Do multiple micronutrient interventions improve child health, growth, and development?

Diet and deprivation in pregnancy: a rat model to investigate the effects of the maternal diet on the growth of the dam and its offspring

The offspring of women in the poorest socio-economic groups in Western societies have an increased risk of developing non-communicable disease in adult life. Deprivation is closely related to the consumption of a diet with an excess of energy (sugar and fat), salt and a shortage of key vitamins. To test the hypothesis that this diet adversely affects the development and long-term health of the offspring, we have formulated two rodent diets, one with a nutrient profile corresponding to the diet of pregnant women in the poorest socio-economic group (DEP) and a second that incorporated current UK recommendations for the diet in pregnancy (REC). Female rats were fed the experimental diets for the duration of gestation and lactation and the offspring compared with those from a reference group fed the AIN-93G diet. The growth trajectory of DEP and REC offspring was reduced compared with the AIN-93G. The REC offspring diet had a transient increase in adipose reserves at weaning, but by 30 weeks of age the body composition of all three groups was similar. The maternal diet had no effect on the homoeostatic model assessment index or the insulin tolerance of the offspring. Changes in hepatic gene expression in the adult REC offspring were consistent with an increased hepatic utilisation of fatty acids and a reduction in de novo lipogenesis. These results show that despite changes in growth and adiposity maternal metabolic adaptation minimises the adverse consequences of the imbalanced maternal diet on the metabolism of the offspring.

Impact of integrated preventive and curative health package on nutritional status of children under 2 years of age in the health area of Tama, Tahoua region (Niger)

Background

Niger, relevant in light of current political coup, is one of the countries with the worst human development indicators, characterized by high fertility rates and extremely high infant mortality rates. Food insecurity in the region is alarming, leading to high malnutrition rates in children. This study aimed to evaluate an integral preventive-curative health program targeting children aged under 2 years in the health area of Tama, district of Bouza, Tahoua.

Methodology

Anthropometric follow-up data of 6,962 children aged under 2 years were included in this study. These children received complete vaccination and malaria chemoprevention, and those older than 6 months received nutritional supplementation with a small quantity of lipid-based nutrient supplements. Fundamental growth indicators (height-for-age, weight-for-height, weight-for-age, and middle-upper arm circumference) and the Composite Index of Anthropometric Failure were calculated at the beginning and end of the program (mean time spent in the program: 14.5 ± 6.6 months) The evolution of these indicators was compared with those of a sample from a vertical vaccination program conducted in the neighboring region of Madarounfa on similar dates.

Results

The proportion of children without anthropometric failure decreased from 59.5 to 40.2% (p < 0.001), with the categories that included stunting increasing the most. When analyzing the anthropometric indicators according to the months of compliance with the program, there was a slight improvement in the indicators of acute malnutrition, whereas those of chronic malnutrition worsened significantly. However, when compared with the Madarounfa sample, the children in the present study registered a significantly lower worsening in all three indicators: height-age (-0.46 vs. -2.44; p < 0.001), weight-height (+0.31 vs. -0.55; p < 0.001) and weight-age (-0.03 vs. -1.63; p < 0.001) difference.

Conclusion

The comprehensive preventive-curative health program slightly slows the worsening of cumulative malnutrition in the early years of life in complex contexts, such as southern Niger.

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

OBJECTIVES

To assess effects of supplementation with 3 or more micronutrients (multiple micronutrients; MMN) compared to no MMN in human milk-fed preterm and low birth weight (LBW) infants.

RESULTS

Data on a subgroup of 414 preterm or LBW infants from 2 randomized controlled trials (4 reports) were included. The certainty of evidence ranged from low to very low. For growth outcomes in the MMN compared to the non-MMN group, there was a small increase in weight-for-age (2 trials, 383 participants) and height-for-age z-scores (2 trials, 372 participants); a small decrease in wasting (2 trials, 398 participants); small increases in stunting (2 trials, 399 participants); and an increase in underweight (2 trials, 396 participants). For neurodevelopment outcomes at 78 weeks, we found small increases in Bayley Scales of Infant Development, Version III (BISD-III), scores (cognition, receptive language, expressive language, fine motor, gross motor) in the MMN compared to the non-MMN group (1 trial, 27 participants). There were no studies examining dose or timing of supplementation.

CONCLUSIONS

Evidence is insufficient to determine whether enteral MMN supplementation to preterm or LBW infants who are fed mother's own milk is associated with benefit or harm. More trials are needed to generate evidence on mortality, morbidity, growth, and neurodevelopment.

Exploring behavioural factors affecting nutritional supplement use among children in Honduras

OBJECTIVE

This study explored social and behavioural factors associated with a home fortification of complementary foods program among families of undernourished children in 14 rural communities in Honduras.

DESIGN

We collected and analysed survey data from a convenience sample of 196 households participating in a nutritional program using home fortification of complementary foods in 2017. The program supplied families with a soy-based atole powder fortified with micronutrients. A research team completed a face-to-face survey exploring social and behavioural factors associated with nutritional supplement use. Anthropometric measurements for participating children were abstracted from health clinic records of previous quarterly appointments.

SETTING

The study took place in San Jose del Negrito, Honduras.

PARTICIPANTS

Participants were parents or guardians of children enrolled in the nutrition program.

RESULTS

Nearly half of participant families shared the nutritional supplement with other family members besides the index child, while 10 % reported using the supplement as a meal replacement for the child. Low education level of mothers was associated with improper use of the supplement (P = 0·005). Poorer families were more likely to share the supplement (P = 0·013).

CONCLUSIONS

These results highlight the challenges of programs using home fortification of complementary foods in the context of food scarcity. Findings highlight the importance of increasing rural children's overall caloric intake, perhaps by increasing access to locally available protein sources. Results also suggest transitioning nutritional programs to family-based interventions to increase overall intended compliance to nutrition programming.

Effect of <em>Moringa oleifera</em> supplementation during pregnancy on the prevention of stunted growth in children between the ages of 36 to 42 months

Background: The government has made provisions to improve the nutrition of stunted children under the age of five nationally by providing iron folic acid (IFA) tablet since conception. However, these drugs were not able to reduce the incidence of stunted growth. The aim of this study is to assess the effect of moringa intervention during pregnancy on the incidence of stunted growth in children between the ages of 36 to 42 months.

Design and Methods: This study is a follow-up to an experimental RCT-DB study during pregnancy. The interventions given were PG (Moringa Flour), EG (Moringa Extract) and IG (IFA) which was used as control.

Results: The highest number of children that had stunted growth after taking the PG by IG and EG extracts were 66 (41.5%), 53 (33.3%) and 40 (25.2%), respectively. The stunted risk factor analysis did not show a significant relationship to the stunted incidence. Furthermore, the consumption and dietary patterns of children were based on only fat consumption which was associated with stunted incidence (p<0.05). The results of multivariate analysis showed that the EG extract was effective in reducing the incidence of stunted growth (p<0.005) and as a protective factor of 0.431 times the incidence of stunted growth (LLUL= 0.246-0.754).

Conclusions: The administration of Moringa oleifera extract during pregnancy prevents the incidence of stunted growth in children.

The Impact of Nutrition-Specific and Nutrition-Sensitive Interventions on Hemoglobin Concentrations and Anemia: A Meta-review of Systematic Reviews

Anemia is a multifactorial condition arising from inadequate nutrition, infection, chronic disease, and genetic-related etiologies. Our aim was to assess the impact of nutrition-sensitive and nutrition-specific interventions on hemoglobin (Hb) concentrations and anemia to inform the prioritization and scale-up of interventions to address the multiple causes of anemia. We performed a meta-review synthesis of information by searching multiple databases for reviews published between 1990 and 2017 and used standard methods for conducting a meta-review of reviews, including double independent screening, extraction, and quality assessment. Quantitative pooling and narrative syntheses were used to summarize information. Hb concentration and anemia outcomes were pooled in specific population groups (children aged <5 y, school-age children, and pregnant women). Methodological quality of the systematic reviews was assessed using Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria. Of the 15,444 records screened, we identified 118 systematic reviews that met inclusion criteria. Reviews focused on nutrition-specific interventions (96%). Daily and intermittent iron supplementation, micronutrient powders, malaria treatment, use of insecticide-treated nets (ITNs), and delayed cord clamping were associated with increased Hb concentration in children aged <5 y. Among children older than 5 y, daily and intermittent iron supplementation and deworming, and in pregnant women, daily iron-folic acid supplementation, use of ITNs, and delayed cord clamping, were associated with increased Hb concentration. Similar results were obtained for the reduced risk of anemia outcome. This meta-review suggests the importance of nutrition-specific interventions for anemia and highlights the lack of evidence to understand the influence of nutrition-sensitive and multifaceted interventions on the condition.

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.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Conventional and food-to-food fortification: An appraisal of past practices and lessons learned

Food fortification is an important nutrition intervention to fight micronutrient deficiencies and to reduce their incidence in many low- and middle-income countries. Food fortification approaches experienced a significant rise in the recent years and have generated a lot of criticism. The present review aimed to shed light on the actual effect of food fortification approaches on the reduction of malnutrition. A set of 100 articles and reports, which have dealt with the impact of food fortification on malnutrition, were included in this review. This review identified a broad selection of local raw materials suitable for a food-to-food fortification approach.

Improved micronutrient status and health outcomes in low- and middle-income countries following large-scale fortification: evidence from a systematic review and meta-analysis

BACKGROUND

Micronutrient malnutrition is highly prevalent in low- and middle-income countries (LMICs) and disproportionately affects women and children. Although the effectiveness of large-scale food fortification (LSFF) of staple foods to prevent micronutrient deficiencies in high-income settings has been demonstrated, its effectiveness in LMICs is less well characterized. This is important as food consumption patterns, potential food vehicles, and therefore potential for impact may vary substantially in these contexts.

OBJECTIVES

The aim of this study was to determine the real-world impact of LSFF with key micronutrients (vitamin A, iodine, iron, folic acid) on improving micronutrient status and functional health outcomes in LMICs.

METHODS

All applicable published/unpublished evidence was systematically retrieved and analyzed. Studies were not restricted by age or sex. Meta-analyses were performed for quantitative outcomes and results were presented as summary RRs, ORs, or standardized mean differences (SMDs) with 95% CIs.

RESULTS

LSFF increased serum micronutrient concentrations in several populations and demonstrated a positive impact on functional outcomes, including a 34% reduction in anemia (RR: 0.66; 95% CI: 0.59, 0.74), a 74% reduction in the odds of goiter (OR: 0.26; 95% CI: 0.16, 0.43), and a 41% reduction in the odds of neural tube defects (OR: 0.59; 95% CI: 0.49, 0.70). Additionally, we found that LSFF with vitamin A could protect nearly 3 million children per year from vitamin A deficiency. We noted an age-specific effect of fortification, with women (aged >18 y) attaining greater benefit than children, who may consume smaller quantities of fortified staple foods. Several programmatic/implementation factors were also reviewed that may facilitate or limit program potential.

CONCLUSIONS

Measurable improvements in the micronutrient and health status of women and children are possible with LSFF. However, context and implementation factors are important when assessing programmatic sustainability and impact, and data on these are quite limited in LMIC studies.

The Long-Term Effects of Dietary Nutrient Intakes during the First 2 Years of Life in Healthy Infants from Developed Countries: An Umbrella Review

The role of both qualitative and quantitative early nutrient intakes on later health has been suggested for decades and supported by observational studies on humans, mainly preterm and low-birth-weight infants, and animal models. However, to date, no comprehensive review has been conducted to evaluate the full impact of nutritional variables on healthy full-term infants. This umbrella review considers meta-analyses and systematic reviews on the health effects of different nutritional exposures or interventions in the first 2 y of life of healthy full-term infants in developed countries. The systematic reviews and meta-analyses published by March 2018 in MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews were included. The following outcomes were considered: growth and obesity, cardiovascular disease, neurodevelopment, allergy and autoimmunity, infections, and malignancy. Breastfeeding and complementary feeding were considered separately and analyzed by means of their differences in delivering heterogeneous food-related variables. The resulting data on the long-term effect of early nutritional differences in healthy full-term infants were found to be inconclusive. Only breastfeeding has a beneficial effect, which is nevertheless slight and limited to just a few outcome measures, whereas the type and duration required to be effective are still unclear. As regards the complementary feeding period, no clear effects of different dietary interventions emerge in terms of health outcomes. Available evidence on the health effects of differences in early nutrition in healthy full-term infants still remains largely inconclusive.

Interactions between nutrients in the maternal diet and the implications for the long-term health of the offspring

Nutritional science has traditionally used the reductionist approach to understand the roles of individual nutrients in growth and development. The macronutrient dense but micronutrient poor diets consumed by many in the Western world may not result in an overt deficiency; however, there may be situations where multiple mild deficiencies combine with excess energy to alter cellular metabolism. These interactions are especially important in pregnancy as changes in early development modify the risk of developing non-communicable diseases later in life. Nutrient interactions affect all stages of fetal development, influencing endocrine programming, organ development and the epigenetic programming of gene expression. The rapidly developing field of stem cell metabolism reveals new links between cellular metabolism and differentiation. This review will consider the interactions between nutrients in the maternal diet and their influence on fetal development, with particular reference to energy metabolism, amino acids and the vitamins in the B group.

Fortified food supplementation in children with reduced dietary energy and micronutrients intake in Southern Mexico

Background

Nutritional supplements are an important source of complementary food for young children, since they may either complement or substitute nutrients obtained from other food sources. Assessing how the introduction of different types of supplements modifies the consumption of other food sources may help in designing supplementation programs that aim to improve the nutrition of vulnerable populations.

The objetive is to quantify dietary energy and nutrient intake among children aged 6–12 months who received one of three nutritional supplements.

Methods

A cluster-randomized trial was conducted from 2005 to 2007. Urban communities were randomly allocated to one of three intervention groups receiving one of the following: a milk-based fortified food, micronutrient powders, or syrup. Each supplement was fortified with equal amounts of micronutrients. Dietary intake was estimated using a food frequency questionnaire (FFQ) to reflect the average consumption over the month prior to the interview. Children between 6 and 12 months of age were recruited. Median regression was performed with adjusted standard errors for clustered data, and the linear predictors for the median included the study group, study stage and their interaction. Adjusted medians by study group and study stage were obtained as post-estimations.

Results

No statistically significant differences between study groups were observed at baseline. After four months of supplementation, the children in the fortified food group had a smaller increase in median dietary energy (183.7 kcal, CI95%: 59.9, 307.5) and dietary protein (6.6 g, CI95%: 2.6, 10.6) intake from their home diet than those in the syrup group (p < 0.05). These differences remained significant after adjusting for group differences at baseline. Regarding covariate-adjusted median changes from baseline to follow-up at 10 months, the children in the fortified food group had a smaller median increase in dietary energy intake than those in the syrup group (698 vs 915 kcal), with a difference of 217.9 kcal (CI95%: 20.4, 415.4).

Conclusion

Children in the fortified food group consumed less dietary energy, protein, and micronutrients than those in the micronutrient powder and syrup groups. It is possible that absolute nutrient intake may be overestimated by the FFQ, but this possibility does not compromise the ability to compare study groups. Given the observed differences in dietary energy consumption among the three supplemented groups, it can be concluded that supplementation with micronutrient powders is an adequate option for urban children who have met their minimum energy and protein requirements.

Effect of zinc and multivitamin supplementation on the growth of Tanzanian children aged 6-84 wk: a randomized, placebo-controlled, double-blind trial

BACKGROUND

Poor child growth increases risks of mortality and morbidity. Micronutrient supplements have the potential to improve child growth.

OBJECTIVE

We assessed the effect of daily zinc, multivitamin (vitamins C, E, and B-complex), and zinc and multivitamin (Zn+MV) supplementation on growth in infants in Tanzania.

DESIGN

In this randomized, 2 × 2 factorial, double-blind trial, 2400 infants were randomly assigned to receive zinc, multivitamins, Zn+MVs, or a placebo at 6 wk of age and were followed up for 18 mo with monthly growth measurements. Mixed-effects models with restricted cubic splines for the mean change in anthropometric z scores were fit for each group. Likelihood ratio tests were used to compare the effect of supplements on growth trajectories. Cox proportional hazards models were used to compare incidences of stunting, wasting, and underweight.

RESULTS

Children in all groups experienced growth faltering. At 19 mo of age, prevalences of stunting, wasting, and underweight were 19.8%, 6.0%, and 10.8%, respectively. Changes in weight-for-age z scores (WAZs) and weight-for-height z scores (WHZs) were significantly different across the 4 groups (P < 0.001 for both). The mean ± SE decline in the WAZ from baseline to the end of follow-up in the Zn+MV group was significantly less than in the placebo group (-0.36 ± 0.04 compared with -0.50 ± 0.04; P = 0.020), whereas the decline in the WHZ was significantly greater in the zinc-only group than in the placebo group (-0.57 ± 0.07 compared with -0.35 ± 0.07; P = 0.021). Supplements did not have a significant effect on mean change in the height-for-age z score or on rates of stunting, wasting, or underweight.

CONCLUSIONS

Although there were small but significant improvements in the WAZ in the Zn+MV group, daily zinc supplementation alone, multivitamin supplementation alone, and the combined Zn+MV did not reduce the incidences of underweight, stunting, or wasting in Tanzanian infants. Alternative approaches to prevent growth faltering should be pursued. This trial was registered at clinicaltrials.gov as NCT00421668.

Iron deficiency anemia in pregnancy

Anemia is the most frequent derailment of physiology in the world throughout the life of a woman. It is a serious condition in countries that are industrialized and in countries with poor resources. The main purpose of this manuscript is to give the right concern of anemia in pregnancy. The most common causes of anemia are poor nutrition, iron deficiencies, micronutrients deficiencies including folic acid, vitamin A and vitamin B12, diseases like malaria, hookworm infestation and schistosomiasis, HIV infection and genetically inherited hemoglobinopathies such as thalassemia. Depending on the severity and duration of anemia and the stage of gestation, there could be different adverse effects including low birth weight and preterm delivery. Treatment of mild anemia prevents more severe forms of anemia, strictly associated with increased risk of fetal-maternal mortality and morbidity.

A 22-element micronutrient powder benefits language but not cognition in Bangladeshi full-term low-birth-weight children

BACKGROUND

Low-birth-weight children are known to be at risk of both anemia and cognitive/language deficits in their early years.

OBJECTIVE

The aim of the current study was to examine the effects of a 22-element multiple micronutrient powder (MNP) on the cognitive and language development of full-term low-birth-weight (LBW-T) children in Bangladesh.

METHODS

The current study was a follow-up of children who were enrolled in a randomized cluster trial at 7-12 mo of age. Children in 12 intervention clusters (communities) were administered a daily 22-element MNP sachet with their food for 5 mo, and both intervention and control groups (also 12 clusters) received nutrition, health, and hygiene education. The current study involved the assessment of children at 16-22 mo of age (22-element MNP group: n = 96; control group: n = 82) on 3 subtests of the Bayley Scales of Infant and Toddler Development III test to measure cognitive, receptive language, and expressive language development.

RESULTS

There was a significant effect of the 22-element MNP on children's expressive language scores (d = 0.39), and stunting moderated the effect on receptive language scores; there was no effect on cognitive development (d = 0.08).

CONCLUSION

An MNP may thus offer one feasible solution to improve language development of LBW-T children in low-resource community settings. This trial was registered at clinicaltrials.gov as NCT01455636.

The effect of folic acid supplementation with ferrous sulfate on the linear and ponderal growth of children aged 6-24 months: a randomized controlled trial

BACKGROUND/OBJECTIVES

Studies evaluating the effect of folic acid supplementation, either alone or in combination with iron, on the linear and ponderal growth of children are practically nonexistent. The aim of this study was to assess the effect of folic acid supplementation with ferrous sulfate on both linear growth and weight gain in anemic and nonanemic children attending Municipal Daycare Centers in Goiania, State of Goias, Brazil.

SUBJECTS/METHODS

A double-blind, randomized, controlled trial was conducted on 188 children aged 6-24 months. The effects of ferrous sulfate and folic acid supplementation were evaluated using the analysis of variance procedure, based on a double factorial model with two factors of fixed effects (folic acid supplementation and ferrous sulfate supplementation), adjusted for initial weight. The level of significance was 0.05.

RESULTS

The children who received folic acid supplementation showed greater weight gain than the monthly average weight gain of those not given the supplement (P=0.026). This effect was independent of the dose of ferrous sulfate (P for interaction=0.693). Folic acid supplementation increased the gain of weight-for-age Z-score when compared with the placebo group (P=0.018), independent of the dose of ferrous sulfate.

CONCLUSION

Folic acid had no effect on linear growth. The use of folic acid supplementation increased the monthly average weight gain and the gain in weight-for-age Z-score compared with the placebo group. This effect was independent of the dose of ferrous sulfate.

Micronutrient research, programs, and policy: From meta-analyses to metabolomics

Micronutrient deficiencies are widespread among women and children in undernourished populations. Research has identified effective approaches to their prevention, including supplementation, fortification, and dietary and other public health interventions. These interventions have made tremendous improvements in the quality of life, health, and survival of populations around the world, yet the impact varies by nutrient, population, and the outcomes chosen that reflect nutritionally driven change. The WHO guides governments and agencies toward effective strategies to prevent micronutrient deficiencies in women and children, but these are often informed by imperfect studies with limited measures of impact and the inadequate program evaluations and survey databases produced by the nutrition community. The resulting knowledge gaps limit our ability to discern what interventions are effective, under what conditions, among whom, and perhaps most important, why. However, we are moving into an era of opportunity to apply the tools of modern nutrition science, including improved methods of assessing nutritional status, "omics," bioarchival access, systems biology thinking, and interdisciplinary collaborations, that can deepen and broaden our understanding of how micronutrients affect health, how their deficiencies diminish human capacity, and how interventions can improve the well-being of those in need. Relevant training and greater cross-disciplinary efforts will be required to ensure a cell-to-society approach that can systematically address where, to whom, and how to provide micronutrients in the future.

Promoting equity through integrated early child development and nutrition interventions

Sustainable development, a foundation of the post-2015 global agenda, depends on healthy and productive citizens. The origins of adult health begin early in life, stemming from genetic-environmental interactions that include adequate nutrition and opportunities for responsive learning. Inequities associated with inadequate nutrition and early learning opportunities can undermine children's health and development, thereby compromising their productivity and societal contributions. Transactional theory serves as a useful framework for examining the associations that link early child development and nutrition because it emphasizes the interplay that occurs between children and the environment, mediated through caregiver interactions. Although single interventions targeting early child development or nutrition can be effective, there is limited evidence on the development, implementation, evaluation, and scaling up of integrated interventions. This manuscript introduces a special edition of papers on six topics central to integrated child development/nutrition interventions: (1) review of integrated interventions; (2) methods and topics in designing integrated interventions; (3) economic considerations related to integrated interventions; (4) capacity-building considerations; (5) examples of integrated interventions; and (6) policy implications of integrated interventions. Ensuring the health and development of infants and young children through integrated child development/nutrition interventions promotes equity, a critical component of sustainable development.

Integrating nutrition and early child-development interventions among infants and preschoolers in rural India

This article describes the development, design, and implementation of an integrated randomized double-masked placebo-controlled trial (Project Grow Smart) that examines how home/preschool fortification with multiple micronutrient powder (MNP) combined with an early child-development intervention affects child development, growth, and micronutrient status among infants and preschoolers in rural India. The 1-year trial has an infant phase (enrollment age: 6-12 months) and a preschool phase (enrollment age: 36-48 months). Infants are individually randomized into one of four groups: placebo, placebo plus early learning, MNP alone, and MNP plus early learning (integrated intervention), conducted through home visits. The preschool phase is a cluster-randomized trial conducted in Anganwadi centers (AWCs), government-run preschools sponsored by the Integrated Child Development System of India. AWCs are randomized into MNP or placebo, with the MNP or placebo mixed into the children's food. The evaluation examines whether the effects of the MNP intervention vary by the quality of the early learning opportunities and communication within the AWCs. Study outcomes include child development, growth, and micronutrient status. Lessons learned during the development, design, and implementation of the integrated trial can be used to guide large-scale policy and programs designed to promote the developmental, educational, and economic potential of children in developing countries.

Rational prescribing in paediatrics in a resource-limited setting

INTRODUCTION

There is evidence of inappropriate medication use, causing unnecessary costs for health systems, particularly those with limited resources. Overprescription is commonly reported and can lead to antibiotic resistance. Prescribing patterns differ between countries; little is known about paediatric prescribing practices in Africa.

OBJECTIVES

To investigate prescribing practices in children in The Gambia, West Africa.

METHOD

A retrospective survey of prescribing practices in children under 5 years of age based on WHO protocol DAP/93.1 was conducted. Twenty government-run health centres across all six regions in The Gambia were assessed. The first 10 encounters each month in 2010 were recorded. For each encounter, patient demographics, diagnoses and medications were recorded as per protocol.

RESULTS

Two thousand and four hundred patient encounters were included. The mean number of medications per encounter was 2.2 (median 2.0, IQR 2.0-3.0). Across different geographical regions within The Gambia antibiotics were prescribed in 63.4% (IQR 62.8-65.8%) and micronutrients in 21.7% (IQR 15.3-27.1%) of patient encounters. There was evidence of high antibiotic prescription in children with cough and coryzal symptoms (54.5%; IQR 35.8-59.0%) and simple diarrhoea without dehydration (44.8%; IQR 36.7-61.3%). 74.8% (IQR 71.8-76.1%) of medications were prescribed generically.

CONCLUSIONS

The study showed an overprescription of antibiotics and substantial usage of micronutrients despite a lack of international evidence-based guidelines. Cost-effective interventions to improve prescribing practices are called for and more studies with a focus on rational prescribing in paediatrics in low-income settings are urgently required to fill the gap in current knowledge.

Multivitamin supplements have no effect on growth of Tanzanian children born to HIV-infected mothers

Growth faltering and micronutrient deficiencies commonly coexist in HIV-exposed children in sub-Saharan Africa, and correcting deficiencies, such as those of vitamins B-complex, C, and E, may improve HIV-related endpoints and child growth. We therefore examined the effect of daily oral supplementation of vitamins B-complex, C, and E on growth among 2341 children born to HIV-infected mothers in Tanzania. HIV-infected women pregnant at ≤32 wk of gestation were enrolled in the study. Children were randomized at age 6 wk to receive multivitamins or placebo until age 104 wk. All women received the same types of vitamins pre- and postnatally. At 6 wk, 256 children (11.1%) were HIV infected and the mean (SD) Z-scores for length for age (LAZ), weight for length (WLZ), and weight for age (WAZ) were -0.39 ± 1.20, -0.21 ± 1.23, and -0.52 ± 1.11, respectively. There was no overall treatment effect on LAZ, WLZ, or WAZ profiles during the follow-up (P ≥ 0.15). There was no treatment effect from 6 to 104 wk on LAZ [(95% CI: -0.14, 0.13); P = 0.94], WLZ [(95% CI: -0.17, 0.13); P = 0.78], or WAZ [(95% CI: -0.15, 0.16); P = 0.97] or on the incidence of growth failure, defined as respective Z-scores < -2 (P ≥ 0.29). Among the subgroup of HIV-uninfected children, there was no treatment effect from 6 to 104 wk on LAZ, WLZ, and WAZ (P ≥ 0.71) or on the incidence of growth failure (P ≥ 0.16). Multivitamin supplements had no effect on growth among children born to HIV-infected women who were themselves receiving multivitamins.

Impact of prenatal multiple micronutrients on survival and growth during infancy: a randomized controlled trial

BACKGROUND

Although prenatal multiple micronutrients can improve fetal growth, their benefit on postnatal health remains uncertain.

OBJECTIVE

We assessed the effect of the UNICEF/WHO/United Nations University multiple micronutrient supplement for pregnant and lactating women (UNIMMAP) compared with the usual iron and folic acid supplement (IFA) on survival, growth, and morbidity during infancy.

DESIGN

In a double-blind, randomized trial, we followed 1294 singleton newborns whose mothers had prenatally received either the UNIMMAP or IFA. We assessed monthly anthropometric measures and health variables up to age 12 mo. Children were assessed again at a mean age of 30 mo. Mixed-effects models accounted for repeated measurements.

RESULTS

The UNIMMAP resulted in a 27% (HR: 0.73; 95% CI: 0.60, 0.87; P = 0.002) reduction in the rate of stunting in 15,261 infant-months with a higher length-for-age z score of 0.13 (95% CI: 0.02, 0.24; P = 0.02) over the whole observation period. However, by age 30 mo, this difference was not observed. An effect of the UNIMMAP on weight-for-length (P-interaction = 0.004) and head circumference-for-age (P-interaction = 0.03) became apparent by the end of the first year of life. By the age of 30 mo, children from the UNIMMAP group had a higher weight-for-height z score of 0.20 (95% CI: 0.06, 0.34; P = 0.004). No difference in mortality or morbidity was identified in groups, except a 14% reduction in reported episodes of fever (95% CI: 1%, 28%; P = 0.04).

CONCLUSIONS

Improved linear fetal growth with continuation into early life and enhanced postnatal growth were 2 mechanisms that mediated the effect of the prenatal UNIMMAP on infant nutritional status. Additional follow-up to assess long-term effects is warranted.

Moving towards evidence-based policy and program planning in multiple micronutrient interventions for children: symposium summary

This article provides a summary of the symposium "Multiple Micronutrient Interventions during Early Childhood: Moving toward Evidence-Based Policy and Program Planning." The symposium reviewed the strength of evidence of multiple micronutrient interventions on child health, growth, and development, case examples demonstrating how information from program evaluations and the local context can be used to improve program design and performance, and the process by which evidence evolves, resulting in guidelines for policy-makers and program managers. The presentations highlighted the importance of an interactive platform at the country level where the scientific community and country stakeholders exchange ideas, develop a priority implementation research agenda, and clarify key issues to generate and modify policy and programs based on the best evidence available and the ability to deliver results in real time.

Multiple micronutrient interventions during early childhood: moving towards evidence-based policy and program planning

There is considerable evidence that micronutrient deficiencies affect child health and well-being. Although the benefits of strategies that improve diet quality and micronutrient density of foods consumed by small children combined with reducing infections are well recognized as optimal for promoting young child growth and development, they have been difficult to accomplish in many resource-poor settings and few countries have clear policies in support of integrated strategies to control micronutrient deficiencies. The focus of a recent symposium that was part of the Annual Meeting of the ASN held in Anaheim in April 2010 was on how we as the scientific community can help governments and organizations design nutrition and specifically micronutrient policies and programs based on the available evidence; papers that were based on the invited presentations are included in this Supplement. The first paper is a critical review of the current state of knowledge regarding the efficacy and effectiveness of multiple micronutrient interventions in developing country settings, followed by a paper that reviews key issues in evidenced-based policy and program development and includes a relevant example from Mexico where this has occurred. These are followed by a paper that describes a systematic process that is being proposed as a method to guide policy makers and program developers to strengthen program design and performance. The final paper is a summary that highlights areas where the nutrition research community has been successful in translating evidence into policy-relevant advice and where we can improve in this process.