONS

Our analysis shows that increasing zinc content in rice ≤45 ppm reduces the burden of zinc inadequacy substantially, after which we encourage programs to increase coverage to reach the highest number of beneficiaries.

Bifidobacterium longum modifies a nutritional intervention for stunting in Zimbabwean infants

Child stunting is an indicator of chronic undernutrition and reduced human capital. However, it remains a poorly understood public health problem. Small-quantity lipid-based nutrient supplements (SQ-LNS) have been widely tested to reduce stunting, but have modest effects. The infant intestinal microbiome may contribute to stunting, and is partly shaped by mother and infant histo-blood group antigens (HBGA). We investigated whether mother-infant fucosyltransferase status, which governs HBGA, and the infant gut microbiome modified the impact of SQ-LNS on stunting at age 18 months among Zimbabwean infants in the SHINE Trial ( NCT01824940 ). We found that mother-infant fucosyltransferase discordance and Bifidobacterium longum reduced SQ-LNS efficacy. Infant age-related microbiome shifts in B. longum subspecies dominance from infantis , a proficient human milk oligosaccharide utilizer, to suis or longum , proficient plant-polysaccharide utilizers, were partly influenced by discordance in mother-infant FUT2+/FUT3- phenotype, suggesting that a "younger" microbiome at initiation of SQ-LNS reduces its benefits on stunting.

Determinants of household-, maternal- and child-related factors associated with nutritional status among children under five in Mali: evidence from a Demographic and Health Survey, 2018

OBJECTIVE

The current study aims to determine household-, maternal- and child-related factors influencing nutritional status among children under five in Mali.

DESIGN

Quantitative cross-sectional study using secondary data extracted from Mali DHS-VI 2018.

SETTING

Urban and rural areas of Mali.

PARTICIPANTS

A total of 8908 children participated, with 3999 in the younger age group (0-24 months) and 4909 in the older age group (25-59 months).

RESULTS

In the younger age group, the prevalence of stunting, wasting and underweight was 18·8 % (95 % CI%: 17·5, 20·0), 24·6 % (95 % CI: 23·2, 26·0) and 13·2 % (95 % CI: 12·1, 14·3), respectively, while in the older age group, it was 24·9 % (95 % CI: 23·7, 26·2), 22·7 % (95 % CI: 21·5, 24·0) and 5·7 % (95 % CI: 5·0, 6·5), respectively. Being average or large size at birth, having piped source of water, receiving Zn, deworming, high maternal BMI, receiving Fe during pregnancy, higher maternal education and being rich were associated with lower odds of one or more form of undernutrition in both groups. On the other hand, children who were anaemic, drank from a bottle, maternal anaemia, current pregnancy of mothers and living in rural areas were associated with higher odds of stunting, wasting or underweight. Interestingly, children who received Fe supplementation had a higher odds of wasting in the younger group but lower odds of all forms of undernutrition in the older group.

CONCLUSIONS

This study emphasised the potential risk factors associated with undernutrition in children. Children who consume non-potable water, have mothers with lower levels of education and BMI and reside in rural areas are more likely to experience undernutrition.

Zinc and vitamin D deficiency and supplementation in hypophosphatasia patients - A retrospective study

Hypophosphatasia (HPP) is characterized by severe skeletal symptoms including mineralization defects, insufficiency fractures, and delayed facture healing or non-unions. HPP is caused by mutations of the tissue non-specific alkaline phosphatase (TNSALP). Zinc is a cofactor of TNSALP and vitamin D an important regulator of bone matrix mineralization. Data from this retrospective study indicates that deficiencies in zinc or vitamin D occur in HPP patients with a similar frequency as in the general population. While guidelines for repletion of these micronutrients have been established for the general population, the transferability of the efficacy and safety of these regiments to HPP patients still needed to be determined. We filtered for variant classification (ACMG 3-5, non-benign) and data completeness from a total cohort of 263 HPP patients. 73.5 % of this sub-cohort were vitamin D deficient while 27.2 % were zinc deficient. We retrospectively evaluated the effect of supplementation according to general guidelines in 10 patients with zinc-deficiency and 38 patients with vitamin d-deficiency. The treatments significantly raised serum zinc or vitamin D levels respectively. All other assessed disease markers (alkaline phosphatase, pyrodoxal-5-phosphate) or bone turnover markers (phosphate, calcium, parathyroid hormone, bone specific alkaline phosphatase, creatinine, desoxypyridinoline) remained unchanged. These results highlight that general guidelines for zinc and vitamin D repletion can be successfully applied to HPP patients in order to prevent deficiency symptoms without exacerbating the disease burden or causing adverse effects due to changes in bone and calcium homeostasis.

Effectiveness of orange almond potato cookie vs. orange potato cookie supplementation on nutritional wellbeing of the Indonesian stunted preschool-aged children during COVID-19 pandemic

Background

Preschool-aged children who experience stunting due to insufficient consumption of macro- and micronutrients exhibit weakened immune systems, rendering them susceptible to contracting COVID-19 during the ongoing epidemic. Therefore, it is imperative to implement interventions aimed at enhancing the nutritional status of preschool-aged children by providing them with nutrient-rich food supplements as a preventive measure against illness transmission. The objective of the study was to evaluate the impact of incorporating potato almond orange cookies into the diet on the nutritional status of preschool-aged children who are experiencing stunting.

Methods

A non-randomized pre-post intervention study was done on 42 individuals aged 12-58 months during 4 weeks. The intervention group was provided with almond potato cookies, while the control group was given orange potato cookies. During the study period, educational sessions on balanced nutrition in preschool-aged children with stunting and COVID-19 were provided to the mothers of both groups. The data analysis involved conducting univariate and bivariate analyses, namely utilizing the independent t-test.

Results

The intervention group exhibited the most significant enhancements in -for-Age Z-score. The mean -for-Age Z-score of the intervention group increased by 0.51 (from -3.15 to -2.64), whereas the control group saw a smaller gain of 0.25 (from -2.69 to -2.44). This increase was influenced by the mother's age; mother's education; father's occupation; family size; good sanitation facilities; healthy home environment; and fat, calcium, and zinc intake from the cookies (p < 0.05). From the perspective of knowledge about balanced nutrition and COVID-19, there was no significant difference in the -for-Age Z-score in the intervention group.

Conclusion

The ingestion of orange almond potato cookies has the potential to enhance the nutritional wellbeing of children in the preschool age group who are experiencing stunted growth.

Micronutrients and Nutrition Status of School-Aged Children in Indonesia

Micronutrient deficiencies (MNDs) in school-aged children are still a major health problem in Indonesia. This study was designed to examine the status of micronutrients and their relationship to the nutritional status of children aged 5-12 years since an up-to-date database on the micronutrient status of children aged 5-12 years is needed. Data from the 2018 Indonesian Basic Health Research (Riskesdas) were used in this study, with 2456 subjects for analysis. Micronutrient analysis was carried out, including iron status (ferritin, C reactive protein (CRP)), levels of zinc, vitamin D, calcium, and vitamin A (retinol) in school-aged children (5-12 years). The ELISA measurement was applied to measure CRP, ferritin, and vitamin D. Zinc levels were analysed with atomic absorbance spectroscopy (AAS). Moreover, high-performance liquid chromatography (HPLC) was applied to calculate vitamin A. In addition, stunting and thinness data were also obtained from the Riskesdas study. The results showed that the prevalence of stunting and thinness in school-aged children was 11.4% and 9.2%, respectively, showing that the stunting prevalence in the city was lower than in the village (4.5% vs. 6.9%, P = 0.000, respectively). In addition, the prevalence of MNDs in Indonesian children was 13.4%, 19.7%, 4.2%, 3%, and 12.7% for ferritin, zinc, calcium, vitamin A, and vitamin D, respectively. The mean serum level of vitamin A and zinc was significantly lower in stunted children compared to normal school children (P = 0.010 and P = 0.014). The serum concentration of vitamin D was significantly lower in overweight children compared to thin and normal children (P = 0.000). Serum values of ferritin, zinc, and vitamin A were significantly higher in overweight children compared to thin and normal children (P = 0.000). A poor correlation was observed between the z-score of height-for-age (HAZ) and the levels of zinc (r = 0.089, P = 0.000), vitamin A (r = 0.105, P = 0.000), and vitamin D (-0.073, P = 0.000). In addition, very weak correlations between z-scores of body mass index-for-age (BAZ) and the serum concentrations of ferritin (0.091, P = 0.000), zinc (r = 0.115, P = 0.000), vitamin A (r = 0.137, P = 0.000), and vitamin D (r = -0.112, P = 0.000) were also seen. In conclusion, school-aged children in Indonesia experienced stunting, thinness, and micronutrient deficiency. Furthermore, stunting and thinness were also related to micronutrient deficiencies.

The effect of zinc supplementation on anthropometric measurements in healthy children over two years: a systematic review and meta-analysis

BACKGROUND

Zinc deficiency is one of the most important micronutrient deficiencies in children that can affect the children's growth pattern. In this regard, different studies were conducted to assess the effect of zinc supplementation on growth patterns in healthy children. To the best of our knowledge, no systematic review has summarized the results of these studies. So, in the present study, we systematically reviewed the result of the studies that assessed the effect of zinc supplementation on anthropometric parameters in healthy, over 2-year-old children.

METHODS

A systematic search was carried out in PubMed, Scopus, and Web of Science from inception to November 2021. Data were pooled using the random-effects method and were expressed as weighted mean difference (WMD) and 95% confidence intervals (CI).

RESULTS

The pooled results of eight studies, including 1586 participants, showed that zinc supplementation significantly increases height [(WMD): 0.9, 95% CI: (0.27, 1.52), p < 0.001], weight [(WMD): 0.51, 95% CI: (0.06, 0.97), p < 0.001], height for age (HAZ) [(WMD): 0.07, 95% CI: (0.03, 0.10), p < 0.001]. Also, meta-regression analysis did not reveal any significant association between dose and duration of intervention and anthropometric parameters.

CONCLUSION

The present study demonstrates the beneficial effects of zinc supplementation on weight, height, and HAZ.

Nutritional Strategies for the Prevention and Management of Cow's Milk Allergy in the Pediatric Age

Cow's milk allergy (CMA) is one of the most common pediatric food allergies. The prevalence and severity of CMA have increased dramatically in the last decades, under the pressure of environmental factors in genetically predisposed individuals. Among the environmental influences, nutritional factors play a crucial role. Diet is the most modifiable factor, representing a potential target for the prevention and treatment of CMA. In this review, we report the most scientific-based nutritional strategies for preventing and managing pediatric CMA. In addition, we propose the most complete supplement of compounds able to prevent nutrient deficiencies in CMA pediatric patients and to positively influence the disease course.

Insulin-like Growth Factor 1 (IGF1), IGF Binding Protein-3 (IGFBP3) and Growth Response to Daily Zinc Supplementation: A Randomized Trial in Rural Laotian Children

OBJECTIVES

To assess (a) the impact of daily preventive zinc tablets (7 mg; PZ), zinc-containing multiple micronutrient powder (10 mg zinc, and 13 other micronutrients; MNP) or placebo, delivered for 9 months, on Insulin-like Growth Factor 1 (IGF1) and IGF Binding Protein 3 (IGFBP3) among Laotian children 6-23 months, and (b) whether the effects of PZ and MNP on length-for-age z-scores (LAZ) and weight-for-age z-scores (WAZ) are modified by baseline IGF1 and IGFBP3.

DESIGN

A double-blind, placebo-controlled trial (N = 419).

METHODS

Plasma IGF1 and IGFBP3 concentrations at baseline and 36 weeks were analyzed by automated chemiluminescent assay. Anthropometry was assessed at baseline, at 18 and 36 weeks. Intervention effects were estimated using ANCOVA.

RESULTS

At 36 weeks, geometric mean IGF1 (~39.0-39.2 ng/mL; p = 0.99) and IGFBP3 (2038-2076 ng/mL; p = 0.83) did not differ by group. At 18 weeks (but not at 36 weeks), LAZ in the PZ group (-1.45) was higher than the MNP (-1.70) and control (-1.55) groups (p = 0.01) among children in the highest baseline IGF1 tertile (p for interaction = 0.006). At 36 weeks (but not at 18 weeks), WAZ in the PZ group (-1.55) was significantly higher than the MNP (-1.75) and control (-1.65) groups (p = 0.03), among children in the lowest baseline IGFBP3 tertile (p for interactions = 0.06).

CONCLUSIONS

Although IGF1 and IGFBP3 did not respond to PZ and MNP, baseline IGF1 and IGFBP3 significantly modified the impact of PZ on linear and ponderal growth, suggesting that IGF1 bioavailability may drive catch-up growth in zinc-supplemented children.

Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years

BACKGROUND

Zinc deficiency is prevalent in low- and middle-income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed.

OBJECTIVES

To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years.

SEARCH METHODS

A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all-cause mortality; and cause-specific mortality, due to all-cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events.

MAIN RESULTS

We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low- or middle-income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow-up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High-certainty evidence showed little to no difference in all-cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate-certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all-cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all-cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate-certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high-certainty evidence) compared to no zinc. There was moderate-certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high-certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co-supplementation of zinc with iron decreased the beneficial effect of zinc.

AUTHORS' CONCLUSIONS

Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high.

Vitamin D and Zinc are Interlinked but Affected by Different Growth Factors in Iranian Children and Adolescents: Vitamin D and Zinc in Iranian Children and Adolescents

Background: Zinc and vitamin D are essential factors required for growth. Recently, studies have shown a possible link between serum zinc and vitamin D levels. Objectives: This study was designed to evaluate this link and its possible affecting growth factors in children and adolescents in Iran. Methods: This cross-sectional study was performed on the data obtained from children aged 2 to 18 years old referring to a growth assessment clinic for routine growth follow-ups in the city of Shiraz from April to August 2019. A total of 454 children who were checked for 25-hydroxyvitamin D and zinc simultaneously were included. Results: Vitamin D was negatively correlated with body mass index (BMI) z-scores, while zinc was positively correlated with vitamin D and height z-scores. Subjects with vitamin D levels ≤ 8.6 ng/mL were 2.081 times more likely to have a zinc deficiency. Vitamin D insufficiency was significantly higher in overweight and obese children. Mean vitamin D and zinc levels were significantly lower, and vitamin D insufficiency was significantly higher in boys than girls. While mean zinc levels were significantly lower in short children, the prevalence of zinc deficiency was not statistically different between short and normal height statures. Conclusions: Very low vitamin D levels are likely to be accompanied by zinc deficiency, possibly caused by malnutrition and the modulatory effect of serum vitamin D on zinc absorption. Unlike zinc deficiency, vitamin D insufficiency is much more prevalent in Iranian children than in children from other countries. Vitamin D and zinc are associated with BMI and height z-scores, respectively.

Reference cut-offs to define low serum zinc concentrations in healthy 1-19 year old Indian children and adolescents

BACKGROUND/OBJECTIVES

Population zinc (Zn) status assessment is based on serum zinc concentration (SZC) cut-offs defined by the International Zinc Nutrition Consultative Group (IZiNCG). The objective of this study is to derive reference SZC cut-offs in apparently healthy 1-19 year Indian children and adolescents using comprehensive national nutrition survey (CNNS) data, and to measure the prevalence of Zn deficiency.

SUBJECTS/METHODS

Apparently healthy children (n = 12,473) were selected from the CNNS, by including the highest 2 wealth quintiles, and excluding stunted, thin and obese children, and those with CRP > 5 mg/L, anaemia, hypo-albuminemia, diabetes, recent diarrhoea and history of smoking. The 2.5th centile of age-based distributions defined the SZC cut-offs, used to measure the prevalence of Zn deficiency in India, as against the IZiNCG cut-offs.

RESULTS

The present study SZC cut-offs were significantly lower, by 10-18 µg/dL, than the IZiNCG cut-offs; more in adolescents. Prevalence of Zn deficiency in the entire CNNS, with these cut-offs, was 2.7 (<10 years) to 5.5 (10-19 years) times lower than with the IZiNCG cut-offs. No geographical state, nor any age group, had Zn deficiency as a serious public health problem (≥20%). In contrast, with IZiNCG cut-offs, 9-27 states (depending on age group) had a public health problem.

CONCLUSIONS

The present study reference SZC cut-offs for Zn deficiency are lower than the IZiNCG cut-offs, and their rigorous selection from a national sample makes them more appropriate for use in India. A re-examination of the global applicability of IZiNCG recommended cut-offs in other LMICs appears appropriate.

Enteral Zinc Supplementation in Preterm or Low Birth Weight Infants: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Evidence on the effect of zinc supplementation on health outcomes in preterm or low birth weight (LBW) infants is unclear. We estimated the effect of enteral zinc versus no zinc supplementation in human milk fed preterm or LBW infants on mortality, growth, morbidities, and neurodevelopment.

METHODS

Data sources include PubMed, Cochrane Central and Embase databases through March 24, 2021. Study selection was randomized or quazi-experimental trials. Two reviewers independently screened, extracted data, and assessed quality. We reported pooled relative risks (RR) for categorical outcomes, and mean differences (MD) for continuous outcomes.

RESULTS

Fourteen trials with 9940 preterm or LBW infants were included. Moderate to low certainty evidence showed that enteral zinc supplementation had little or no effect on mortality (risk ratio 0.73, 95% confidence interval [CI] 0.46 to 1.16), but increased weight (MD 378.57, 95% CI 275.26 to 481.88), length (MD 2.92, 95% CI 1.53 to 4.31), head growth (MD 0.56, 95% CI 0.23 to 0.90), and decreased diarrhea (RR 0.81; 95% CI 0.68 to 0.97). There was no effect on acute respiratory infections, bacterial sepsis, and psychomotor development scores. The effect of zinc supplementation on mental development scores is inconclusive. There was no evidence of serious adverse events. Eight trials had some concerns or high risk of bias, small-sized studies, and high heterogeneity between trials led to moderate to very low certainty of evidence.

CONCLUSIONS

Zinc supplementation in preterm or LBW infants have benefits on growth and diarrhea prevention. Further research is needed to generate better quality evidence.

The Effects of Nutrition on Linear Growth

Linear growth is a complex process and is considered one of the best indicators of children’s well-being and health. Genetics, epigenetics and environment (mainly stress and availability of nutrients) are the main regulators of growth. Nutrition exerts its effects on growth throughout the course of life with different, not completely understood mechanisms. Cells have a sophisticated sensing system, which allows growth processes to occur in the presence of an adequate nutrient availability. Most of the nutritional influence on growth is mediated by hormonal signals, in turn sensitive to nutritional cues. Both macro- and micro-nutrients are required for normal growth, as demonstrated by the impairment of growth occurring when their intake is insufficient. Clinical conditions characterized by abnormal nutritional status, including obesity and eating disorders, are associated with alterations of growth pattern, confirming the tight link between growth and nutrition. The precise molecular mechanisms connecting nutrition to linear growth are far from being fully understood and further studies are required. A better understanding of the interplay between nutrients and the endocrine system will allow one to develop more appropriate and effective nutritional interventions for optimizing child growth.

Effect of enteral zinc supplementation on growth and neurodevelopment of preterm infants: a systematic review and meta-analysis

OBJECTIVE

To evaluate effect of enteral zinc supplementation on growth and neurodevelopmental outcomes of preterm infants.

STUDY DESIGN

A systematic review and meta-analysis of randomized-controlled trials (RCTs) examining growth and neurodevelopmental outcomes after zinc supplementation in preterm infants.

RESULTS

Of eight RCTs involving 742 infants included, seven reported growth anthropometrics at 3-6 months corrected age (CA) and two reported neurodevelopmental outcomes at 6-12 months CA. Zinc supplementation was associated with increased weight z-score (weighted mean difference (WMD) = 0.50; 95% CI 0.23-0.76, heterogeneity I2 = 89.1%; P < 0.01), length z-score (WMD = 1.12; 95% CI 0.63-1.61, heterogeneity I2 = 96.0%; P < 0.01) and motor developmental score (WMD = 9.54; 95% CI 6.6-12.4 heterogeneity I2 = 0%; P = 0.52). There was no effect on head circumference and total developmental score. Evidence is "moderate" certainty for weight and length and "very low" certainty for neurodevelopment.

CONCLUSION

Zinc supplementation may enhance weight gain and linear growth in preterm infants. There is a lack of data about relationship between zinc supplementation and neurodevelopment.

Coherence for nutrition: insights from nutrition-relevant policies and programmes in Burkina Faso and Nigeria

There is consensus that policy coherence is necessary for implementing effective and sustainable approaches to tackle malnutrition. We look at whether policies and programmes provide a coherent pathway to address nutrition priorities and if programmes are designed to deliver interventions aligned to the nutrition policy agenda in Nigeria and Burkina Faso. A systematic desk review was performed on nutrition-relevant policy and programme documents, obtained through grey literature searches and expert recommendations. We developed a framework with an impact pathway structure that includes five process steps, which was used to guide coding, data reduction and synthesis and structure the analysis. We assessed internal coherence along process steps within a given document and external coherence across process steps for explicitly linked policy/programme pairs. The majority of policies and programmes had partial internal coherence for both countries. The identification of relevant nutrition interventions to address challenges and reach objectives was the strongest connection within policies (16 out of 45 had complete coherence), while among programmes, the strongest connection was coverage indicators that measure interventions (9 out of 21 had complete coherence). Eight programmes explicitly referenced at least one nutrition-relevant policy, with a total of 16 linked policy/programme pairs (13 pairs for Burkina Faso and 3 for Nigeria) across health, nutrition, agriculture and social focus areas. However, none of the linked pairs were assessed to have complete external coherence, suggesting that priorities at the policy level are not fully realized nor translated at the programme level. This study offers a new approach for the assessment of policy and programme coherence and specifically examines policy and programme linkages. We conclude that improved leadership on country priority setting and better alignment for nutrition within and across sectors is needed to enhance the effectiveness of nutrition investments.

Prevalence of Zinc Deficiency in Healthy 1-3-Year-Old Children from Three Western European Countries

Zinc deficiency (ZnD) has adverse health consequences such as stunted growth. Since young children have an increased risk of developing ZnD, it is important to determine its prevalence and associated factors in this population. However, only a few studies have reported on ZnD prevalence in young children from Western high-income countries. This study evaluated ZnD prevalence and associated factors, including dietary Zn intake, in healthy 1–3-year-old children from Western European, high-income countries. ZnD was defined as serum Zn concentration <9.9 µmol/L. A total of 278 children were included with a median age of 1.7 years (Q1–Q3: 1.2–2.3). The median Zn concentration was 11.0 µmol/L (Q1–Q3: 9.0–12.2), and ZnD prevalence was 31.3%. No significant differences were observed in the socio-economic characteristics between children with and without ZnD. Dietary Zn intake was not associated with ZnD. ZnD is common in healthy 1–3-year-old children from Western European countries. However, the use of currently available cut-off values defining ZnD in young children has its limitations since these are largely based on reference values in older children. Moreover, these values were not evaluated in relation to health consequences, warranting further research.

Prevalence of low serum zinc concentrations in Indian children and adolescents: findings from the Comprehensive National Nutrition Survey 2016-18

BACKGROUND

It is thought that there is a high risk of zinc deficiency in India, but there are no representative national estimates.

OBJECTIVES

We aimed to evaluate the national and state-level prevalence of low serum zinc concentrations (SZCs) in Indian children from the nationally representative Comprehensive National Nutrition Survey.

METHODS

Prevalence of low SZC, adjusted for C-reactive protein, was estimated among preschool (1-4 y; n = 7874) and school-age children (5-9 y; n = 10,430) and adolescents (10-19 y; n = 10,140), using SZC cutoffs defined by the International Zinc Nutrition Consultative Group.

RESULTS

Prevalence of low SZC was high among adolescents (31.1%; 95% CI: 29.8%, 32.4%), compared with school-age (15.8%; 95% CI: 15.3%, 16.3%) or preschool children (17.4%; 95% CI: 16.7%, 18.0%). However, stratification of prevalence by fasting status or using an alternative lower SZC cutoff independent of fasting status led to a reduction in prevalence by 3.7% or 7.8% in children <10 y, respectively. The prevalence of low SZC was higher among rural preschool children, those belonging to households with poor socioeconomic status, and those with severe stunting or underweight. Preschool children with diarrhea (22.6%; 95% CI: 20.8%, 24.4%), productive cough (22.7%; 95% CI: 18.5%, 27.5%), or malaria/dengue (38.5%; 95% CI: 29.4%, 48.2%) in the 2 wk preceding the survey had a higher prevalence of low SZC than those without morbidity (16.5%; 95% CI: 15.9%, 17.2%; 17.6%; 95% CI: 16.9%, 18.2%; and 17.5%; 95% CI: 16.8%, 18.1%, respectively).

CONCLUSIONS

The national prevalence of low SZC among preschool (17%) or school-age children (16%) was <20%, which is considered the cutoff indicating a problem of public health significance; but there were variations by state and socioeconomic status. In adolescents, however, the prevalence of low SZC was 31%, which warrants further investigation. The association of low SZC with diarrhea in preschool children necessitates better coverage of Zn administration in the management of diarrhea.

Tenth year reenrollment randomized trial investigating the effects of childhood probiotics and calcium supplementation on height and weight at adolescence

Microbiota and its modification with specific probiotics in early life could provide long term health benefits. Probiotics and calcium strengthen intestinal integrity and may support linear growth. This study investigated the long-term effects of childhood probiotics and calcium supplementation on growth in adolescence. We re-enrolled 238 adolescents aged 11-18 years from 494 children 10-years after 6-months of supplementation with either low-lactose milk fortified with low levels of calcium (LC, ∼50 mg/day, n = 53/124), with regular levels of calcium (RC, ∼440 mg/day, n = 70/126), or with regular calcium + 5 x 108 CFU/day Lactobacillus reuteri DSM 17938 (Reuteri, n = 55/124), or regular calcium + 5 x 108 CFU/day L. casei CRL 431 (Casei, n = 60/120). Changes in height-for-age z-score (HAZ) and body mass index-for-age z-score (BMIZ) were determined from the end of intervention to re-enrollment. General linear models were used to assess the effects on HAZ and BMIZ of group, gender, living area, maternal education, family income, physical activity, diet quality, nutritional status, and gut integrity as determined by urinary lactulose/mannitol ratio (L:M). Adolescent mean age was 15.3 years, mean HAZ was - 1.11, mean BMIZ was - 0.2 and median L:M (n = 155) was 0.23. Changes in HAZ and BMIZ were not significantly different between Casei, Reuteri, LC compared to RC. However, a significant decrease in BMIZ was observed among female adolescents in the Casei compared to RC group (- 0.5 SD, 95% CI - 0.8 to - 0.003, p = 0.048). Childhood probiotic and calcium supplementation may therefore selectively affect female adolescents.Clinical trial registration: This follow-up study has been registered at www.clinicaltrials.gov , Registry name: Rina Agustina, Registration number: NCT04046289, First Registration Date 06/08/19. web link: https://www.clinicaltrials.gov/ct2/show/NCT04046289 .

Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review

Background

Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation.

Objectives

To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy.

Search Methods

We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies.

Selection Criteria

We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis.

Data Collection and Analysis

Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach.

Main Results

A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1.

Authors' Conclusions

The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.

Micronutrient Deficiencies and Stunting Were Associated with Socioeconomic Status in Indonesian Children Aged 6-59 Months

Micronutrient deficiencies and stunting are known as a significant problem in most developing countries, including Indonesia. The objective of this study was to analyze the association between micronutrient deficiencies and stunting with socioeconomic status (SES) among Indonesian children aged 6–59 months. This cross-sectional study was part of the South East Asian Nutrition Surveys (SEANUTS). A total of 1008 Indonesian children were included in the study. Anemia, iron deficiency, vitamin A deficiency, vitamin D deficiency, and stunting were identified in this study. Structured questionnaires were used to measure SES. Differences between micronutrient parameters and anthropometric indicators with the SES groups were tested using one-way ANOVA with post-hoc test after adjusted for age, area resident (rural and urban), and sex. The highest prevalence of anemia, stunting, and severe stunting were found to be most significant in the lowest SES group at 45.6%, 29.3%, and 54.5%, respectively. Children from the lowest SES group had significantly lower means of Hb, ferritin, retinol, and HAZ. Severely stunted children had a significantly lower mean of Hb concentration compared to stunted and normal height children. Micronutrient deficiencies, except vitamin D, and stunting, were associated with low SES among Indonesian children aged 6–59 months.

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.

Soil zinc, serum zinc, and the potential for agronomic biofortification to reduce human zinc deficiency in Ethiopia

Human zinc deficiency is a global public health problem. Many African soils are zinc deficient (ZnD), indicating fertilizers could increase crop yields and grain Zn levels, thereby increasing Zn in the food supply and alleviating human Zn deficiency. To analyze associations among soil Zn, human Zn deficiency, and child nutritional status, we combined the Ethiopian soil Zn map and the Ethiopian National Micronutrient Survey (ENMS). ENMS provides representative, georeferenced data on child nutritional status using anthropometry of children under five years old (CU5) and on human Zn deficiency among CU5 and women of reproductive age (WRA) using the recommended biomarker, serum Zn. ZnD soils mostly occur in lower altitudes, which are less populated and outside the main crop-producing areas. Serum Zn deficiencies were high, and correlated to soil Zn for children, but not for WRA. About 4 million Ethiopian CU5 are ZnD, and, of these, about 1.5 million live on low-Zn soils (< 2.5 mg/kg), while 0.3 million live on ZnD soils (< 1.5 mg/kg). Therefore, if Zn fertilizers are only applied on ZnD soils, their impact on child Zn deficiency may be limited. Greater impact is possible if Zn fertilizers are applied to soils with sufficient Zn for plant growth and if this results in increased grain Zn. Optimal soil Zn levels for plant and human nutrition may be different, and context-specific optimal levels for the latter must be determined to develop nutrition-sensitive fertilizer policies and recommendations.

Enteral zinc supplementation for prevention of morbidity and mortality in preterm neonates

BACKGROUND

Preterm and low birth weight infants are born with low stores in zinc, which is a vital trace element for growth, cell differentiation and immune function. Preterm infants are at risk of zinc deficiency during the postnatal period of rapid growth. Systematic reviews in the older paediatric population have previously shown that zinc supplementation potentially improves growth and positively influences the course of infectious diseases. In paediatric reviews, the effect of zinc supplementation was most pronounced in those with low nutritional status, which is why the intervention could also benefit preterm infants typically born with low zinc stores and decreased immunity.

OBJECTIVES

To determine whether enteral zinc supplementation, compared with placebo or no supplementation, affects important outcomes in preterm infants, including death, neurodevelopment, common morbidities and growth.

SEARCH METHODS

Our searches are up-to-date to 20 February 2020. For the first search, we used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 8), MEDLINE via PubMed (1966 to 29 September 2017), Embase (1980 to 29 September 2017), and CINAHL (1982 to 29 September 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. We ran an updated search from 1 January 2017 to 20 February 2020 in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost.

SELECTION CRITERIA

We included RCTs and quasi-RCTs that compared enteral zinc supplementation versus placebo or no supplementation in preterm infants (gestational age < 37 weeks), and low birth weight babies (birth weight < 2500 grams), at any time during their hospital admission after birth. We included zinc supplementation in any formulation, regimen, or dose administered via the enteral route. We excluded infants who underwent gastrointestinal (GI) surgery during their initial hospital stay, or had a GI malformation or another condition accompanied by abnormal losses of GI juices, which contain high levels of zinc (including, but not limited to, stomas, fistulas, and malabsorptive diarrhoea).

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors separately screened abstracts, evaluated trial quality and extracted data. We synthesised effect estimates using risk ratios (RR), risk differences (RD), and standardised mean differences (SMD). Our primary outcomes of interest were all-cause mortality and neurodevelopmental disability. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included five trials with a total of 482 preterm infants; there was one ongoing trial. The five included trials were generally small, but of good methodological quality. Enteral zinc supplementation compared to no zinc supplementation Enteral zinc supplementation started in hospitalised preterm infants may decrease all-cause mortality (between start of intervention and end of follow-up period) (RR 0.55, 95% CI 0.31 to 0.97; 3 studies, 345 infants; low-certainty evidence). No data were available on long-term neurodevelopmental outcomes at 18 to 24 months of (post-term) age. Enteral zinc supplementation may have little or no effect on common morbidities such as bronchopulmonary dysplasia (RR 0.66, 95% CI 0.31 to 1.40, 1 study, 193 infants; low-certainty evidence), retinopathy of prematurity (RR 0.14, 95% CI 0.01 to 2.70, 1 study, 193 infants; low-certainty evidence), bacterial sepsis (RR 1.11, 95% CI 0.60 to 2.04, 2 studies, 293 infants; moderate-certainty evidence), or necrotising enterocolitis (RR 0.08, 95% CI 0.00 to 1.33, 1 study, 193 infants; low-certainty evidence). The intervention probably improves weight gain (SMD 0.46, 95% CI 0.28 to 0.64; 5 studies, 481 infants; moderate-certainty evidence); and may slightly improve linear growth (SMD 0.75, 95% CI 0.36 to 1.14, 3 studies, 289 infants; low-certainty evidence), but may have little or no effect on head growth (SMD 0.21, 95% CI -0.02 to 0.44, 3 studies, 289 infants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Enteral supplementation of zinc in preterm infants compared to no supplementation or placebo may moderately decrease mortality and probably improve short-term weight gain and linear growth, but may have little or no effect on common morbidities of prematurity. There are no data to assess the effect of zinc supplementation on long-term neurodevelopment.

Effective interventions to address maternal and child malnutrition: an update of the evidence

Malnutrition-consisting of undernutrition, overweight and obesity, and micronutrient deficiencies-continues to afflict millions of women and children, particularly in low-income and middle-income countries (LMICs). Since the 2013 Lancet Series on maternal and child nutrition, evidence on the ten recommended interventions has increased, along with evidence of newer interventions. Evidence on the effectiveness of antenatal multiple micronutrient supplementation in reducing the risk of stillbirths, low birthweight, and babies born small-for-gestational age has strengthened. Evidence continues to support the provision of supplementary food in food-insecure settings and community-based approaches with the use of locally produced supplementary and therapeutic food to manage children with acute malnutrition. Some emerging interventions, such as preventive small-quantity lipid-based nutrient supplements for children aged 6-23 months, have shown positive effects on child growth. For the prevention and management of childhood obesity, integrated interventions (eg, diet, exercise, and behavioural therapy) are most effective, although there is little evidence from LMICs. Lastly, indirect nutrition strategies, such as malaria prevention, preconception care, water, sanitation, and hygiene promotion, delivered inside and outside the health-care sector also provide important nutritional benefits. Looking forward, greater effort is required to improve intervention coverage, especially for the most vulnerable, and there is a crucial need to address the growing double burden of malnutrition (undernutrition, and overweight and obesity) in LMICs.

Effects of therapeutic zinc supplementation for diarrhea and two preventive zinc supplementation regimens on the incidence and duration of diarrhea and acute respiratory tract infections in rural Laotian children: A randomized controlled trial

Background

Diarrhea and respiratory tract infections are leading causes of childhood morbidity and mortality. This individually randomized, double-blind placebo-controlled trial was designed to evaluate the effects of different zinc supplementation regimens on the incidence and duration of diarrhea and acute lower (ALRI) and upper (AURI) respiratory tract infections among rural Laotian children. The study included 3407 children, 6-23 months at enrollment.

Methods

Children were randomized to one of four study groups: therapeutic zinc supplements for diarrhea treatment (20 mg/d for 10 days with each episode; TZ), daily preventive zinc tablets (7 mg/d; PZ), daily multiple micronutrient powder (10 mg/d zinc, 6 mg/d iron and 13 other micronutrients; MNP), or daily placebo powder for 9 months. Incidence and duration of diarrhea (≥3 liquid stools/24 hours), ALRI (persistent cough with wheezing, stridor or chest in-drawing) and AURI (purulent nasal discharge with cough) were assessed by parental report during weekly home visits and analyzed using negative binomial models.

Results

Baseline mean age was 14.2 ± 5.1 months, and 71% had low plasma zinc (<65 μg/dL). Overall diarrhea incidence (0.61 ± 0.01 episodes/100 days at risk) and duration (2.12 ± 0.03 days/episode) did not differ by study group. Age modified the impact of the interventions on diarrhea incidence (P = 0.06) and duration (P = 0.01). In children >18 months, TZ reduced diarrhea incidence by 24% vs MNP (P = 0.035), and 36% vs Control (P = 0.004), but there was no difference with PZ. This patterned remained when analyses were restricted to diarrhea episode occurring after the first treatment with TZ. Also, in children >18 months, TZ reduced diarrhea duration by 15% vs PZ (P = 0.03), and 16% vs Control (P = 0.03), but there was no difference with MNP. There were no overall effects of study group on incidence of ALRI (overall mean 0.005 ± 0.001 episodes/100 days, P = 0.14) or AURI (overall mean 0.09 ± 0.01 episodes/100 days, P = 0.72).

Conclusions

There was no overall impact of TZ, PZ or MNP on diarrhea, ALRI and AURI. However, in children >18 months, TZ significantly reduced both the duration of diarrhea episodes and the incidence of future diarrhea episodes compared with placebo.

Trial registration

ClinicalTrials.gov: NCT02428647.

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

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

Antimicrobial and micronutrient interventions for the management of infants under 6 months of age identified with severe malnutrition: a literature review

BACKGROUND

Infants under 6 months (U6M) contribute a significant proportion of the burden and mortality of severe malnutrition globally. Evidence of underlying aetiology in this population is sparse, but it is known that the group includes ex-preterm and low birthweight (LBW) infants. They represent a unique population given their dependence on breastmilk or a safe, secure alternative. Nutrition agencies and health providers struggle to make programming decisions on which interventions should be provided to this group based upon the 2013 WHO Guidelines for the 'Management of Severe Acute Malnutrition in Infants and Young Children' since there are no published interventional trial data focussed on this population. Interim guidance for this group might be informed by evidence of safety and efficacy in adjacent population groups.

METHODOLOGY

A narrative literature review was performed of systematic reviews, meta-analyses and randomised controlled trials of antimicrobial and micronutrient interventions (antibiotics, deworming, vitamin A, vitamin D, iron, zinc, folic acid and oral rehydration solution (ORS) for malnutrition) across the population groups of low birthweight/preterm infants, infants under 6 months, infants and children over 6 months with acute malnutrition or through supplementation to breastfeeding mothers. Outcomes of interest were safety and efficacy, in terms of mortality and morbidity.

RESULTS

Ninety-four articles were identified for inclusion within this review. None of these studied interventions exclusively in severely malnourished infants U6M. 64% reported on the safety of studied interventions. Significant heterogeneity was identified in definitions of study populations, interventions provided, and outcomes studied. The evidence for efficacy and safety across population groups is reviewed and presented for the interventions listed.

CONCLUSIONS

The direct evidence base for medical interventions for severely malnourished infants U6M is sparse. Our review identifies a specific need for accurate micronutrient profiling and interventional studies of micronutrients and oral fluid management of diarrhoea amongst infants U6M meeting anthropometric criteria for severe malnutrition. Indirect evidence presented in this review may help shape interim policy and programming decisions as well as the future research agenda for the management of infants U6M identified as malnourished.

Child Feeding Practice and Primary Health Care as Major Correlates of Stunting and Underweight among 6- to 23-Month-Old Infants and Young Children in Food-Insecure Households in Ethiopia

BACKGROUND

Child undernutrition is a major public health problem in Ethiopia. Stunting is highest in food-insecure areas and insufficient evidence may impair the design of suitable interventions.

OBJECTIVES

This study aimed to identify key factors contributing to undernutrition among 6- to 23-mo-old children.

METHODS

A community-based cross-sectional study in food-insecure areas of Amhara and Oromia regions in April-June, 2018, enrolled 464 mother-child dyads. Bivariate and multivariate logistic regression analyses were conducted.

RESULTS

The prevalence of stunting (43.1%), wasting (12.3%), and underweight (27.3%) were high. Factors significantly associated with both stunting and underweight were child age of 12-23 mo (vs 6-11 mo), female, more siblings, lack of zinc supplement for diarrhea, inadequate diet diversity, and lack of iodized salt in complementary food. Conclusions: Our findings support the need to emphasize appropriate child feeding practices and iodized salt utilization. Improvement of primary health care services related to micronutrient supplementation and family spacing also are important to address child undernutrition in the study area.

A Search for Similar Patterns in Hair Trace Element and Mineral Content in Children with Down's Syndrome, Obesity, and Growth Delay

The objective of the present study was to perform comparative analysis of hair trace element and mineral levels in children with Down's syndrome, growth delay, and obesity in order to reveal common and specific patterns. Hair Zn (14, 7, and 15%), Ca (38%, 24%, and 47%), and Mg (33%, 31%, and 49%) levels in children with Down's syndrome, obesity, and growth delay were lower than the respective control values. At the same time, patients with Down's syndrome and growth delay were characterized by 27% and 21%, as well as 24% and 20% lower hair Co as well as Cu content than healthy examinees. Certain alterations were found to be disease-specific. Particularly, in Down's syndrome children, hair Cr, Fe, and V levels were significantly lower, whereas hair P content exceeded the control values. Obese children were characterized by significantly increased hair Cr content. At the same time, hair Mn and Si levels in children with growth delay were lower as compared with the controls. In regression models, all three studied diseases were considered as negative predictors of hair Cu content. Down's syndrome and growth delay, but not obesity, were inversely associated with hair Co content. Both Down's syndrome and obesity were inversely associated with hair Zn content. Based on the revealed similarities in altered hair element, content it is proposed that deficiency of essential elements may predispose Down's syndrome patients to certain syndrome comorbidities including growth delay and obesity, although further detailed studies are required.

Zinc deficiency in low- and middle-income countries: prevalence and approaches for mitigation

This review addresses the prevalence of zinc deficiency in Low- and Middle-income Countries (LMICs) and assesses the available strategies for its alleviation. The paucity of national-level data on the zinc deficiency in LMICs is partially a result of the lack of a reliable biomarker. Zinc deficiency appears to be a public health problem in almost all the LMICs, irrespective of the recommended indicators (plasma zinc concentration, dietary zinc adequacy and stunting prevalence) used. Based on plasma/serum zinc concentration (PZC), which is the most appropriate indicator at present, the prevalence of zinc deficiency in LMICs is of concern. Among the 25 countries for which national PZC data were available, 23 had a zinc deficiency prevalence of >20% for at least one physiological group. Zinc supplementation is largely restricted as an adjunct therapy for diarrhoea management in children, and the best platform and the most effective way of preventive zinc supplementation delivery remains to be established. Impact assessment for current zinc fortification programmes in LMICs and the effectiveness of zinc supplementation as part of a multi-micronutrient powder is to be determined. Dietary diversification, though promising for LMICs, is in the nascent stages of development at present. Inclusion of meat and animal products can be an important way of improving zinc status. Programmatic experience with the promotion of home processing techniques to increase absorbable zinc in the diet is lacking. Conventional biofortification techniques are gaining recognition in LMICs; however, transgenic biofortification as a strategy remains controversial.

Zinc supplementation for the promotion of growth and prevention of infections in infants less than six months of age

BACKGROUND

Zinc is a vital micronutrient for humans and is essential for protein synthesis, cell growth, and differentiation. Severe zinc deficiency can lead to slower physical, cognitive and sexual growth, cause skin disorders, decrease immunity, increase incidence of acute illnesses in infants and children and contribute to childhood stunting. By estimation, 17.3% of the world population is at risk of inadequate zinc intake. Such nutritional impairment increases the risk of diarrhoea and pneumonia by 20%, as well as leads to a global loss of more than 16 million disability-adjusted life years in children less than five years of age. Not only does zinc deficiency affect lives, it adds to the considerable financial burden on depleted resources in countries that are most affected. By preventing or curing this deficiency, we can improve childhood mortality, morbidity and growth.

OBJECTIVES

To assess the effectiveness of zinc supplementation for the promotion of growth, reduction in mortality, and the prevention of infections in infants less than six months of age.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 4), MEDLINE via PubMed (1966 to 18 May 2018), Embase (1980 to 18 May 2018), and CINAHL (1982 to 18 May 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. An updated search from 1 January 2018 to 29 January 2020 was run in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost.

SELECTION CRITERIA

All randomised controlled (individual and cluster randomised) and quasi-randomised trials of zinc supplementation in healthy, term infants, less than six months of age comparing infant mortality, incidence of diarrhoea or respiratory illnesses, growth and/or serum zinc levels were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors screened search results (title and abstracts) and relevant full texts. Studies fulfilling prespecified inclusion criteria were included with any disagreements resolved by consensus. Extraction and analysis were then conducted. We used the GRADE approach to assess the quality of evidence as indicated by certainty in effect estimates.

MAIN RESULTS

Eight studies (with 85,629 infants) were included and five studies were meta-analysed, out of which four studies compared zinc with placebo, and one compared zinc plus riboflavin versus riboflavin. Certain growth outcomes after six months of intervention (Weight for Age Z-scores (WAZ) (standardised mean difference) (SMD) 0.16, 95% CI 0.03 to 0.29; three studies, n = 955; fixed-effect; heterogeneity Chi² P = 0.96); I² = 0%); change in WAZ (SMD 0.16, 95% CI 0.07 to 0.25; one study, n = 386; fixed-effect); (Weight-for-Length Z-score (WLZ) (SMD 0.15, 95% CI 0.02 to 0.28; three studies, n = 955; fixed-effect; heterogeneity: Chi² P = 0.81); I² = 0%); (change in WLZ (SMD 0.17, 95% CI 0.06 to 0.28; one study, n = 386; fixed-effect)) were positively affected by zinc supplementation compared to placebo. A single study reported no difference in the incidence of diarrhoea and lower respiratory tract infection with zinc supplementation. Zinc had no effect on mortality in children younger than 12 months. When zinc plus riboflavin was compared to riboflavin only, significant improvement was observed in the incidence of wasting at 24 months (risk ratio (RR) 0.59, 95% CI 0.37 to 0.96; one study, n = 296; fixed-effect), but significant worsening of incidence of stunting was present at 21 months (RR 1.53, 95% CI 1.09 to 2.16; one study, n = 298; fixed-effect).

AUTHORS' CONCLUSIONS

There was a significant positive impact of zinc supplementation on WAZ and WLZ after six months of intervention in infants compared to placebo. When a combined supplement of zinc and riboflavin was compared to riboflavin, there was a significant reduction in wasting at 24 months, but stunting at 21 months was negatively affected. Although included trials were of good-to-moderate quality, evidence that could be meta-analysed was based on a few studies which affected the overall quality of results. Regardless, there is a need for strong trials conducted in infants younger than six months before a strong recommendation can be made supporting zinc supplementation in this age group.

Vision of Research on Human Linear Growth

The human body grows in length from conception to the maximal adult height over two decades. The shortest male population averages ∼150 cm and the tallest ∼183 cm. Nonetheless the dimensions of head and trunk are highly comparable, with the vast difference in the leg length. Stunting is a personal condition in which an individual has a standing height-for-age (HAZ) of less than two standard deviations of the standard curve median. It is associated with increased mortality, morbidity, and functional deficits. The process of losing relative stature is known as linear growth retardation, first attributed to chronic protein deficiency, then to an assortment of micronutrient deficiencies, and most recently to inflammation from unhygienic environmental conditions. Public health intervention trials responding to each of these possibilities have failed to produce true reversal responses measured in the 10s of centimeters. As to biological insights, there is no convenient way to separate weight from length growth with sonographic monitoring, but a third of infants can be born stunted. Normative growth (standard curves) competes with epigenetic adaptation (programming) as the beacon for in utero growth. Major investments into field trials allow us to discard multiple micronutrients and water/sanitation/hygiene interventions as measures to reverse established stunting. The preponderance of evidence is against catch-up growth during puberty. Future publications will be in the conceptual domain, resolving metrics, while the full range of stimuli and exposures impeding growth will be elucidated. Advances in measurement techniques in anthropometry and immunology and endocrinology will be mobilized to the literature.

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

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

Effects of Zinc Supplementation on Nutritional Status in Children with Chronic Kidney Disease: A Randomized Trial

BACKGROUND

Zinc is an essential micronutrient for human beings and its deficiency affects their normal growth and development.

OBJECTIVE

The main aim was to evaluate the effect of two doses of zinc supplementation (ZS) on the nutritional status in chronic kidney disease (CKD) children.

METHODS

A randomized-trial multicentric study was conducted in 48 CKD (23 females) patients under 18-years-old, for a year. At random, participants took 30 or 15 mg/day of ZS, respectively. Anthropometric measurements and biochemical analysis were performed. Hypozincemia was determined by serum zinc concentration (SZC) using atomic absorption spectrophotometry. The positive or negative change in patients' body mass index (BMI) Z-score, serum albumin, zinc and C-reactive protein (CRP) levels were used to evaluate the effect of ZS.

RESULTS

Mean SZC was normal before and after ZS. Despite ZS, there were no significant changes in serum albumin, zinc and CRP levels. A positive and significant association was observed between SZC and serum albumin before (p = 0.000) and after (p = 0.007) ZS. In both groups of ZS, there was a small but positive and significant change in body mass and normalization in BMI Z-score, hypoalbuminemia, hypozincemia and high CRP, especially with 30 mg/day of ZS.

CONCLUSIONS

Zinc supplementation may be beneficial for nutritional status in children and adolescents with CKD.

Zinc supplementation is an effective and feasible strategy to prevent growth retardation in 6 to 24 month children: A pragmatic double blind, randomized trial

Background

Zinc is an essential nutrient that is naturally available in most foods. Deficiency of this micronutrient in particular can cause a number of health complications. Zinc deficiency during infancy is more troublesome as rapid growth and nutrient relied development takes place in this period. Most severe outcomes of zinc deficiency during infancy are considered to be, impaired immunity, growth retardation and impaired neurodevelopment. The aim of this pragmatic study is to determine whether zinc supplementation strategy is feasible and effective for reducing growth retardation at national level.

Methods

A randomized, multicenter, double-blind, parallel group effectiveness trial that evaluated the effect of zinc supplementation in infant development. Children aged 6–24 months were recruited from healthcare centers of Damavand, Pishva and Varamin in the beginning of the study (n = 682). The Subjects were then randomly allocated in two groups of intervention (n = 272), and control (n = 308), where a daily dose of zinc sulfate (5ml) suspension containing 5mg elemental zinc and placebo were administered for the period of 6 month. Investigators, care givers and the parents of the children were blinded to the nature of the intervention. Anthropometric measures were evaluated at the beginning and after the six month intervention period. The primary outcome measured was linear growth and length difference, serum zinc and ferritin concentrations were the secondary outcomes.

Findings

Following the intervention, compared with the placebo, zinc supplementation was associated with significant difference in the average length increment (primary outcome) (placebo 5·23 ± 2·19 vs. intervention 5·79 ± 2·18 cm, p = 0·02). No significant difference was observed in concentrations of serum zinc and ferritin. After the intervention the prevalence of zinc deficiency was significantly lower in the intervention group compared to the placebo group. No complications and adverse effects were reported and the compliance was very good (7 children out of 344 didn't comply with the intake of syrup).

Interpretation

Zinc supplementation for six month among children (6–24 months) had beneficial outcomes on growth and average length increment, therefore we propose it is a feasible strategy for preventing growth retardation.

Effects of scaling up various community-level interventions on child mortality in Burundi, Kenya, Rwanda, Uganda and Tanzania: a modeling study

BACKGROUND

Improving child health remains one of the most significant health challenges in sub-Saharan Africa, a region that accounts for half of the global burden of under-five mortality despite having approximately 13% of the world population and 25% of births globally. Improving access to evidence-based community-level interventions has increasingly been advocated to contribute to reducing child mortality and, thus, help low-and middle-income countries (LMICs) achieve the child health related Sustainable Development Goal (SDG) target. Nevertheless, the coverage of community-level interventions remains suboptimal. In this study, we estimated the potential impact of scaling up various community-level interventions on child mortality in five East African Community (EAC) countries (i.e., Burundi, Kenya, Rwanda, Uganda and the United Republic of Tanzania).

METHODS

We identified ten preventive and curative community-level interventions that have been reported to reduce child mortality: Breastfeeding promotion, complementary feeding, vitamin A supplementation, Zinc for treatment of diarrhea, hand washing with soap, hygienic disposal of children's stools, oral rehydration solution (ORS), oral antibiotics for treatment of pneumonia, treatment for moderate acute malnutrition (MAM), and prevention of malaria using insecticide-treated nets and indoor residual spraying (ITN/IRS). Using the Lives Saved Tool, we modeled the impact on child mortality of scaling up these 10 interventions from baseline coverage (2016) to ideal coverage (99%) by 2030 (ideal scale-up scenario) relative to business as usual (BAU) scenario (forecasted coverage based on prior coverage trends). Our outcome measures include number of child deaths prevented.

RESULTS

Compared to BAU scenario, ideal scale-up of the 10 interventions could prevent approximately 74,200 (sensitivity bounds 59,068-88,611) child deaths by 2030 including 10,100 (8210-11,870) deaths in Burundi, 10,300 (7831-12,619) deaths in Kenya, 4350 (3678-4958) deaths in Rwanda, 20,600 (16049-25,162) deaths in Uganda, and 28,900 (23300-34,002) deaths in the United Republic of Tanzania. The top four interventions (oral antibiotics for pneumonia, ORS, hand washing with soap, and treatment for MAM) account for over 75.0% of all deaths prevented in each EAC country: 78.4% in Burundi, 76.0% in Kenya, 81.8% in Rwanda, 91.0% in Uganda and 88.5% in the United Republic of Tanzania.

CONCLUSIONS

Scaling up interventions that can be delivered at community level by community health workers could contribute to substantial reduction of child mortality in EAC and could help the EAC region achieve child health-related SDG target. Our findings suggest that the top four community-level interventions could account for more than three-quarters of all deaths prevented across EAC countries. Going forward, costs of scaling up each intervention will be estimated to guide policy decisions including health resource allocations in EAC countries.

Projecting stunting and wasting under alternative scenarios in Odisha, India, 2015-2030: a Lives Saved Tool (LiST)-based approach

OBJECTIVE

Although nutrition-specific interventions are designed based on maternal, household and community-level correlates, no attempt has been made to project stunting and wasting and identify intervention priorities in India. The objective of this paper is to model the stunting and wasting in the state of Odisha, India by scaling up maternal and child health interventions under alternative scenarios.

DESIGN

This study primarily used data from National Family Health Survey 4, 2015-2016.

MEASURES

The LiST (Lives Saved Tool) software is used to model the nutritional outcomes and prioritise interventions. The projections were carried out under four alternative scenarios: scenario 1-if the coverage indicators continued based on past trends; scenario 2-scaled up to the level of the richest quintile; scenario 3-scaled up to that of Tamil Nadu; and scenario 4-scaled up to an aspirational coverage level.

RESULTS

In 2015, out of 3.52 million under-5 children in Odisha, around 1.20 million were stunted. By 2030, the numbers of stunted children will be 1.11 million under scenario 1, 1.07 million under scenario 2, 1.09 million under scenario 3 and 0.89 million under scenario 4. The projected stunting level will be 25% under scenario 4 and around 31% under all other scenarios. By 2030, the level of wasting will remain unchanged at 20% under the first three scenarios and 4.3% under scenario 4. Appropriate complementary feeding would avert about half of the total stunting cases under all four scenarios, followed by zinc supplementation. Water connection at home, washing hands with soap and improved sanitation are other effective interventions.

CONCLUSION

Sustaining the maternal and child health interventions, promoting evidence-based stunting and wasting reduction interventions, and a multisectoral approach can achieve the World Health Assembly targets and Sustainable Development Goals of undernutrition in Odisha.

Effects of Daily Zinc, Daily Multiple Micronutrient Powder, or Therapeutic Zinc Supplementation for Diarrhea Prevention on Physical Growth, Anemia, and Micronutrient Status in Rural Laotian Children: A Randomized Controlled Trial

OBJECTIVES

To evaluate the optimal zinc supplementation strategy for improving growth and hematologic and micronutrient status in young Laotian children.

STUDY DESIGN

In total, 3407 children aged 6-23 months were randomized to receive either daily preventive zinc tablets (7 mg/d), high-zinc, low-iron micronutrient powder (10 mg/d zinc, 6 mg/d iron, and 13 other micronutrients), therapeutic zinc supplementation for diarrhea (20 mg/d for 10 days per episode), or daily placebo powder; all were followed for ~9 months. Anthropometry, hemoglobin, zinc, and iron status were assessed at baseline and endline. Analyses were by intention-to-treat, using linear and modified Poisson regression.

RESULTS

At baseline, mean (±SD) age was 14.2 ± 5.1 months and stunting and anemia prevalence were 37.9% and 55.6%, respectively. At endline, zinc deficiency in the preventive zinc (50.7%) and micronutrient powder (59.1%) groups were significantly lower than in the therapeutic zinc (79.2%) and control groups (78.6%; P < .001), with no impact on stunting (37.1%-41.3% across the groups, P = .37). The micronutrient powder reduced iron deficiency by 44%-55% compared with other groups (P < .001), with no overall impact on anemia (P = .14). Micronutrient powder tended to reduce anemia by 11%-16% among children who were anemic at baseline (P = .06).

CONCLUSIONS

Despite improving zinc status, preventive zinc and micronutrient powder had no impact on growth. The micronutrient powder improved iron status and tended to reduce anemia among the subset of previously anemic children.

TRIAL REGISTRATION

ClinicalTrials.govNCT02428647.

Soil Zinc Is Associated with Serum Zinc But Not with Linear Growth of Children in Ethiopia

To our knowledge, the relationships among soil zinc, serum zinc and children's linear growth have not been studied geographically or at a national level in any country. We use data from the cross-sectional, nationally representative Ethiopian National Micronutrient Survey (ENMS) (n = 1776), which provided anthropometric and serum zinc (n = 1171) data on children aged 6⁻59 months. Soil zinc levels were extracted for each child from the digital soil map of Ethiopia, developed by the Africa Soil Information Service. Children's linear growth was computed using length/height and age converted into Z-scores for height-for-age. Multi-level mixed linear regression models were used for the analysis. Nationally, 28% of children aged 6⁻59 months were zinc deficient (24% when adjusted for inflammation) and 38% were stunted. Twenty percent of households in the ENMS were located on zinc-deficient soils. Soil zinc (in mg/kg) was positively associated with serum zinc (in µg/dL) (b = 0.9, p = 0.020) and weight-for-height-Z-score (b = 0.05, p = 0.045) but linear growth was not associated with soil zinc (p = 0.604) or serum zinc (p = 0.506) among Ethiopian preschool children. Intervention studies are needed to determine whether there are causal links between soil and human zinc status.

Micronutrient-rich food consumption, intra-household food allocation and child stunting in rural Nigeria

Objective

Children from rural households are often deprived of adequate micronutrient intakes either from food or supplementation. The present study examines: (i) the determinants of households’ micronutrient-rich food consumption; and (ii) the combined effect of vitamin A supplementation and micronutrient-rich food consumption on child stunting in households with different food allocation patterns.

Design

Cross-sectional study. Households’ micronutrient-rich food consumption frequency and vitamin A supplementation were used as a proxy measure for child micronutrient intakes. Intra-household food allocation patterns were assessed from caregivers’ perception of the disparity in food distribution within the household. Descriptive statistics and logistic regression were employed in analysing the study’s objectives.

Setting

Rural communities in Kwara State, Nigeria.

Participants

Included 419 children aged 6–59 months and 413 households.

Results

Owning small livestock and a refrigerator, knowledge of micronutrient-rich foods and higher parental education had strong associations with households’ micronutrient-rich food consumption. Children from households that consumed micronutrient-rich foods and received more diverse diets were less likely to experience stunting. The combined effect of micronutrient-rich food consumption and vitamin A supplementation was stronger on the likelihood of stunting reduction than the separate effect of each.

Conclusions

Assets ownership, human capital and knowledge of micronutrient-rich foods improve consumption of micronutrient-rich foods among the study population. Micronutrient supplementation to children with poor access to micronutrient-rich foods may not substantially enhance child growth unless reinforced through consumption of micronutrient-rich foods. Fruit and vegetable gardening, livestock holdings and nutrition education to parents should be integral parts of community nutrition programming.

Trends and Determinants of Child Growth Indicators in Malawi and Implications for the Sustainable Development Goals

Sustainable development goals (SGD) 2 links malnutrition, morbidity and child mortality to stunting, wasting and overweight among children under-5 years of age. Sub-Saharan Africa still registers high nutritionally insecure people. In particular, Malawi has made modest progress in improving nutritional outcomes; and still experiences a number of structural challenges leading to negative nutritional outcomes. We describe trends of under nutrition and how the effect of selected determinants of child nutrition affect Malawian children under-5 from 1992 to 2015–16; and examine the changing patterns of the effect of selected socio-demographic characteristics on stunting and underweight using data from demographic and health surveys (DHS). The analysis included 31,630 children under-5 years from 1992, 2000, 2004, 2010, and 2015–16 DHS. Our outcome measures are stunting (height/length-for-age) and underweight (weight-for-age) less than -2 SD (Z-score). We perform logistic regression to assess the relationship between selected socio-demographic characteristics with the stunting and underweight variables. Underweight decreased by 14.0% from 24.7% (1992) to 10.7% (2015–16). Stunting decreased by 23.0% from 55.6% (1992) to 32.6% (2015–16). Underweight was more prevalent among children from central and southern regions; among male children; and children above 6 months of age or more. Later surveys were associated with reduced likelihood of underweight than the earliest surveys. Similar trends were observed between socioeconomic factors and stunting. The observed underweight and stunting prevalence is 2.2% and 1.9% lower than expected, respectively. Despite modest declines in underweight and stunting among young children in Malawi, underweight and stunting remain significant public health challenges particularly in southern and central Malawi which constitute about 85% of the total population. Interventions to address the critical malnutrition challenges in Malawi are inevitable within the context of SDG 2 on health.

The co-occurrence of anaemia and stunting in young children

Anaemia and stunting are prevalent nutritional problems among children of low-income countries that have profound effects on development, morbidity, and mortality. Many use a single conceptual framework to identify the basic determinants of these and other forms of malnutrition. One would expect that problems with matching underlying determinants should co-occur in affected individuals to a greater degree than by chance. In 2 populations of children-ages 6-18 months in Bihar, India, (n = 5,664) and 6-36 months in Lambayeque, Peru (n = 688)-we measured the frequency of the co-occurrence of anaemia and stunting. We compared this value with the value expected by chance, the product of the prevalence of anaemia and stunting, using a chi-square test. We also built logistic regression models for each condition. The frequency of co-occurrence in the Indian population was 21.5%, and in the Peruvian population, it was 30.4%, which are similar to frequencies expected by chance, 21.3% (p = .97) and 31.5% (p = .85). In Peru, anaemia was associated with age and consumption of treated water. Stunting was associated with age, sex, dietary diversity, hand washing, language spoken, and wealth. In India, anaemia was associated with age, sex, caste, dietary diversity, and household hunger. Stunting was associated with age, sex, caste, wealth, and maternal illiteracy. Despite some basic shared factors, anaemia and stunting are more independent than commonly assumed. Interventions that target children based on 1 condition may miss children with the other form of malnutrition.

Factors Associated with Undernutrition in Children under the Age of Two Years: Secondary Data Analysis Based on the Pakistan Demographic and Health Survey 2012⁻2013

In Pakistan, 96% of the children under the age of two years do not receive an adequate diet. The main aim of this paper is to identify the sociodemographic, nutritional, and health-related factors associated with stunting, wasting, and underweight in children under the age of two years in Pakistan. Secondary data analysis was performed based on the Pakistan Demographic and Health Survey, 2012⁻2013. The analysis was limited to children under the age of two years (n = 984). Analysis was done using bivariate and multivariable binary logistic regression. The incidence of stunting, wasting, and underweight in children was 28.3%, 12.1%, and 27.9%, respectively. The odds of stunting, wasting, and underweight increased with the child's age. The odds of stunting and underweight increased with the mother's low body mass index, low access to information, high birth order of child, consanguineous marriages, father's low education, rural settlement, poor toilet facilities, and low vitamin A consumption. The odds of wasting increased in children who were not being breastfed, but no significant relation was seen with stunting and underweight. There is a need to improve child nutritional status in Pakistan by addressing issues such as poverty, low parental education, low micronutrient intake, and targeting provinces where undernutrition was found to be higher.

Effect of Zinc Supplementation on Growth Outcomes in Children under 5 Years of Age

(1) Background: The effects of zinc supplementation on child growth, and prior reviews of these studies, have shown mixed results. We aim to systematically review and meta-analyze randomized controlled trials evaluating effects of preventive zinc supplementation for 3 months or longer during pregnancy or in children up to age 5 years on pregnancy outcomes and child growth; (2) Methods: We searched PubMed, EMBASE, Cochrane Library, Web of Science, and trial registries for eligible trials up to October 10, 2017. Inclusion selection and data extractions were performed independently and in duplicate. Study quality was evaluated by the Cochrane Risk of Bias tool. Findings were pooled using random effects meta-analysis, with heterogeneity assessed by I² and τ² statistic, stratified analyses, and meta-regression, and publication bias by Egger's and Begg's tests; (3) Results: Seventy-eight trials with 34,352 unique participants were identified, including 24 during pregnancy and 54 in infancy/childhood. Maternal zinc supplementation did not significantly increase birth weight (weighted mean difference (WMD) = 0.08 kg, 95%CI: -0.05, 0.22) or decrease the risk of low birth weight (RR = 0.76, 95%CI: 0.52-1.11). Zinc supplementation after birth increased height (WMD = 0.23 cm, 95%CI: 0.09-0.38), weight (WMD = 0.14 kg, 95%CI: 0.07-0.21), and weight-for-age Z-score (WMD = 0.04, 95%CI: 0.001-0.087), but not height-for-age Z-score (WMD = 0.02, 95%CI: -0.01-0.06) or weight-for-height Z score (WMD = 0.02, 95%CI: -0.03-0.06). Child age at zinc supplementation appeared to modify the effects on height (P-interaction = 0.002) and HAZ (P-interaction = 0.06), with larger effects of supplementation starting at age ≥2 years (WMD for height = 1.37 cm, 95%CI: 0.50-2.25; WMD for HAZ = 0.12, 95%CI: 0.05-0.19). No significant effects of supplementation were found on the risk of stunting, underweight or wasting; (4) Conclusion: Although the possibility of publication bias and small study effect could not be excluded, the current meta-analysis indicates that zinc supplementation in infants and early childhood, but not pregnancy, increases specific growth outcomes, with evidence for a potentially stronger effect after 2 years of age. These findings inform recommendation and policy development for zinc supplementation to improve growth among young children.