Effect of micronutrient powder supplementation for two and four months on hemoglobin level of children 6–23 months old in a slum in Dhaka: a community based observational study

Effectiveness of locally produced ready to use supplementary food on hemoglobin, anthropometrics, and plasma micronutrients concentrations of 6 to 23 months age children: a non-randomized community-based trial from Pakistan

Background

Micronutrient deficiencies including vitamin A, vitamin D, and zinc are highly prevalent in children below 5 years of age in low and -middle-income countries. We aimed to evaluate the effectiveness of ready-to-use Lipid-based Nutrient Supplement-Medium Quantity (LNS-MQ) local name "Wawa-mum" on plasma micronutrient status, hemoglobin concentration and anthropometric measurements.

Methods

A community-based non-randomized trial was conducted in the Kurram district of Khyber Pakhtunkhwa from January 2018 to June 2019. A total of 110 children aged 6 to 23 months old were recruited and allocated to the intervention and control arm of the study. A total of 57 children in the intervention arm received a daily ration of 50 g of Wawa-mum, for one year. To assess the impact of the intervention on primary outcome measures, i.e., serum vitamin A, D concentration, plasma zinc, and hemoglobin concentration. Blood samples were collected at baseline and after one year following the intervention. The vitamins concentration in serum were assessed using Enzyme-Linked Immunosorbent Assay (ELISA) and plasma zinc by atomic absorption spectrometry. The hemoglobin concentration was measured by an automated hematology analyzer. A 24-h dietary recall interview was used to assess the nutrient intake adequacy. Multivariate Linear regression models were used to analyze the outcomes while controlling for potential confounders.

Results

In the intervention arm, children had on average 6.2 μg/dL (95% CI 3.0-9.3, value of p<0.001) increase in the serum vitamin A concentration, 8.1 ng/mL (95% CI 1.3-14.9, value of p 0.02) increase in serum vitamin D concentration and 49.0 μg/dL (95% CI 33.5-64.5, value of p<0.001) increase in the plasma zinc concentration, and 2.7 g/dL (95% CI 2.0-3.3, value of p<0.001) increase in hemoglobin concentration while adjusted for covariates. An addition, length-for-age z-score (LAZ), weight-for-length z-score (WLZ), weight-for-age z-score (WAZ), and prevalence of undernutrition including stunting, wasting, and underweight were calculated as a secondary outcome to investigate the impact of micronutrients on growth parameters, that has been improved significantly after receiving the Wawa-mum.

Conclusion

Wawa-mum (LNS-MQ) is an effective intervention to improve the micronutrient status, hemoglobin concentration, and growth parameters in 6 to 23 months children, which can be scaled up in the existing health system to address the alarming rates of under nutrition in Pakistan and other developing countries.

Clinical trial registration

https://doi.org/10.1186/ISRCTN94319790, ISRCTN94319790.

Effect of Nutrition Education and Multi-Nutrient Biscuit Interventions on Nutritional and Iron Status: A Cluster Randomized Control Trial on Undernourished Children Aged 6-23 Months in Aceh, Indonesia

Undernutrition and iron deficiencies on under-five children in Indonesia remain high and very closely related to inadequate complementary feeding. This study investigated the effect of weekly nutrition education by home visite using the food monitoring card (FMC) models and daily provision multi-nutrient biscuits and combination on growth and reduction of iron deficiency and anemia among underweight children aged 6-23 mo in Aceh Indonesia. A 6-mo, cluster randomized, control trial was conducted on 121 children received nutrition education (NE), multi-nutrient biscuit (MNB), combination both nutrition education and biscuits (NE+MNB), and control group. The outcome weight gain and prevalence of underweight (weight for age z-score <-2SD) were collected by anthropometric and iron deficiency were serum ferritin measuring with ELISA method. After the 6-mo intervention, the rate of weight gain was higher in combination intervention group 1.51±0.68 kg than multi-biscuit group 1.40±0.72 kg, NE group 1.34±0.66 kg and control group 1.21±0.42 kg, and the rate increase of serum ferritin was higher in combination NE+MNB and biscuit group (2.54 μg/L and 2,17 μg/L). At the end of study there were a significant decrease in prevalence of underweight (p=0.003), the incidence of underweight in NE+MNB (45.2%) lower than NE group (63.3%), MNB group (64.5%) and control group (69,0%) and significant decrease of iron deficiency (p=0.02), the incidence lower in MNB group (6.5%) than NE+MNB (22.6%), NE group (23.3%) and control group (24.1%). The combination of nutritional education and multi-nutrient biscuits intervention improving nutritional and iron deficiency status on undernourished children. These risearch highlight the need integration of nutrition education and food base intervention to prevent underweight and iron deficiency on children 6-23 mo old.

Effectiveness of Nutrition and WASH/malaria educational community-based interventions in reducing anemia in children from Angola

We found no published data in Angola regarding the effect of combining nutrition-specific and nutrition-sensitive approaches in the reduction of anemia in preschool children. Thus, we implemented a cluster-randomized controlled trial to determine the effectiveness of two educational-plus-therapeutic interventions, in Nutrition and WASH/Malaria, in reducing anemia. We compared them to (1) a test-and-treat intervention and (2) with each other. A block randomization was performed to allocate 6 isolated hamlets to 3 study arms. A difference-in-difference technique, using Fit Generalized estimating models, was used to determine differences between the children successfully followed in all groups, between 2015 and 2016. We found no significant differences in anemia´s and hemoglobin variability between educational and the control group. However, the WASH/Malaria group had 22.8% higher prevalence of anemia when compared with the Nutrition group, having also higher prevalence of P. falciparum. Thus, our results suggest that adding a 12-month educational Nutrition or a WASH/Malaria component to a test-and-treat approach may have a limited effect in controlling anemia. Possibly, the intensity and duration of the educational interventions were not sufficient to observe the amount of behavior change needed to stop transmission and improve the general child feeding practices.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

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

Supplementary Information

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Why Do Children in Slums Suffer from Anemia, Iron, Zinc, and Vitamin A Deficiency? Results from a Birth Cohort Study in Dhaka

Considering the high burden of micronutrient deficiencies in Bangladeshi children, this analysis aimed to identify the factors associated with micronutrient deficiencies and association of plasma micronutrient concentration trajectories from 7 to 24 months with the concentrations at 60 months of age. Plasma samples were collected at 7, 15, 24, and 60 months of age, and hemoglobin, ferritin, zinc, and retinol concentrations of 155, 153, 154, and 155 children were measured, respectively. A generalized estimating equation was used to identify the factors associated with micronutrient deficiencies, while latent class growth modeling identified the trajectories of plasma micronutrients from 7 to 24 months and its association with the concentrations of micronutrients at 60 months was examined using multiple linear regression modeling. Early (AOR = 2.21, p < 0.05) and late convalescence (AOR = 1.65, p < 0.05) stage of an infection, low ferritin (AOR = 3.04, p < 0.05), and low retinol (AOR = 2.07, p < 0.05) were associated with increased anemia prevalence. Wasting at enrollment was associated with zinc deficiency (AOR = 1.8, p < 0.05) and birth weight was associated with ferritin deficiency (AOR = 0.58, p < 0.05). Treatment of drinking water was found protective against vitamin A deficiency (AOR = 0.57, p < 0.05). Higher trajectories for ferritin and retinol during 7–24 months were positively associated with plasma ferritin (β = 13.72, p < 0.05) and plasma retinol (β = 3.99, p < 0.05) at 60 months.

Effect of Micronutrient Powder (MNP) with a Low-Dose of Iron on Hemoglobin and Iron Biomarkers, and Its Effect on Morbidities in Rural Bangladeshi Children Drinking Groundwater with a High-Level of Iron: A Randomized Controlled Trial

Micronutrient Powder (MNP) is beneficial to control anemia, but some iron-related side-effects are common. A high level of iron in the groundwater used for drinking may exacerbate the side-effects among MNP users. We conducted a randomized controlled trial examining the effect of a low-dose iron MNP compared with the standard MNP in children aged 2–5 years residing in a high-groundwater-iron area in rural Bangladesh. We randomized 327 children, who were drinking from the “high-iron” wells (≥2 mg/L), to receive either standard (12.5 mg iron) or low-dose iron (5.0 mg iron) MNP, one sachet per day for two months. Iron parameters were measured both at baseline and end-point. The children were monitored weekly for morbidities. A generalized linear model was used to determine the treatment effect of the low-dose iron MNP. Poisson regressions were used to determine the incidence rate ratios of the morbidities. The trial was registered at ISRCTN60058115. Changes in the prevalence of anemia (defined as a hemoglobin level < 11.0 g/dL) were 5.4% (baseline) to 1.0% (end-point) in the standard MNP; and 5.8% (baseline) to 2.5% (end-point) in the low-dose iron MNP groups. The low-dose iron MNP was non-inferior to the standard MNP on hemoglobin outcome (β = −0.14, 95% CI: −0.30, 0.013; p = 0.07). It resulted in a lower incidence of diarrhea (IRR = 0.29, p = 0.01, 95% CI: 0.11–0.77), nausea (IRR = 0.24, p = 0.002, 95% CI: 0.09–0.59) and fever (IRR = 0.26, p < 0.001, 95% CI: 0.15–0.43) compared to the standard MNP. Low-dose iron MNP was non-inferior to the standard MNP in preventing anemia yet demonstrated an added advantage of lowering the key side-effects.

Efficacy of Different Doses of Multiple Micronutrient Powder on Haemoglobin Concentration in Children Aged 6-59 Months in Arusha District

In Tanzania's Arusha District, anaemia is a significant public health problem. Recently, home fortification with multiple micronutrient powder was recommended, and daily use of one sachet has shown to be effective. However, it is a challenge for deprived families with low income to afford the daily sachet. The aim of this study was to compare the efficacy of different administration frequencies of micronutrient powder in reducing anaemia in children aged 6-59 months. This research used a community-based, randomized longitudinal trial design with the intent to treat anaemia. Children aged 6 to 59 months (n=369) were randomly assigned to one of four intervention groups which received, on a weekly basis, either five sachets (n=60), three sachets (n=80), two sachets (n=105), or one sachet (n=124) for six months; 310 children completed the study. Using the HemoCue technique, a finger-prick blood was taken at baseline, middle, and end points of the intervention to determine haemoglobin levels. The effect of treatment on haemoglobin was assessed with analysis of covariates with Bonferroni post hoc to test group difference (p > 0.05) from each other. At the end, haemoglobin levels were significantly higher in participants who received three or five sachets of micronutrient powder per week compared to those who received one or two micronutrient powder sachets per week (p < 0.05). The prevalence of illnesses was reduced from 65% to 30.5% in all groups. This finding indicates that economically challenged families may opt for three times per week sachet administration rather than a more costly daily administration. This trial is registered with PACTR201607001693286.