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Imdad A, Rogner J, Sherwani RN, Sidhu J, Regan A, Haykal MR, Tsistinas O, Smith A, Chan XHS, Mayo-Wilson E, Bhutta ZA. Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years. Cochrane Database Syst Rev 2023; 3:CD009384. [PMID: 36994923 PMCID: PMC10061962 DOI: 10.1002/14651858.cd009384.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
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.
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Affiliation(s)
- Aamer Imdad
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Jaimie Rogner
- Departments of Medicine and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Rida N Sherwani
- Department of Pediatrics, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Jasleen Sidhu
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Allison Regan
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Maya R Haykal
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Olivia Tsistinas
- Health Sciences Library, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Abigail Smith
- Health Sciences Library, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Xin Hui S Chan
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
| | - Evan Mayo-Wilson
- Department of Epidemiology, UNC Gillings School of Global Public HealthMcGavran-Greenberg Hall, Chapel Hill, NC, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for SickKids, Toronto, Canada
- Center of Excellence for Women and Child Health, Aga Khan University, Karachi, Pakistan
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Effects of Different Doses, Forms, and Frequencies of Zinc Supplementation on Biomarkers of Iron and Zinc Status among Young Children in Dhaka, Bangladesh. Nutrients 2022; 14:nu14245334. [PMID: 36558493 PMCID: PMC9781687 DOI: 10.3390/nu14245334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Young children in resource-constrained settings are susceptible to zinc deficiency and its deleterious health effects. The objective of this secondary analysis was to evaluate the effects of the following six interventions on biomarkers of iron and zinc status among a subgroup of young children in Dhaka, Bangladesh, who participated in the Zinc in Powders Trial (ZiPT): (1) standard micronutrient powders (MNPs) containing 4.1 mg zinc and 10 mg iron, daily; (2) high-zinc (10 mg) and low-iron (6 mg) (HiZn LoFe) MNP, daily; (3) HiZn (10 mg) and LoFe (6 mg)/HiZn (10 mg) and no-iron MNPs on alternating days; (4) dispersible zinc tablet (10 mg), daily; (5) dispersible zinc tablet (10 mg), daily for 2 weeks at enrollment and at 12 weeks; (6) placebo powder, daily. At the end of the 24 week intervention period, children in the daily dispersible zinc tablet group exhibited a mean serum zinc concentration (SZC) of 92.5 μg/dL, which was significantly higher than all other groups except the HiZn LoFe MNP alternating group (81.3 μg/dL). MNPs containing 10 mg and 6 mg of iron had a similar impact on biomarkers of iron status, with no evidence of an adverse interaction with zinc.
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Abstract
OBJECTIVES Stunting [length-for-age z score (LAZ) <-2] has multiple causes and is prevalent in areas with low dietary zinc (Zn) intake. Zinc kinetics from non-stunted infants were used in a published model for predicting linear growth; here, we directly measure zinc kinetics in stunted infants. METHODS Zinc kinetics were determined in 9-month-old Bangladeshi infants (n = 10), who were non-wasted [weight-for-length z score (WLZ) > -2], ranging in LAZ from -2.9 to -0.43. Stable isotopes were administered 2 hours after a meal as oral ( 70 Zn) and intravenous ( 67 Zn) tracers. After isotope administration, blood was sampled within 5 hours and all urine and feces were collected for 24 hours. Urine was sampled twice-daily out to 9 days. Data were analyzed by compartmental modeling. Daily zinc intake was estimated by the model as the sum of zinc used for growth plus that lost via urine and feces. Zinc absorbed (the amount required to maintain steady state) was the sum of zinc used for growth plus urine and endogenous fecal excretions. RESULTS The LAZ score correlated with serum zinc concentration ( R = 0.77, P = 0.001), urinary zinc excretion ( R = 0.66, P = 0.010), and fractional zinc absorption from calculated daily intake ( R = 0.58, P = 0.030). In stunted infants (n = 8), the amount of zinc absorbed did not increase with calculated zinc intake unlike published values for non-stunted infants. CONCLUSIONS Zinc kinetics in Bangladeshi infants correlate with LAZ and show that malabsorption of supplemental sources of zinc may occur in stunted infants.
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Islam MM, Black RE, Krebs NF, Westcott J, Long J, Islam KM, Peerson JM, Sthity RA, Khandaker AM, Hasan M, El Arifeen S, Ahmed T, King JC, McDonald CM. Different Doses, Forms, and Frequencies of Zinc Supplementation for the Prevention of Diarrhea and Promotion of Linear Growth among Young Bangladeshi Children: A Six-Arm, Randomized, Community-Based Efficacy Trial. J Nutr 2022; 152:1306-1315. [PMID: 35015856 DOI: 10.1093/jn/nxab439] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/29/2021] [Accepted: 12/23/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Children in resource-limited settings remain vulnerable to zinc deficiency and its consequences. OBJECTIVES To evaluate the effects of different doses, durations, and frequencies of zinc supplementation on the incidence of diarrhea and change in linear growth among young children. METHODS We conducted a randomized, partially double-blind, controlled, 6-arm, community-based efficacy trial in Dhaka, Bangladesh. Children aged 9-11 mo were randomly assigned to receive 1 of the following interventions for 24 wk: 1) standard micronutrient powder (MNP) containing 4.1 mg zinc and 10 mg iron, daily; 2) high-zinc (10 mg), low-iron (6 mg) (HiZn LoFe) MNP, daily; 3) HiZn (10 mg) LoFe (6 mg)/HiZn (10 mg), no-iron MNPs on alternating days; 4) dispersible zinc tablet (10 mg), daily; 5) dispersible zinc tablet (10 mg), daily for 2 wk at enrollment and 12 wk; 6) placebo powder, daily. Primary outcomes were incidence of diarrhea and change in length-for-age z-score (LAZ) over the 24-wk intervention period. Home visits were conducted twice weekly to assess diarrhea and other morbidity. Incidence and prevalence outcomes were compared among groups with Poisson regression; continuous outcomes were compared using ANCOVA. RESULTS A total of 2886 children were enrolled between February 2018 and July 2019. The mean incidence and prevalence of diarrhea among all participants was 1.21 episodes per 100 d and 3.76 d per 100 d, respectively. There were no differences in the incidence or prevalence of diarrhea across intervention groups. The decline in LAZ was slightly smaller among children in the daily HiZn LoFe MNP group compared with the placebo powder group (P < 0.05). CONCLUSIONS The dose of zinc in MNPs as well as the duration and frequency of supplementation evaluated in this trial were not effective in reducing diarrhea; however, the daily HiZn LoFe MNP formulation offered modest improvements in linear growth among young children. This trial was registered at clinicaltrials.gov as NCT03406793.
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Affiliation(s)
- M Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Robert E Black
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Nancy F Krebs
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jamie Westcott
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Julie Long
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kazi Munisul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | | | - Rahvia Alam Sthity
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Afsana Mim Khandaker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Mehedi Hasan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Shams El Arifeen
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Janet C King
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Children's Hospital Oakland Research Institute, Oakland, CA, USA.,Department of Nutritional Sciences and Toxicology, University of California, Berkeley, CA, USA
| | - Christine M McDonald
- International Zinc Nutrition Consultative Group, San Francisco, CA, USA.,Children's Hospital Oakland Research Institute, Oakland, CA, USA.,Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, School of Medicine, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA, USA
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Exchangeable Zinc Pool Size Reflects Form of Zinc Supplementation in Young Children and Is Not Associated with Markers of Inflammation. Nutrients 2022; 14:nu14030481. [PMID: 35276840 PMCID: PMC8838617 DOI: 10.3390/nu14030481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 11/24/2022] Open
Abstract
A sensitive and reliable biomarker of zinc status has yet to be identified, but observational research suggests that the exchangeable zinc pool (EZP) size may be a possible biomarker. This randomized, placebo-controlled trial aimed to compare the change in EZP size from baseline to endline in 174 children who were preventatively supplemented with 10 mg of zinc as part of a multiple micronutrient power (MNP) or as a standalone dispersible tablet for 24 weeks versus a placebo powder. The effects of systemic inflammation on EZP size were also evaluated. Zinc stable isotopes were administered intravenously to children at baseline and endline, and the EZP was measured by the urine extrapolation method. A total of 156 children completed the study with the zinc dispersible tablet group having the greatest increase in EZP (14.1 mg) over 24 weeks when compared with the MNP group (6.8 mg) (p < 0.01) or placebo group (2.0 mg) (p < 0.001). Median EZP size was not different between children with normal or elevated serum inflammatory markers. EZP size was responsive to longitudinal zinc supplementation and reflected the expected difference in bioavailability for two forms of supplementation. The apparent absence of an effect of inflammation on EZP size may offer an advantage for use as a biomarker for group comparisons between different interventions.
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Hayman T, Hickey P, Amann-Zalcenstein D, Bennett C, Ataide R, Sthity RA, Khandaker AM, Islam KM, Stracke K, Yassi N, Watson R, Long J, Westcott J, Krebs NF, King JC, Black RE, Islam MM, McDonald CM, Pasricha SR. Zinc Supplementation with or without Additional Micronutrients Does Not Affect Peripheral Blood Gene Expression or Serum Cytokine Level in Bangladeshi Children. Nutrients 2021; 13:nu13103516. [PMID: 34684517 PMCID: PMC8541127 DOI: 10.3390/nu13103516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022] Open
Abstract
Preventive zinc supplementation provided as a stand-alone dispersible tablet, or via home fortification as multiple micronutrient powders (MNPs), has been considered a potential strategy to prevent zinc deficiency and improve health (including immune) outcomes among children in low- and middle-income countries. However, the impact of zinc supplementation on immune profiles has not been well characterized. We sought to define the effect of zinc supplementation on peripheral blood gene expression and cytokine levels among young children in Dhaka, Bangladesh. In a sub-study of a large randomized, controlled, community-based efficacy trial where children 9–11 months of age received one of the following interventions on a daily basis for 24 weeks: (1) MNPs containing 10 mg of zinc; (2) dispersible tablet containing 10 mg zinc; or (3) placebo powder, we used RNA sequencing to profile the peripheral blood gene expression, as well as highly sensitive multiplex assays to detect cytokine profiles. We profiled samples from 100 children enrolled in the parent trial (zinc MNPs 28, zinc tablets 39, placebo 33). We did not detect an effect from either zinc intervention on differential peripheral blood gene expression at the end of the intervention, or an effect from the intervention on changes in gene expression from baseline. We also did not detect an effect from either intervention on cytokine concentrations. Exploratory analysis did not identify an association between undernutrition (defined as stunting, underweight or wasting) and peripheral blood gene expression. Zinc interventions in children did not produce a gene expression or cytokine signature in the peripheral blood. However, this study demonstrates a proof of principle that sensitive multi-omic techniques can be applied to samples collected in field studies.
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Affiliation(s)
- Thomas Hayman
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; (T.H.); (C.B.); (R.A.); (K.S.); (N.Y.); (R.W.)
| | - Peter Hickey
- Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia; (P.H.); (D.A.-Z.)
- Advanced Technology and Biology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Daniela Amann-Zalcenstein
- Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia; (P.H.); (D.A.-Z.)
- Advanced Technology and Biology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Cavan Bennett
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; (T.H.); (C.B.); (R.A.); (K.S.); (N.Y.); (R.W.)
- Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia; (P.H.); (D.A.-Z.)
| | - Ricardo Ataide
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; (T.H.); (C.B.); (R.A.); (K.S.); (N.Y.); (R.W.)
- Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia; (P.H.); (D.A.-Z.)
| | - Rahvia Alam Sthity
- International Centre for Diarrheal Disease Research, Nutrition and Clinical Services Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (R.A.S.); (A.M.K.); (K.M.I.); (M.M.I.)
| | - Afsana Mim Khandaker
- International Centre for Diarrheal Disease Research, Nutrition and Clinical Services Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (R.A.S.); (A.M.K.); (K.M.I.); (M.M.I.)
| | - Kazi Munisul Islam
- International Centre for Diarrheal Disease Research, Nutrition and Clinical Services Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (R.A.S.); (A.M.K.); (K.M.I.); (M.M.I.)
| | - Katharina Stracke
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; (T.H.); (C.B.); (R.A.); (K.S.); (N.Y.); (R.W.)
| | - Nawaf Yassi
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; (T.H.); (C.B.); (R.A.); (K.S.); (N.Y.); (R.W.)
- Melbourne Brain Centre, Departments of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia
| | - Rosie Watson
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; (T.H.); (C.B.); (R.A.); (K.S.); (N.Y.); (R.W.)
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia
| | - Julie Long
- Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA; (J.L.); (J.W.); (N.F.K.)
| | - Jamie Westcott
- Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA; (J.L.); (J.W.); (N.F.K.)
| | - Nancy F. Krebs
- Department of Pediatrics, Anschutz Medical Campus, University of Colorado, Aurora, CO 80045, USA; (J.L.); (J.W.); (N.F.K.)
- International Zinc Nutrition Consultative Group, University of California, San Francisco, CA 94158, USA; (J.C.K.); (R.E.B.); (C.M.M.)
| | - Janet C. King
- International Zinc Nutrition Consultative Group, University of California, San Francisco, CA 94158, USA; (J.C.K.); (R.E.B.); (C.M.M.)
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, CA 94720, USA
| | - Robert E. Black
- International Zinc Nutrition Consultative Group, University of California, San Francisco, CA 94158, USA; (J.C.K.); (R.E.B.); (C.M.M.)
- Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Md. Munirul Islam
- International Centre for Diarrheal Disease Research, Nutrition and Clinical Services Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh; (R.A.S.); (A.M.K.); (K.M.I.); (M.M.I.)
| | - Christine M. McDonald
- International Zinc Nutrition Consultative Group, University of California, San Francisco, CA 94158, USA; (J.C.K.); (R.E.B.); (C.M.M.)
- Departments of Pediatrics and Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA 94158, USA
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; (T.H.); (C.B.); (R.A.); (K.S.); (N.Y.); (R.W.)
- Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia; (P.H.); (D.A.-Z.)
- Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
- Clinical Haematology at the Peter MacCallum Cancer Centre, The Royal Melbourne Hospital, Parkville, VIC 3050, Australia
- Correspondence:
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Mutisya M, Markey O, Rousham EK, Chintsanya JMN, Pradeilles R, Kimani-Murage EW, Madise NJ, Munthali AC, Kalimbira A, Holdsworth M, Griffiths PL, Haycraft E. Improving nutritional status among urban poor children in sub-Saharan Africa: An evidence-informed Delphi-based consultation. MATERNAL AND CHILD NUTRITION 2020; 17:e13099. [PMID: 33145974 PMCID: PMC7988854 DOI: 10.1111/mcn.13099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 01/26/2023]
Abstract
In sub‐Saharan Africa (SSA), rapid urbanisation coupled with the high prevalence of infant and young child (IYC) undernutrition in low‐income settings means that interventions to support IYC nutrition are a priority. Little is known about how urbanisation influences IYC feeding (IYCF) practices, and evidence‐based interventions to improve IYC health/nutrition in the urban poor are lacking. Therefore, this research aimed to (a) systematically review evidence on interventions for improving the nutritional status of IYC aged 6–23 months living in urban poor areas (PROSPERO CRD42018091265) and (b) engage stakeholders to identify the highest ranking evidence gaps for improving IYCF programmes/policies. First, a rapid systematic review was conducted. This focused on the literature published regarding nutrition‐specific and nutrition‐sensitive complementary feeding interventions in urban poor areas, specifically low‐income informal settlements, in low‐ and middle‐income countries (LMICs). Six intervention studies met the review inclusion criteria. Intervention adherence was generally high, and indicators of maternal knowledge and IYC nutritional intake typically increased because of the interventions, but the impact on anthropometric status was small. Second, stakeholders working across SSA were engaged via a Delphi‐based approach to identify priority areas for future intervention. Stakeholders reported that a situational analysis was required to better understand IYCF in urban poor areas, particularly the causes of IYC undernutrition, and highlighted the need to involve local communities in defining how future work should proceed. Together, these findings indicate a need for more evidence regarding IYCF and the factors that drive it in urban poor areas across LMIC settings, but particularly in SSA.
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Affiliation(s)
- Maurice Mutisya
- African Population and Health Research Center, Nairobi, Kenya
| | - Oonagh Markey
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Emily K Rousham
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Jesman M N Chintsanya
- Department of Population Studies, Chancellor College, University of Malawi, Zomba, Malawi
| | - Rebecca Pradeilles
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | - Alister C Munthali
- Centre for Social Research, Chancellor College, University of Malawi, Zomba, Malawi
| | | | - Michelle Holdsworth
- School of Health and Related Research, University of Sheffield, Sheffield, UK.,UMR NUTRIPASS, Research Institute for Development, Montpellier, France
| | - Paula L Griffiths
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Emma Haycraft
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Suchdev PS, Jefferds MED, Ota E, da Silva Lopes K, De‐Regil LM. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database Syst Rev 2020; 2:CD008959. [PMID: 32107773 PMCID: PMC7046492 DOI: 10.1002/14651858.cd008959.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vitamin and mineral deficiencies, particularly those of iron, vitamin A, and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Multiple micronutrient powders (MNPs) are single-dose packets containing multiple vitamins and minerals in powder form, which are mixed into any semi-solid food for children six months of age or older. The use of MNPs for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age. In 2014, MNP interventions were implemented in 43 countries and reached over three million children. This review updates a previous Cochrane Review, which has become out-of-date. OBJECTIVES To assess the effects and safety of home (point-of-use) fortification of foods with MNPs on nutrition, health, and developmental outcomes in children under two years of age. For the purposes of this review, home fortification with MNP refers to the addition of powders containing vitamins and minerals to semi-solid foods immediately before consumption. This can be done at home or at any other place that meals are consumed (e.g. schools, refugee camps). For this reason, MNPs are also referred to as point-of-use fortification. SEARCH METHODS We searched the following databases up to July 2019: CENTRAL, MEDLINE, Embase, and eight other databases. We also searched four trials registers, contacted relevant organisations and authors of included studies to identify any ongoing or unpublished studies, and searched the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs with individual randomisation or cluster-randomisation. Participants were infants and young children aged 6 to 23 months at the time of intervention, with no identified specific health problems. The intervention consisted of consumption of food fortified at the point of use with MNP formulated with at least iron, zinc, and vitamin A, compared with placebo, no intervention, or use of iron-containing supplements, which is standard practice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, and assessed the risk of bias of included studies. We reported categorical outcomes as risk ratios (RRs) or odds ratios (ORs), with 95% confidence intervals (CIs), and continuous outcomes as mean differences (MDs) and 95% CIs. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 29 studies (33,147 children) conducted in low- and middle-income countries in Asia, Africa, Latin America, and the Caribbean, where anaemia is a public health problem. Twenty-six studies with 27,051 children contributed data. The interventions lasted between 2 and 44 months, and the powder formulations contained between 5 and 22 nutrients. Among the 26 studies contributing data, 24 studies (26,486 children) compared the use of MNP versus no intervention or placebo; the two remaining studies compared the use of MNP versus an iron-only supplement (iron drops) given daily. The main outcomes of interest were related to anaemia and iron status. We assessed most of the included studies at low risk of selection and attrition bias. We considered some studies to be at high risk of performance and detection bias due to lack of blinding. Most studies were funded by government programmes or foundations; only two were funded by industry. Home fortification with MNP, compared with no intervention or placebo, reduced the risk of anaemia in infants and young children by 18% (RR 0.82, 95% CI 0.76 to 0.90; 16 studies; 9927 children; moderate-certainty evidence) and iron deficiency by 53% (RR 0.47, 95% CI 0.39 to 0.56; 7 studies; 1634 children; high-certainty evidence). Children receiving MNP had higher haemoglobin concentrations (MD 2.74 g/L, 95% CI 1.95 to 3.53; 20 studies; 10,509 children; low-certainty evidence) and higher iron status (MD 12.93 μg/L, 95% CI 7.41 to 18.45; 7 studies; 2612 children; moderate-certainty evidence) at follow-up compared with children receiving the control intervention. We did not find an effect on weight-for-age (MD 0.02, 95% CI -0.03 to 0.07; 10 studies; 9287 children; moderate-certainty evidence). Few studies reported morbidity outcomes (three to five studies each outcome) and definitions varied, but MNP did not increase diarrhoea, upper respiratory infection, malaria, or all-cause morbidity. In comparison with daily iron supplementation, the use of MNP produced similar results for anaemia (RR 0.89, 95% CI 0.58 to 1.39; 1 study; 145 children; low-certainty evidence) and haemoglobin concentrations (MD -2.81 g/L, 95% CI -10.84 to 5.22; 2 studies; 278 children; very low-certainty evidence) but less diarrhoea (RR 0.52, 95% CI 0.38 to 0.72; 1 study; 262 children; low-certainty of evidence). However, given the limited quantity of data, these results should be interpreted cautiously. Reporting of death was infrequent, although no trials reported deaths attributable to the intervention. Information on side effects and morbidity, including malaria and diarrhoea, was scarce. It appears that use of MNP is efficacious among infants and young children aged 6 to 23 months who are living in settings with different prevalences of anaemia and malaria endemicity, regardless of intervention duration. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups. AUTHORS' CONCLUSIONS Home fortification of foods with MNP is an effective intervention for reducing anaemia and iron deficiency in children younger than two years of age. Providing MNP is better than providing no intervention or placebo and may be comparable to using daily iron supplementation. The benefits of this intervention as a child survival strategy or for developmental outcomes are unclear. Further investigation of morbidity outcomes, including malaria and diarrhoea, is needed. MNP intake adherence was variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.
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Affiliation(s)
- Parminder S Suchdev
- Emory UniversityDepartment of Pediatrics1760 Haygood DrAtlantaGAUSA30322
- Centers for Disease Control and PreventionNutrition Branch, Division of Nutrition, Physical Activity, and ObesityAtlantaGAUSA
| | - Maria Elena D Jefferds
- Centers for Disease Control and PreventionNutrition Branch, Division of Nutrition, Physical Activity, and ObesityAtlantaGAUSA
| | - Erika Ota
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Science10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
| | - Katharina da Silva Lopes
- St. Luke's International UniversityGraduate School of Public Health3‐6‐2 TsukijiChuo‐KuTokyoMSJapan104‐0045
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