Effect of ready-to-use foods for preventing child undernutrition in Niger: analysis of a prospective intervention study over 15 months of follow-up

Effectiveness of Food-Based Intervention to Improve the Linear Growth of Children under Five: A Systematic Review and Meta-Analysis

Food-based interventions to improve linear growth are most often applied in low- and middle-income countries. However, not all food interventions have been proven to be effective in promoting linear growth. This study aimed to assess the impact and effectiveness of food interventions for improving linear growth in children under five years old. This study was conducted by following the PRISMA guidelines and the data were extracted and presented following the PRISMA recommendations. Studies were identified through a literature search of the SCOPUS, Web of Science, PubMed, ScienceDirect, and ProQuest databases from 2000 to 2022. Only randomized control studies were included in this review based on the inclusion and exclusion criteria. Out of 1125 studies identified, a total of 15 studies were included in this systematic review and meta-analysis. The review result indicated that food-based intervention can help to improve linear growth (MD: 0.20, 95% CI: 0.04 to 0.35, p = 0.01) among children under five. However, there was no significant difference in changes in underweight status (MD: 0.25; CI: -0.15 to 0.64; p = 0.22) and wasting status (MD: 0.09; CI: -0.02 to 0.20; p = 0.12) between the intervention and control groups. Overall, food-based interventions were found to be helpful for improving children's linear growth.

Effect of lipid-based nutrient supplement-Medium quantity on reduction of stunting in children 6-23 months of age in Sindh, Pakistan: A cluster randomized controlled trial

Background

Chronic childhood malnutrition, or stunting, remains a persistent barrier to achieve optimal cognitive development, child growth and ability to reach full potential. Almost half of children under-five years of age are stunted in the province of Sindh, Pakistan.

Objective

The primary objective of this study was to test the hypothesis that the provision of lipid-based nutrient supplement—medium-quantity (LNS-MQ) known as Wawamum will result in a 10% reduction in risk of being stunted at the age of 24 months in the intervention group compared with the control group.

Design

A cluster randomized controlled trial was conducted in Thatta and Sujawal districts of Sindh province, Pakistan. A total of 870 (419 in intervention; 451 in control) children between 6–18 months old were enrolled in the study. The unit of randomization was union council and considered as a cluster. A total of 12 clusters, 6 in each study group were randomly assigned to intervention and control group. All children received standard government health services, while children in the intervention group also received 50 grams/day of Wawamum.

Results

Children who received Wawamum were found to have a significantly reduced risk of stunting (RR = 0.91, 95% CI; 0.88–0.94, p<0.001) and wasting (RR = 0.78, 95% CI; 0.67–0.92, p = 0.004) as compared to children who received the standard government health services. There was no evidence of a reduction in the risk of underweight (RR = 0.94, 95% CI; 0.85–1.04, p = 0.235) in the intervention group compared to the control group. Statistically significant reduction in anaemia in the intervention group was also found as compared to the control group (RR = 0.97, 95% CI; 0.94–0.99, p = 0.042). The subgroup analysis by age, showed intervention effect is significant in reduction of risk of stunting in younger children of aged 6–12 month (RR = 0.83, 95% CI; 0.81–0.86, p = <0.001) and their older peers aged 13–18 month- (RR = 0.90, 95% CI; 0.83–0.97, p = 0.008). The mean compliance of Wawamum was 60% among children.

Conclusions

The study confirmed that the provision of Wawamum to children 6–23 months of age is effective in reducing the risk of stunting, wasting and anaemia. This approach should be scaled up among the most food insecure areas/households with a high prevalence of stunting to achieve positive outcomes for nutrition and health. This study was registered at clinicaltrials.gov as NCT02422953.

Clinical Trial Registration Number: NCT02422953

Intrahousehold management and use of nutritional supplements during the hunger gap in Maradi region, Niger: a qualitative study

Background

Nutritional supplements are used for preventing and treating childhood malnutrition. While there is a growing body of evidence on product efficacy, less emphasis has been placed on how they are perceived and used at the household level. Here, we report on the intrahousehold management of three different supplements (Ready to Use Supplementary food (RUSF), medium quantity lipid-based nutrient supplements (LNS-MQ) and Super Cereal Plus (SC+)) in the region of Maradi (Niger). The main objective of this study was to describe the use, consumption and perception of the three different nutritional products at the household level.

Methods

The study was conducted in the Madarounfa district in the region of Maradi (February – March 2012). Female caregivers were purposely selected from eligible households and invited to participate. Data were collected through focus group discussion and interviews and were analyzed using thematic content analysis.

Results

In total, 114 caregivers participated. Three major themes were initially identified and included preparation and conservation; consumption and sharing practices as well as perception of impact. The data showed good acceptance at the household level including perceived benefits for the target children, health improvement, prevention of illness and malnutrition. Sharing and gifting at both household and community level were also reported.

Conclusions

Caregivers displayed positive perceptions toward the investigated supplements. Patterns of actual management should be considered in the design, implementation, monitoring and evaluation of future programs.

Cost-Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso: A Geographically Randomized Trial

BACKGROUND

There is a variety of specialized nutritious foods available for use in programs targeting undernutrition, but evidence supporting the choice of product is limited.

OBJECTIVES

We compared the cost-effectiveness of 4 specialized nutritious foods to prevent stunting and wasting in children aged 6-23 mo in Burkina Faso.

METHODS

Four geographic regions were randomly assigned to 1 of 4 intervention arms: Corn-Soy Blend Plus (CSB+) programmed with separate fortified vegetable oil (the reference food), Corn-Soy-Whey Blend (CSWB; a new formulation) with oil, SuperCereal Plus (SC+), and ready-to-use supplementary food (RUSF). We compared the effects of each intervention arm on growth (length-for-age z score (LAZ), weight-for-length z score (WLZ), end-line stunting (LAZ < -2), and total monthly measurements of wasting (WLZ < -2). Rations were ∼500 kcal/d, distributed monthly. Children were enrolled in the blanket supplementary feeding program at age ∼6 mo and measured monthly for ∼18 mo. Average costs per child reached were linked with effectiveness to compare the cost-effectiveness of each arm with CSB+ with oil.

RESULTS

In our sample of 6112 children (CSB+, n = 1519; CSWB, n = 1503; SC+, n = 1564; RUSF, n = 1526), none of the foods prevented declines in growth. Children in the SC+ and RUSF arms were not significantly different than those in the CSB+ with oil arm. Children in the CSWB with oil arm experienced higher end-line (measurement at age 22.9-23.9 mo) stunting (OR: 2.07; 95% CI: 1.46, 2.94) and more months of wasting (incidence rate ratio: 1.29; 95% CI: 1.09, 1.51). CSB+ with oil was the least-expensive ration in all costing scenarios ($113-131 2018 US dollars/enrolled child) and similar in effectiveness to SC+ and RUSF, and thus the most cost-effective product for the defined purposes.

CONCLUSIONS

CSB+ with oil was the most cost-effective ration in the prevention of wasting and stunting in this trial. This trial was registered at clinicaltrials.gov as NCT02071563.

Performance of mid-upper arm circumference to diagnose acute malnutrition in a cross-sectional community-based sample of children aged 6-24 months in Niger

BACKGROUND/OBJECTIVES

Accurate, early identification of acutely malnourished children has the potential to reduce related child morbidity and mortality. The current World Health Organisation (WHO) guidelines classify non-oedematous acute malnutrition among children under five using Mid-Upper Arm Circumference (MUAC) or Weight-for-Height Z-score (WHZ). However, there is ongoing debate regarding the use of current MUAC cut-offs. This study investigates the diagnostic performance of MUAC to identify children aged 6–24 months with global (GAM) or severe acute malnutrition (SAM).

SUBJECTS/METHODS

Cross-sectional, secondary data from a community sample of children aged 6-24 months in Niger were used for this study. Children with complete weight, height and MUAC data and without clinical oedema were included. Using WHO guidelines for GAM (WHZ < −2, MUAC < 12.5 cm) and SAM (WHZ < −3, MUAC < 11.5 cm), the sensitivity (Se), specificity (Sp), predictive values, Youden Index and Receiver Operating Characteristic (ROC) curves were calculated for MUAC when compared with the WHZ reference criterion.

RESULTS

Of 1161 children, 23.3% were diagnosed with GAM using WHZ, and 4.4% with SAM. Using current WHO cut-offs, the Se of MUAC to identify GAM was greater than for SAM (79 vs. 57%), yet the Sp was lower (84 vs. 97%). From inspection of the ROC curve and Youden Index, Se and Sp were maximised for MUAC < 12.5 cm to identify GAM (Se 79%, Sp 84%), and MUAC < 12.0 cm to identify SAM (Se 88%, Sp 81%).

CONCLUSIONS

The current MUAC cut-off to identify GAM should continue to be used, but when screening for SAM, a higher cut-off could improve case identification. Community screening for SAM could use MUAC < 12.0 cm followed by appropriate treatment based on either MUAC < 11.5 cm or WHZ < −3, as in current practice. While the practicalities of implementation must be considered, the higher SAM MUAC cut-off would maximise early case-finding of high-risk acutely malnourished children.

Preventive lipid-based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes

BACKGROUND

One nutritional intervention advocated to prevent malnutrition among children is lipid-based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, OBJECTIVES: To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non-hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP).This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition.

SEARCH METHODS

In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs that evaluated the impact of LNS plus complementary foods given at point-of-use (for any dose, frequency, duration) to non-hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point-of-use fortification of complementary foods.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random-effects meta-analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,.

MAIN RESULTS

Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre-specified primary outcomes, and five studies included multiple comparison groups.Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate.LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate-quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate-quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate-quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate-quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low-quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants).LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta-analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate-quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate-quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate-quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low-quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate-quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low-quality evidence).LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta-analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate-quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low-quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants).

AUTHORS' CONCLUSIONS

The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low- and middle-income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes.

Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali

Introduction

Moderate acute malnutrition (MAM) causes substantial child morbidity and mortality, accounting for 4.4% of deaths and 6.0% of disability-adjusted life years (DALY) lost among children under 5 each year. There is growing consensus on the need to provide appropriate treatment of MAM, both to reduce associated morbidity and mortality and to halt its progression to severe acute malnutrition. We estimated health outcomes, costs and cost-effectiveness of four dietary supplements for MAM treatment in children 6–35 months of age in Mali.

Methods

We conducted a cluster-randomised MAM treatment trial to describe nutritional outcomes of four dietary supplements for the management of MAM: ready-to-use supplementary foods (RUSF; PlumpySup); a specially formulated corn–soy blend (CSB) containing dehulled soybean flour, maize flour, dried skimmed milk, soy oil and a micronutrient pre-mix (CSB++; Super Cereal Plus); Misola, a locally produced, micronutrient-fortified, cereal–legume blend (MI); and locally milled flour (LMF), a mixture of millet, beans, oil and sugar, with a separate micronutrient powder. We used a decision tree model to estimate long-term outcomes and calculated incremental cost-effectiveness ratios (ICERs) comparing the health and economic outcomes of each strategy.

Results

Compared to no MAM treatment, MAM treatment with RUSF, CSB++, MI and LMF reduced the risk of death by 15.4%, 12.7%, 11.9% and 10.3%, respectively. The ICER was US$9821 per death averted (2015 USD) and US$347 per DALY averted for RUSF compared with no MAM treatment.

Conclusion

MAM treatment with RUSF is cost-effective across a wide range of willingness-to-pay thresholds.

Trial registration

NCT01015950.

The effect of paid maternity leave on early childhood growth in low-income and middle-income countries

Background

Despite recent improvements, low height-for-age, a key indicator of inadequate child nutrition, is an ongoing public health issue in low-income and middle-income countries. Paid maternity leave has the potential to improve child nutrition, but few studies have estimated its impact.

Methods

We used data from 583 227 children younger than 5 years in 37 countries surveyed as part of the Demographic and Health Surveys (2000–2014) to compare the change in children’s height-for-age z score in five countries that increased their legislated duration of paid maternity leave (Uganda, Zambia, Zimbabwe, Bangladesh and Lesotho) relative to 32 other countries that did not. A quasiexperimental difference-in-difference design involving a linear regression of height-for-age z score on the number of weeks of legislated paid maternity leave was used. We included fixed effects for country and birth year to control for, respectively, fixed country characteristics and shared trends in height-for-age, and adjusted for time-varying covariates such as gross domestic product per capita and the female labour force participation rate.

Results

The mean height-for-age z scores in the pretreatment period were -1.91 (SD=1.44) and –1.47 (SD=1.57) in countries that did and did not change their policies, respectively. The scores increased in treated and control countries over time. A 1-month increase in legislated paid maternity leave was associated with a decrease of 0.08(95% CI −0.20 to 0.04) in child height-for-age z score. Sensitivity analyses did not support a robust association between paid maternity leave policies and height-for-age z score.

Conclusion

We found little evidence that recent changes in legislated paid maternity leave have been sufficient to affect child height-for-age z scores. The relatively short durations of leave, the potential for low coverage and the strong increasing trend in children’s growth may explain our findings. Future studies considering longer durations or combined interventions may reveal further insight to support policy.

The Nexus Between Nutrition and Early Childhood Development

This article looks at both nutrition and early childhood stimulation interventions as part of an integrated life cycle approach to development. We build on recent systematic reviews of child development, which are comprehensive in regard to what is currently known about outcomes reported in key studies. We then focus particularly on implementation, scaling, and economic returns, drawing mainly on experience in low- and middle-income countries where undernutrition and poor child development remain significant public health challenges with implications across the life course.

Effect of ready-to-use foods for preventing child undernutrition in Niger: analysis of a prospective intervention study over 15 months of follow-up

Strategies for preventing undernutrition comprise a range of interventions, including education, provision of complementary food and cash transfer. Here, we compared monthly distributions of two different lipid-based nutrient supplements (LNS), large-quantity LNS (LNS-LQ) and medium-quantity LNS (LNS-MQ) for 15 months on prevention of undernutrition among children 6 to 23 months. Both groups also received cash transfer for the first 5 months of the intervention. We conducted a prospective intervention study in Maradi, Niger, between August 2011 and October 2012. Six and 11 villages were randomly allocated to LNS-LQ/Cash and LNS-MQ/Cash, respectively. Children measuring 60-80 cm were enrolled in the respective groups and followed up monthly. Poisson regression was used to assess differences between interventions and adjust for baseline characteristics, intervention periods and child-feeding practices. The analysis included 2586 children (1081 in the LNS-LQ/Cash group and 1505 in the LNS-MQ/Cash group). This study suggests that provision of LNS-LQ (reference) or LNS-MQ had, overall, similar effect on incidence of severe acute malnutrition (RR = 0.97; 95% CI: 0.67-1.40; P = 0.88), moderate acute malnutrition (RR = 1.20; 95% CI: 0.97-1.48; P = 0.08), severe stunting (RR = 0.94; 95% CI: 0.70-1.26; P = 0.69), moderate stunting (RR = 0.95; 95% CI: 0.76-1.19; P = 0.67) and mortality (RR = 0.83; 95% CI: 0.41-1.65; P = 0.59). Compared with LNS-LQ, LNS-MQ showed a greater protective effect on moderate acute malnutrition among children with good dietary adequacy: RR = 0.72; 95% CI: 0.56-0.94; P = 0.01. These results highlight the need to design context-specific programmes. Provision of LNS-LQ might be more appropriate when food insecurity is high, while when food security is better, distribution of LNS-MQ might be more appropriate.