Point-of-use micronutrient fortification: lessons learned in implementing a preschool-based pilot trial in South Africa

Weekly iron-folic acid supplementation and its impact on children and adolescents iron status, mental health and school performance: a systematic review and meta-analysis in sub-Saharan Africa

OBJECTIVE

This systematic review and meta-analysis aimed to comprehensively assess the impact of weekly iron-folic acid supplementation (WIFAS) on the nutrition, health and educational outcomes of children and adolescents in sub-Saharan Africa.

DESIGN

A systematic review and meta-analysis was used.

DATA SOURCES

Five databases, namely, MEDLINE, Scopus, Web of Science, Cochrane Library and Google Scholar, were systematically searched for relevant articles up to 23 August 2023.

ELIGIBILITY CRITERIA

It was focused on randomised controlled trials involving children and adolescents in sub-Saharan Africa, exploring the effects of iron supplementation on various outcomes, such as serum ferritin and haemoglobin levels, anaemia, mental health and school performance.

DATA EXTRACTION AND SYNTHESIS

The Joanna Briggs Institute Critical Appraisal tools were used for quality assessment, with two independent reviewers thoroughly evaluating each paper. Using the Cochrane risk of bias tool, we evaluated the certainty of evidence such as the risk of bias, inconsistency, indirectness, imprecision and publication bias.

RESULTS

A systematic review of 10 articles revealed that WIFAS significantly increased serum ferritin levels in adolescent girls (Hedge's g=0.53, 95% CI 0.28 to 0.78; heterogeneity I2=41.21%, p<0.001) and haemoglobin levels in school-aged children (Hedge's g=0.37, 95% CI 0.01 to 0.73; heterogeneity I2=91.62%, p<0.001). The analysis further demonstrated a substantial reduction in the risk of anaemia by 20% (risk ratio=0.8, 95% CI 0.69 to 0.93; heterogeneity I2=28.12%, p<0.001).

CONCLUSION

WIFAS proved effective in enhancing serum ferritin and haemoglobin concentrations and lowering the risk of anaemia in school-aged children and adolescents compared with a placebo. Similarly, there are not enough studies to examine the effects of WIFAS on school performance. However, information regarding mental health problems, mortality and potential side effects remains insufficient.

PROSPERO REGISTRATION NUMBER

CRD42023397898.

Evaluation of a Physical Activity and Multi-Micronutrient Intervention on Cognitive and Academic Performance in South African Primary Schoolchildren

Executive functions (EFs) are essential for optimal academic development. Appropriate nutrition and physical activity (PA) have been shown to facilitate optimal cognitive development. Therefore, this study examined whether a 12-week school-based PA and multi-micronutrient supplementation (MMNS) intervention would improve cognitive and academic performance. A cluster-randomized controlled trial (RCT) was conducted. Children from four schools located in a peri-urban area of South Africa were randomly assigned to (i) PA + MMNS, (ii) PA + placebo, (iii) MMNS or (iv) placebo. Information processing and inhibitory control were measured with a computerized Flanker task. End-of-year results provided insight into academic achievement. Anthropometric measures were used to determine nutritional status. Data were analyzed with linear mixed-models, adjusting for baseline scores, school classes and age; 932 children (458 girls (49.1%), M_age (mean age) = 8.42 ± 1.94 years) completed baseline and post-intervention assessments. Cognitive performance improved among all four groups, with no significant group × time effects. For academic achievement, there was no significant interaction effect between the combined intervention group and placebo. We encourage future studies in this neglected area in order to determine the most optimal design of school-based nutrition and PA programs to enhance overall cognitive performance.

First 1,000 days: enough for mothers but not for children? Long-term outcomes of an early intervention on maternal depressed mood and child cognitive development: follow-up of a randomised controlled trial

BACKGROUND

Child cognitive development is often compromised in contexts of poverty and adversity, and these deficits tend to endure and affect the child across the life course. In the conditions of poverty and violence that characterise many low- and middle-income countries (LMIC), the capacity of parents to provide the kind of care that promotes good child development may be severely compromised, especially where caregivers suffer from depression. One avenue of early intervention focuses on the quality of the early mother-infant relationship. The aim of this study was to examine the long-term impact of an early intervention to improve the mother-infant relationship quality on child cognitive outcomes at 13 years of age. We also estimated the current costs to replicate the intervention.

METHOD

We re-recruited 333 children from an early childhood maternal-infant attachment intervention, 'Thula Sana', when the children were 13 years old, to assess whether there were impacts of the intervention on child cognitive outcomes, and maternal mood. We used the Kaufman Assessment Battery to assess the child cognitive development and the Patient Health Questionnaire (PHQ-9) and the Self-Reporting Questionnaire (SRQ-20) to assess maternal mental health.

RESULTS

Effect estimates indicated a pattern of null findings for the impact of the intervention on child cognitive development. However, the intervention had an effect on caregiver psychological distress (PHQ-9, ES = -0.17 [CI: -1.95, 0.05] and SRQ-20, ES = -0.30 [CI: -2.41, -0.19]), but not anxiety. The annual cost per mother-child pair to replicate the Thula Sana intervention in 2019 was estimated at ZAR13,365 ($780).

CONCLUSION

In a socio-economically deprived peri-urban settlement in South Africa, a home visiting intervention, delivered by community workers to mothers in pregnancy and the first six postpartum months, had no overall effect on child cognitive development at 13 years of age. However, those caregivers who were part of the original intervention showed lasting improvements in depressed mood. Despite the fact that there was no intervention effect on long-term child outcomes, the improvements in maternal mood are important.

The Effects of Nutritional Interventions on the Cognitive Development of Preschool-Age Children: A Systematic Review

The developing human brain requires all essential nutrients to form and to maintain its structure. Infant and child cognitive development is dependent on adequate nutrition. Children who do not receive sufficient nutrition are at high risk of exhibiting impaired cognitive skills. This systematic review aimed to examine the effects of nutritional interventions on cognitive outcomes of preschool-age children. PubMed, PsycInfo, Academic Search Complete, and Cochrane Library electronic databases were searched to identify Randomized Controlled Trials (RCTs) published after the year 2000. Studies assessing the effects of food-based, single, and multiple micronutrient interventions on the cognition of nourished and undernourished children aged 2-6 years were deemed eligible. A total of 12 trials were identified. Eight out of the twelve studies found significant positive effects on cognitive outcomes. Iron and multiple-micronutrients supplementation yield improvements in the cognitive abilities of undernourished preschool-age children. Increased fish consumption was found to have a beneficial effect in the cognitive outcomes of nourished children. On the other hand, B-vitamin, iodized salt, and guava powder interventions failed to display significant results. Findings of this review highlight the importance of adequate nutrition during preschool years, and the crucial role sufficient nutrition plays in cognitive development.

Characteristics and effects of integrated nutrition and stimulation interventions to improve the nutritional status and development of children under 5 years of age: a systematic review and meta-analysis

Introduction

Around 250 million children in low-income and middle-income countries are at risk of not fulfilling their developmental potential. There is a need to update syntheses investigating the effects of combined nutrition and stimulation interventions on children’s growth and development and identify intervention characteristics associated with positive effects.

Methods

We did a systematic review to: (1) understand the effects of integrated nutrition and stimulation interventions versus (i) usual care and (ii) standalone nutrition or stimulation interventions, on the growth and development of children under five; (2) explore intervention characteristics (delivery strategies, behaviour change techniques, intensity and personnel) associated with positive effects. We searched eight databases for studies published from inception to 16 November 2020. Eligible studies were randomised and non-randomised controlled trials of integrated nutrition and stimulation interventions examining growth and developmental outcomes. We performed meta-analyses for length-for-age/height-for-age, weight-for-age and weight-for-length/weight-for-height Z scores and cognitive, motor and language development scores, and subgroup analyses by intervention characteristics. We conducted random-effects metaregression to assess potential subgroup differences in outcomes by intervention characteristics.

Results

Twenty trials were included in the meta-analysis. Pooled effect sizes showed significant benefits of integrated interventions on developmental outcomes compared with usual care and standalone nutrition interventions (I² >75%) but not on growth outcomes. Moreover, integrated interventions have non-significant effects on developmental outcomes compared with standalone stimulation interventions. Integrated interventions showed greater effects on cognitive (p=0.039) and language (p=0.040) outcomes for undernourished children compared with adequately nourished children. The effects of integrated interventions on developmental outcomes did not differ by intervention characteristics.

Conclusion

Integrated interventions have greater benefits for children’s development than usual care or standalone nutrition interventions, especially in settings with high levels of undernutrition. Future studies should use standardised reporting of implementation processes to identify intervention characteristics linked to positive effects.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Harvesting time and roasting effects on colour properties, xanthophylls, phytates, tannins and vitamin C contents of orange maize hybrid

Biofortified maize varieties form an essential part of a nutritious diet; available evidence suggests that different processing methods may affect the final food products. The study aimed to evaluate the effects of processing (roasting) and harvesting time on the bioactive components (lutein, zeaxanthin, β-cryptoxanthin, phytate, tannin and vitamin C) and colour properties (L*, a*, b*), of biofortified orange maize. The orange maize hybrids used for the study were obtained from the International Institute of Tropical Agriculture (IITA) diverse lines with high provitamin A (PVA) content. The results showed that harvesting time and roasting methods significantly (P ≤ 0.001) affected the colour properties. The positive values of ∆b* 30.7, 36.0 and 38.1 at 20 days after pollination (DAP), 27DAP and 34DAP, respectively showed that the intensity of orange colour increased with delay in harvesting time. In unprocessed freshly harvested orange hybrid maize; lutein, zeaxanthin, β-cryptoxanthin, tannin and vitamin C increased with an increase in harvesting time. For roasted hybrid, the mean concentrations of all the bioactive components increased with increases in harvesting time except for tannin and vitamin C that showed a decrease at 20DAP and 27DAP. The results revealed that processing and time of harvest affect the levels of non-provitamin A carotenoids, tannins, phytic acid, Vitamin C and the colour properties of biofortified maize genotypes.

Dietary Diversity and Nutritional Status of Preschool Children in North West Province, South Africa: A Cross Sectional Study

Preschool children consume diets inadequate to meet their macro and micronutrient requirements, which ultimately affect their nutritional status due to lack of dietary diversity. A cross sectional study was conducted to investigate the association between dietary diversity scores (DDS) and the nutritional status of 379 preschool children in North West Province of South Africa. A 24 h qualitative recall by mothers of their children's food consumption was used to calculate DDS based on 12-foods groups following Food and Agriculture Organization protocols. DDS was calculated by counting each of 12-food groups and classified as low (≤4), medium (5-8) and high (9-12). The weight and height of children were measured and height-for-age (HAZ), weight-for-age (WAZ) and BMI-for-age (BAZ) z-scores were calculated based on 2006 WHO standards. Stunting, underweight and thinness were defined as HAZ, WAZ and BAZ < -2SD, respectively. Linear and logistic regression analyses were used to assess the association between DDS and the nutritional indicators. Mean age for children was 4 ± 0.7 years, and the prevalence of stunting (29%), underweight (13%) and thinness (6%) was observed. Mean DDS was 4.39 ± 1.55 out of 12-food groups, with a prevalence of 61% and 39% for low and medium DDS, respectively. Cereals (100%) accounted for the main food group consumed, while fish and other seafood (17%) were the least consumed. Consumption of a diversified diet was associated with lower odds of being stunted [AOR = 0.25, 95%CI: 0.10 to 0.92] among the four-year olds, while in the unadjusted model, 5-year-olds had lower odds of being underweight [OR = -0.32, 95%CI: -0.57 to 0.07]. The findings of this study reinforce the importance of continued nutrition education of mothers, caregivers and preschool staff on the need to ensure consumption of diverse food sources in order to improve the nutritional status of children. Further studies are recommended on the association of DDS with the nutritional status, and factors associated with low dietary diversity among preschool children.

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

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

Nutrient and aflatoxin contents of traditional complementary foods consumed by children of 6-24 months

The nutrient composition and safety of complementary foods have recently become areas of concern, especially with regard to aflatoxin contamination which has been found to adversely affect health outcomes. This study presents the nutrient and aflatoxin contents of complementary foods consumed by children (6-24 months) and infants and young child feeding practices of mothers from two districts in eastern and southern Zambia. A total of 400 mother-child pairs were recruited from Monze and Chipata districts, and data on breastfeeding and complementary feeding practices were collected twice at 3-month interval using a structured questionnaire. Samples of two traditional complementary foods (Maize Nshima and Maize porridge) were collected from the mothers and analyzed for nutrient contents and aflatoxin contamination. The results showed that there is a high level of awareness on exclusive breastfeeding among mothers. Fat, protein, carbohydrate, and ash contents of Maize nshima from Chipata were significantly lower (p < .05) compared to those from Monze district except for starch and sugar. Monze mothers preferred to prepare a thicker Maize nshima and Maize porridge compared to their Chipata counterparts. The aflatoxin contamination showed that the Maize porridge samples from Chipata were the most contaminated with mean aflatoxin content of 5.8 ± 15.93 mg/100 g, while Maize nshima was the most contaminated of the two complementary foods from Monze districts with mean aflatoxin level of 3.8 ± 6.41 mg/100 g. There were significant (p < .05) positive correlations between fat and aflatoxin contents for Chipata samples (r = .12409) and for Monze samples (r = .13666). The traditional complementary foods studied were found to be low in fat and protein and high in aflatoxin contamination. Thus, it is imperative that best practices and interventions are designed and introduced to reduce the possible lethal health implications of consumption of such complementary foods by children under 5 years.

Experiences and lessons learned for programme improvement of micronutrient powders interventions

Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of “The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance,” 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.

Validity of Neuropsychological Testing in Young African Children Affected by HIV

Introduction

Western-constructed neuropsychological tests have been used in low and middle income countries to assess the impact of HIV/AIDS and other chronic illnesses. We explore using such instruments cross-culturally in a sub-Saharan Africa setting.

Methods

IMPAACT P1104S was a two-year observational study carried out at six clinical sites (South Africa- 3 sites, Malawi, Uganda and Zimbabwe) to assess and compare neuropsychological outcomes in three cohorts of children 5-11 years of age: HIV-infected (HIV), HIV-exposed but uninfected (HEU) and HIV unexposed and uninfected (HU). Descriptive statistics compared socio-demographic characteristics among children at sites. Instruments included the KABC-II cognitive ability, TOVA attention/impulsivity, BOT-2 motor proficiency tests, and BRIEF executive function problems. Test characteristics were assessed using intraclass and Spearman non-parametric correlations, linear regression and principal factor analyses.

Results

Of the 611 participants, 50% were male and mean age ranged from 6.6 to 8 years. In Malawi, Uganda and Zimbabwe, substantial proportions of families lived in rural settings in contrast to the South African sites. Intraclass correlation coefficients between weeks 0 and 48 were highest for the KABC scores, ranging between 0.42 to 0.71.Correlations among similar test domains were low to moderate but significant, with positive correlation between KABC Sequential and TOVA scores and negative correlation between BRIEF and KABC scores. TOVA response time scores correlated negatively with the BOT-2 Total points score. Strong and significant associations between individual measures of growth, disability and development with all test scores were observed. Performance-based measures were markedly lower for HIV compared to HEU and HU participants, even after controlling for age, sex and site. Factor analyses confirmed the underlying theoretical structure of the KABC scaled item scores.

Conclusion

The KABC, TOVA, BRIEF and BOT-2 were valid and reliable tools for assessing the neuropsychological impact of HIV in four sub-Saharan African countries.

Infant Development at the Age of 6 Months in Relation to Feeding Practices, Iron Status, and Growth in a Peri-Urban Community of South Africa

Background: Evidence on the association between feeding practices, iron deficiency, anaemia, stunting, and impaired psychomotor development during infancy is limited. This study assessed the association between psychomotor development with early feeding practices, growth, iron status, and anaemia. Methods: This was cross-sectional baseline data of a randomised controlled trial which included 6-month-old infants and their mothers or primary caregivers (n = 750) in a peri-urban community in the North West province of South Africa. The Kilifi Developmental Inventory and a parent rating scale were used to assess psychomotor development. Feeding practices and anthropometric measurements were based on the World Health Organisation (WHO) guidelines. Anaemia and iron status were determined by blood sample analysis. Results: Prevalence of anaemia and stunting for the infants were 36.4% and 28.5%, respectively. Multiple regression analysis showed that birth weight was related to combined psychomotor scores (β = −3.427 (−4.603, 1.891), p < 0.001), as well as parent rating scores (β = −0.843 (−1.507, −0.180), p = 0.013). Length-for-age z-scores were associated with combined psychomotor scores (β = −1.419 (−2.466, 0.373), p = 0.008), as well as parent rating scores (β = −0.747 (−1.483, −0.010), p = 0.047). Conclusions: In this setting, with high prevalence of anaemia and stunting, important associations between lower psychomotor development scores and birthweight as well as length-for-age z-scores in 6-month-old infants were found. These findings warrant further investigation to develop a greater understanding of factors influencing the association between child growth and psychomotor development within the first 1000 days of life.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Confirmatory factor analysis of the Kaufman assessment battery in a sample of primary school-aged children in rural South Africa

The Kaufman Assessment Battery for Children, Second Edition, measures cognitive processing, includes non-verbal sub-tests, and is increasingly used in low- and middle-income countries. While the Kaufman Assessment Battery for Children, Second Edition, has been validated in the United States, a psychometric evaluation has not been conducted in Southern Africa. This study aims to establish the reliability and validity of the Kaufman Assessment Battery for Children, Second Edition, among a sample of 376 primary school-aged children in rural South Africa (7–11 years). We examined Cronbach’s alpha and conducted a confirmatory factor analysis. The battery showed good reliability (mental processing index [α = .78]), and the originally validated structure of the Kaufman Assessment Battery for Children, Second Edition, was maintained (χ2 = 16.30, p = .432). Mean scores were low on the Planning sub-scale. On the Simultaneous sub-scale, the mean score was higher for the supplementary sub-test Block Counting versus the core sub-test Triangles. With translation and the inclusion of supplementary sub-tests, the Kaufman Assessment Battery for Children, Second Edition, is an appropriate assessment to use in this context (150/150).

Iodine status and associations with feeding practices and psychomotor milestone development in six-month-old South African infants

Iodine is important for normal growth and psychomotor development. While infants below 6 months of age receive iodine from breast milk or fortified infant formula, the introduction of complementary foods poses a serious risk for deteriorating iodine status. This cross-sectional analysis assessed the iodine status of six-month-old South African infants and explored its associations with feeding practices and psychomotor milestone development. Iodine concentrations were measured in infant (n = 386) and maternal (n = 371) urine (urinary iodine concentration [UIC]), and in breast milk (n = 257 [breast milk iodine concentrations]). Feeding practices and psychomotor milestone development were assessed in all infants. The median (25th-75th percentile) UIC in infants was 345 (213-596) μg/L and was significantly lower in stunted (302 [195-504] μg/L) than non-stunted (366 [225-641] μg/L) infants. Only 6.7% of infants were deficient. Maternal UIC (128 [81-216] μg/L; rs  = 0.218, p < 0.001) and breast milk iodine concentrations (170 [110-270] μg/kg; rs  = 0.447, p < 0.0001) were associated with infant UIC. Most infants (72%) were breastfed and tended to have higher UIC than non-breastfed infants (p = 0.074). Almost all infants (95%) consumed semi-solid or solid foods, with commercial infant cereals (60%) and jarred infant foods (20%) being the most common solid foods first introduced. Infants who reported to consume commercial infant cereals ≥4 days weekly had significantly higher UIC (372 [225-637] μg/L) than those reported to consume commercial infant cereals seldom or never (308 [200-517] μg/L; p = 0.023). No associations between infant UIC and psychomotor developmental scores were observed. Our results suggest that iodine intake in the studied six-month-old infants was adequate. Iodine in breast milk and commercial infant cereals potentially contributed to this adequate intake.

A systematic review of sub-national food insecurity research in South Africa: Missed opportunities for policy insights

Food insecurity is an intractable problem in South Africa. The country has a tradition of evidence-based decision making, grounded in the findings of national surveys. However, the rich insights from sub-national surveys remain a largely untapped resource for understandings of the contextual experience of food insecurity. A web-based search identified 169 sub-national food insecurity studies conducted in the post-apartheid period between 1994 and 2014. The systematic review found that the studies used 27 different measures of food insecurity, confounding the comparative analysis of food insecurity at this level. While social grants have brought a measure of poverty relief at household level, unaffordable diets were the root cause of food insecurity. The increasing consumption of cheaper, more available and preferred 'globalised' foods with high energy content and low nutritional value lead to overweight and obesity alongside child stunting. Unless a comparable set of indicators is used in such surveys, they are not able to provide comparable information on the scope and scale of the problem. Policy makers should be engaging with researchers to learn from these studies, while researchers need to share this wealth of sub-national study findings with government to strengthen food security planning, monitoring, and evaluation at all levels.

Effects of wheat-flour biscuits fortified with iron and EDTA, alone and in combination, on blood lead concentration, iron status, and cognition in children: a double-blind randomized controlled trial

BACKGROUND

Lead is a common neurotoxicant and its absorption may be increased in iron deficiency (ID). Thus, iron fortification to prevent ID in populations is a promising lead mitigation strategy. Two common fortificants are ferrous sulfate (FeSO₄) and ferric sodium EDTA (NaFeEDTA). EDTA can chelate iron and lead.

OBJECTIVES

Our study objective was to determine the effects of iron and EDTA, alone and in combination, on blood lead (BPb) concentration, iron status, and cognition.

DESIGN

In this 2 × 2 factorial, double-blind placebo-controlled trial, 457 lead-exposed Moroccan children were stratified by school and grade and randomly assigned to consume biscuits (6 d/wk at school) containing 1) ∼8 mg Fe as FeSO₄, 2) ∼8 mg Fe as NaFeEDTA that contained ∼41 mg EDTA, 3) ∼41 mg EDTA as sodium EDTA (Na₂EDTA), or 4) placebo for 28 wk. The primary outcome was BPb concentration; secondary outcomes were iron status and cognitive outcomes from subtests of the Kaufman Assessment Battery for Children and the Hopkins Verbal Learning Test. These outcomes were measured at baseline and endpoint. All data were analyzed by intention-to-treat.

RESULTS

The adjusted geometric mean BPb concentration at baseline was 4.3 μg/dL (95% CI: 4.2, 4.3 μg/dL), and at endpoint these values were 3.3 μg/dL (95% CI: 3.1, 3.5 μg/dL) for FeSO₄, 2.9 μg/dL (95% CI: 2.7, 3.0 μg/dL) for NaFeEDTA, 3.3 μg/dL (95% CI: 3.1, 3.5 μg/dL) for EDTA, and 3.7 μg/dL (95% CI: 3.5, 3.9 μg/dL) for placebo. We found an effect of iron (P = 0.009) and EDTA (P = 0.012) for reduced BPb concentrations at endpoint, but no iron × EDTA interaction. Iron fortification improved iron status, but there were no positive effects of iron or EDTA on cognitive test scores.

CONCLUSIONS

Food fortification with iron and EDTA additively reduces BPb concentrations. Our findings suggest that NaFeEDTA should be the iron fortificant of choice in lead-exposed populations. This trial was registered at clinicaltrials.gov as NCT01573013.

Measures and indicators for assessing impact of interventions integrating nutrition, health, and early childhood development

When implementing interventions integrating nutrition, health, and early childhood development, evaluation studies of effectiveness that assess the intermediate and ultimate impacts on the four domains of food and nutrition, family care, health, and child development are needed. Such studies should demonstrate impact, both benefits and potential harms, and understand mechanisms through which impact has been achieved. This article reviews and suggests measures and indicators suitable for use in evaluation studies of effectiveness of integrated interventions for children under 5 years of age. Within each of the four domains, multiple constructs and subconstructs were considered. For each construct and subconstruct, we identified measures and indicators, using several search processes, and reviewed them in relation to validity, responsiveness to intervention inputs and activities, equivalence in constructs and items across contexts with appropriate adaptation, and feasibility for use in effectiveness studies. Suggested measures and indicators for each domain, construct, and subconstruct are tabulated and described. We discuss the strengths and weaknesses of measures and indicators across domains and constructs, further research establishing validity, and guidance on adaptation of measures to particular contexts.

Effects of integrated child development and nutrition interventions on child development and nutritional status

We conducted a systematic review of studies that examined the effect of interventions combining a child development component with a nutrition one; in some cases the nutrition interventions also included health-promotion components. Only papers with both child development and nutrition outcomes and rated as moderate-to-good quality were included. Eleven efficacy and two nonrandomized trials, and eight program evaluations were identified. Only six trials examined interventions separately and combined. The trials showed nutritional interventions usually benefited nutritional status and sometimes benefited child development. Stimulation consistently benefited child development. There was no significant loss of any effect when interventions were combined, but there was little evidence of synergistic interaction between nutrition and stimulation on child development. Only three trials followed up the children after intervention. All at-scale program evaluations were combined interventions. Five benefited child development, but one did not, and two showed deficits. There was generally little benefit of at-scale programs to nutritional status. We found no rigorous evaluations of adding stimulation to health and nutrition services at scale and there is an urgent need for them. There is also a need to establish quality-control mechanisms for existing scaled-up programs and to determine their long-term effects. There is also a need to determine if there are any sustained benefits for the children after programs finish.

A program impact pathway analysis identifies critical steps in the implementation and utilization of a behavior change communication intervention promoting infant and child feeding practices in Bangladesh

Mapping pathways of how interventions are implemented and utilized enables contextually grounded interpretation of results, differentiates poor design from poor implementation, and identifies factors that might influence the utilization of interventions. Few studies in nutrition have comprehensively examined the steps of implementation and utilization in behavior change communication (BCC) interventions, thus limiting the interpretation of variable impacts of BCC interventions. A program impact pathway (PIP) analysis was used to study a BCC intervention implemented in Bangladesh to improve infant and young child feeding (IYCF) practices. The PIP was developed through an iterative process with the program implementation team; the PIP then guided the choice of methods and tools. Using mixed methods, we reviewed the content of training materials for implementation staff, measured their IYCF knowledge (n = 100), observed their communication with mothers (n = 37), and examined factors influencing promotion of IYCF practices and their trial and adoption by mothers (n = 64). Implementation staff demonstrated good knowledge and maintained fidelity to the intervention to a large extent. Mothers identified them as their primary sources of information, and a majority of mothers tried recommended IYCF practices. Key facilitators included family support and availability of resources, whereas lack of time, maternal and family perceptions of age-appropriate feeding, and lack of resources were salient barriers to adopting recommended practices. Using a PIP analysis identified critical issues pertaining to implementation (e.g., the role of paid and volunteer staff) and utilization (e.g., resource and time constraints that require complementary interventions) and the need for further research and programmatic attention.

Effect of provision of daily zinc and iron with several micronutrients on growth and morbidity among young children in Pakistan: a cluster-randomised trial

BACKGROUND

Powders containing iron and other micronutrients are recommended as a strategy to prevent nutritional anaemia and other micronutrient deficiencies in children. We assessed the effects of provision of two micronutrient powder formulations, with or without zinc, to children in Pakistan.

METHODS

We did a cluster randomised trial in urban and rural sites in Sindh, Pakistan. A baseline survey identified 256 clusters, which were randomly assigned (within urban and rural strata, by computer-generated random numbers) to one of three groups: non-supplemented control (group A), micronutrient powder without zinc (group B), or micronutrient powder with 10 mg zinc (group C). Children in the clusters aged 6 months were eligible for inclusion in the study. Powders were to be given daily between 6 and 18 months of age; follow-up was to age 2 years. Micronutrient powder sachets for groups B and C were identical except for colour; investigators and field and supervisory staff were masked to composition of the micronutrient powders until trial completion. Parents knew whether their child was receiving supplementation, but did not know whether the powder contained zinc. Primary outcomes were growth, episodes of diarrhoea, acute lower respiratory tract infection, fever, and incidence of admission to hospital. This trial is registered with ClinicalTrials.gov, number NCT00705445.

RESULTS

The trial was done between Nov 1, 2008, and Dec 31, 2011. 947 children were enrolled in group A clusters, 910 in group B clusters, and 889 in group C clusters. Micronutrient powder administration was associated with lower risk of iron-deficiency anaemia at 18 months compared with the control group (odds ratio [OR] for micronutrient powder without zinc=0·20, 95% CI 0·11-0·36; OR for micronutrient powder with zinc=0·25, 95% CI 0·14-0·44). Compared with the control group, children in the group receiving micronutrient powder without zinc gained an extra 0·31 cm (95% CI 0·03-0·59) between 6 and 18 months of age and children receiving micronutrient powder with zinc an extra 0·56 cm (0·29-0·84). We recorded strong evidence of an increased proportion of days with diarrhoea (p=0·001) and increased incidence of bloody diarrhoea (p=0·003) between 6 and 18 months in the two micronutrient powder groups, and reported chest indrawing (p=0·03). Incidence of febrile episodes or admission to hospital for diarrhoea, respiratory problems, or febrile episodes did not differ between the three groups.

INTERPRETATION

Use of micronutrient powders reduces iron-deficiency anaemia in young children. However, the excess burden of diarrhoea and respiratory morbidities associated with micronutrient powder use and the very small effect on growth recorded suggest that a careful assessment of risks and benefits must be done in populations with malnourished children and high diarrhoea burdens.

FUNDING

Bill & Melinda Gates Foundation.

Effects of a multi-micronutrient-fortified beverage, with and without sugar, on growth and cognition in South African schoolchildren: a randomised, double-blind, controlled intervention

Little is known about the effects of combined micronutrient and sugar consumption on growth and cognition. In the present study, we investigated the effects of micronutrients and sugar, alone and in combination, in a beverage on growth and cognition in schoolchildren. In a 2 × 2 factorial design, children (n 414, 6-11 years) were randomly allocated to consume beverages containing (1) micronutrients with sugar, (2) micronutrients with a non-nutritive sweetener, (3) no micronutrients with sugar or (4) no micronutrients with a non-nutritive sweetener for 8.5 months. Growth was assessed and cognition was tested using the Kaufman Assessment Battery for Children version II (KABC-II) subtests and the Hopkins Verbal Learning Test (HVLT). Micronutrients decreased the OR for Fe deficiency at the endpoint (OR 0.19; 95% CI 0.07, 0.53). Micronutrients increased KABC Atlantis (intervention effect: 0.76; 95% CI 0.10, 1.42) and HVLT Discrimination Index (1.00; 95% CI 0.01, 2.00) scores. Sugar increased KABC Atlantis (0.71; 95% CI 0.05, 1.37) and Rover (0.72; 95% CI 0.08, 1.35) scores and HVLT Recall 3 (0.94; 95% CI 0.15, 1.72). Significant micronutrient × sugar interaction effects on the Atlantis, Number recall, Rover and Discrimination Index scores indicated that micronutrients and sugar in combination attenuated the beneficial effects of micronutrients or sugar alone. Micronutrients or sugar alone had a lowering effect on weight-for-age z-scores relative to controls (micronutrients - 0.08; 95% CI - 0.15, - 0.01; sugar - 0.07; 95% CI - 0.14, - 0.002), but in combination, this effect was attenuated. The beverages with micronutrients or added sugar alone had a beneficial effect on cognition, which was attenuated when provided in combination.

Effects of iron and n-3 fatty acid supplementation, alone and in combination, on cognition in school children: a randomized, double-blind, placebo-controlled intervention in South Africa

BACKGROUND

Little is known about the combined effects of iron and n-3 (omega-3) fatty acid (FA) supplementation on cognitive performance. The provision of either DHA/EPA or iron alone in rats with combined iron and n-3 FA deficiency has been reported to exacerbate cognitive deficits associated with deficiency.

OBJECTIVE

We investigated the effects of iron and DHA/EPA supplementation, alone and in combination, in children with poor iron and n-3 FA status.

DESIGN

In a 2-by-2 factorial trial, children with iron deficiency (ID) (n = 321; aged 6-11 y) were allocated to receive 1) iron (50 mg) plus DHA/EPA (420/80 mg), 2) iron plus placebo, 3) placebo plus a mixture of DHA and EPA (DHA/EPA), or 4) placebo plus placebo as oral supplements (4/wk) for 8.5 mo. Cognition was assessed at baseline and endpoint by using the Hopkins Verbal Learning Test (HVLT) and subscales of the Kaufman Assessment Battery for Children.

RESULTS

Both iron and DHA/EPA significantly increased weight-for-age z scores. Iron increased the number of words recalled at HVLT recall 2 (intervention effect: 0.90; 95% CI: 0.18, 1.62), and in anemic children, iron increased scores in the Atlantis Delayed test (1.51; 95% CI: 0.03, 2.99) and HVLT recall 2 (2.02; 95% CI: 0.55, 3.49). DHA/EPA showed no benefit in any of the cognitive tests but decreased Atlantis test scores (-2.48; 95% CI: -3.99, -0.96) in children who were anemic at baseline and decreased Atlantis delayed scores (-0.9; 95% CI: -1.45, -0.36) in girls with ID, whereas boys tended to perform better.

CONCLUSIONS

In children with poor iron and n-3 FA status, iron supplementation improved verbal and nonverbal learning and memory, particularly in children with anemia. In contrast, DHA/EPA supplementation had no benefits on cognition and impaired working memory in anemic children and long-term memory and retrieval in girls with ID.