Complementary Feeding Interventions Have a Small but Significant Impact on Linear and Ponderal Growth of Children in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Age Decomposition of Mortality Rates Among Children Younger Than 5 Years in 47 LMICs

Importance

Despite a global decline in the mortality rate of children younger than 5 years (the under-5 mortality rate), neonatal deaths continue to present a substantial challenge. The etiology behind deaths varies between the early and late neonatal periods as well as at later ages.

Objective

To decompose the under-5 mortality rate in 47 low- and middle-income countries into 8 age intervals, providing a comprehensive understanding of varying vulnerability across age groups.

Design, Setting, and Participants

This cross-sectional study used nationally representative data from 47 Demographic and Health Surveys conducted between 2014 and 2023 in low- and middle-income countries, including 1.4 million live births.

Exposure

Age in days, weeks, months, or years.

Main Outcomes and Measures

The under-5 mortality rate was decomposed by age based on a life table approach, using true cohort probabilities for the early and late neonatal periods and synthetic cohort probabilities for other age intervals, to obtain deaths per 1000 live births (ie, the cohort entering the life table) for each age interval.

Results

In the pooled sample of 1 448 001 live births, there were 14 576 deaths in the early neonatal period (age 0 to 6 days); 3400 in the late neonatal period (age 7-27 days); 6760 in the early postneonatal period (age 28 days to 5 months); 4912 in the late postneonatal period (age 6-11 months); and 5145, 3990, 2674, and 1640 at ages 1, 2, 3, and 4 years, respectively. The early neonatal mortality rate accounted for 21.3 (95% CI, 20.5-22.1) deaths per 1000 births from a total under-5 mortality rate of 57.7 (95% CI, 56.2-59.3) deaths per 1000 births. The early neonatal mortality rate was significantly higher than mortality at subsequent ages (eg, median [IQR] mortality rates: early neonatal period, 18.8 [14.3-23.2] deaths per 1000 births; late neonatal period, 4.7 [3.1-5.9] deaths per 1000 births) and much higher when considering the average daily mortality rate. The early neonatal mortality rate accounted for the greatest share of under-5 mortality rate in all but 2 countries. In most countries the lowest mortality rates were observed at age 3 or 4 years. The share of deaths occurring in the late postneonatal period and later was greater in countries with greater under-5 mortality rates.

Conclusions and Relevance

The concentration of mortality in the first week after birth underscores a critical need for enhanced maternal and neonatal health care. Furthermore, early neonatal mortality rates should be routinely reported and included in health targets. In this study, the age of 6 months emerged as an important turning point: high-mortality countries were characterized by a greater concentration of deaths after age 6 months than countries with lower under-5 mortality rate.

Childhood stunting severity level and associated factors among under-five children in Tanzania: a multi-level ordinal logistic regression analysis using 2022 Tanzanian demographic and health survey

INTRODUCTION

Childhood stunting is a significant public health challenge in Tanzania, affecting over one-third of the children. It has long-term consequences for growth, development, and the overall health status. The high prevalence of stunting in Tanzania necessitates an understanding of its severity levels and determinants. Therefore, this study aimed to explore the varying severity levels of stunting and its associated factors among under-5 children in Tanzania, using data from the Demographic and Health Survey.

MATERIALS AND METHODS

A cross-sectional study utilizing secondary data from Tanzanian Demographic and Health Survey (TDHS) 2022 was employed. A weighted sample of 4,866 children under-5 years of age was included in the analysis. A multilevel ordinal logistic regression model was employed to account for the ordinal nature of stunting and hierarchical structure of the TDHS data. The Brant test was used to assess whether the proportional odds assumption was met, with a p-value greater than 0.05 indicating that the assumption was satisfied. The deviance measure was used to compare the fitness of the different models. A multilevel proportional odds model was used to investigate the impact of risk factors contributing to stunting.

RESULTS

The prevalence of stunting among Tanzanian under-5 children was 29.66%. Of these, 22.16% were moderately stunted, and 8.67% were severely stunted. Being Male, children aged 6-23 months, those born as part of multiple births, children from low- or middle-income households, those whose mothers have no formal or only primary education, and those living in areas with high poverty rates, children residing in the southern and southwestern highland administrative regions are more likely to experience severe stunting.

CONCLUSION

This study revealed that stunting among under-5 children in Tanzania remains a significant public health concern. By addressing these determinants, such as ensuring access to proper nutrition, improving maternal education, and promoting community awareness, Tanzania can make significant strides toward reducing the burden of stunting and improving the health and well-being of children under-5 years of age.

CLINICAL TRIAL NUMBER

Not applicable.

National Trends and Disparities in Complementary Food Diversity Among Infants: A 12-Year Cross-Sectional Birth Cohort Study

Background: The complementary food introduction and consumption guidelines for atopic dermatitis and food allergy prevention have evolved; however, their impact on infant feeding practices remains unclear. This study aimed to analyze complementary food diversity trends in infants, identify vulnerable infants with limited food diversity, and examine the trends in infants with or without vulnerable factors over time. Methods: This study analyzed infants aged 9-12 months who participated in the food diversity survey, conducted as part of the National Health Screening Program in Korea from 2009 to 2020. The complementary food items included grains, vegetables, fruits, eggs, fish, and meats. Infants consuming "six" and "less than six" complementary food items were categorized into high- and low-food-diversity groups, respectively. The study employed logistic regression models to examine the trends in food diversity and vulnerable factors with an assessment of the interaction effects. Results: This study included 3,425,301 participants (51.5% male) aged 11.3 months (standard deviation, 0.8). The high-food-diversity prevalence significantly increased over time, from 30.8% in 2009 to 52.9% in 2020 (p < 0.001). Vulnerable infants included those with preterm birth, low birth weight, non-breastfeeding status, high socioeconomic status, non-Seoul residence at birth, any perinatal conditions, hospitalization due to wheezing, atopic dermatitis and food allergies. The high-diversity proportion increased significantly over the study period across all vulnerable factors (p for interaction < 0.001). However, no significant interactions were observed between the study years and vulnerable factors, except for food allergy (β Coefficient, -0.0117, p for interaction = 0.004). Conclusions: The increasing trends in high-complementary-food-diversity proportions highlight the substantial progress over the study period. However, persistent disparities in vulnerable populations underline the importance of targeted interventions, including tailored nutritional education and policies, that promote equitable dietary practices during early life.

The effect of an intervention to reduce aflatoxin consumption from 6 to 18 mo of age on length-for-age z-scores in rural Tanzania: a cluster-randomized trial

BACKGROUND

Linear growth faltering continues to negatively affect children in low- and middle-income countries and is associated with poor cognitive, developmental, and educational outcomes. Laboratory and observational data suggest that aflatoxin (AF) is a contributor to stunting.

OBJECTIVE

The Mycotoxin Mitigation Trial was a cluster-randomized, community-based 2-group trial conducted in Kongwa District, Tanzania, between 2018 and 2020. The trial assessed whether a 12-mo intervention to reduce AF consumption increased length-for-age z-scores (LAZ) at 18 mo.

METHODS

Low-AF maize and groundnut flours were provided to the intervention group each month; skin lotion was distributed to the control group monthly. Infant and young child feeding education was delivered equally in 52 health facilities (clusters). Anthropometry and the AF blood biomarker serum AF-albumin (AF-alb) were assessed at 6, 12, and 18 mo of age. Outcomes were analyzed as intention-to-treat and per-protocol using linear mixed-effects models.

RESULTS

Two thousand eight hundred forty-two maternal-infant dyads were recruited into the study. The intervention did not create a contrast in AF-alb. At 18 mo, 36% (n = 186/520) of infants had detectable levels of AF-alb compared with 54% (n = 195/364) at baseline, with no difference between groups. Mean LAZ in the intervention group at 18 mo was -1.83 (n = 1231, 95% CI: -1.93, -1.73) compared to -1.90 (n = 1287, 95% CI: -1.99, -1.82) in the control group (P = 0.28).

CONCLUSIONS

An intervention to reduce AF exposure did not alter AF-alb nor anthropometric measures between treatment groups. Drought and agricultural data indicated less favorable conditions for toxin production, resulting in low levels of exposure in both trial arms. Annual, seasonal, and geographic heterogeneity of AF contamination make it difficult to study in an ethically designed trial. Our formative research and early trial data indicate that stunting and intermittent AF exposure continue to be a problem in this region. However, the low-AF exposure levels during the trial led to inconclusive results.

TRIAL REGISTRATION NUMBER

NCT03940547 (ClinicalTrials.org).

The Environmental Enteric Dysfunction Biopsy Initiative (EEDBI) Consortium: mucosal investigations of environmental enteric dysfunction

Environmental enteric dysfunction (EED) is an asymptomatic acquired disorder characterized by upper small bowel inflammation, villus blunting, and gut permeability. It is a major contributor to poor growth in childhood as well as other highly consequential outcomes such as delayed neuorcognitive development. After decades of intermittent interest in this entity, we are now seeing a resurgence in the field of EED. However, recent studies have been hampered by a lack of investigation of the target tissue-the upper small bowel. In 2016, the EEDBI (Environmental Enteric Dysfunction Biopsy Initiative) Consortium was established as a common scientific platform across 3 independent EED biopsy cohort studies in Bangladesh, Pakistan, and Zambia. Two centers in the United States recruited comparison groups of children undergoing endoscopy for clinical indications. The EEDBI Consortium goal was to augment the contributions of the individual centers and answer high-level questions amenable to analysis and interpretation across the studies. Here, we describe the Consortium and its cohorts and recruitment procedures across studies. We also offer details applicable to all papers in this supplement, which describe EED mucosal histology, morphometry, immunohistochemistry, and transcriptomics as well as histology relationship to pathogens and biomarkers.

Pathways through which intermittent preventive treatment for malaria in pregnancy influences child growth faltering: a mediation analysis

Background

Intermittent preventive treatment for malaria in pregnancy (IPTp) can improve birth outcomes, but whether it confers benefits to postnatal growth is unclear. We investigated the effect of IPTp on infant growth in Uganda and its pathways of effects using causal mediation analyses.

Methods

We analyzed data from 633 infants born to mothers enrolled in a randomized trial of monthly IPTp with dihydroartemisinin-piperaquine (DP) vs sulfadoxine-pyrimethamine (SP) (NCT02793622). Weight and length were measured from 0-12 months of age. Using generalized linear models, we estimated effects of DP vs. SP on gravidity-stratified mean length-for-age (LAZ) and weight-for-length Z-scores (WLZ). We investigated mediation by placental malaria, gestational weight change, maternal anemia, maternal inflammation-related proteins, preterm birth, birth length, and birth weight. Mediation models adjusted for infant sex, gravidity, gestational age at enrollment, maternal age, maternal parasitemia at enrollment, education, and wealth.

Findings

SP increased LAZ by 0.18-0.28 Z from birth through age 4 months compared to DP, while DP increased WLZ by 0.11-0.28 Z from 2-8 months compared to SP among infants of multigravidae. We did not observe these differences among primigravida. Mediators of SP included increased birth weight and length and maternal stem cell factor at delivery. Mediators of DP included placental malaria and birth length, maternal IL-18, CDCP1, and CD6 at delivery.

Interpretation

In high malaria transmission settings, different IPTp regimens influenced infant growth among multigravidae through distinct pathways in the period of exclusive breastfeeding, when few other interventions are available.

Funding

Stanford Center for Innovation and Global Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bill & Melinda Gates Foundation.

Evidence for Policies and Practices to Address Global Food Insecurity

Food insecurity affects an estimated 691-783 million people globally and is disproportionately high in Africa and Asia. It arises from poverty, armed conflict, and climate change, among other demographic and globalization forces. This review summarizes evidence for policies and practices across five elements of the agrifood system framework and identifies gaps that inform an agenda for future research. Under availability, imbalanced agriculture policies protect primarily staple food producers, and there is limited evidence on food security impacts for smallholder and women food producers. Evidence supports the use of cash transfers and food aid for affordability and school feeding for multiple benefits. Food-based dietary guidelines can improve the nutritional quality of dietary patterns, yet they may not reflect the latest evidence or food supplies. Evidence from the newer food environment elements, promotion and sustainability, while relatively minimal, provides insight into achieving long-term impacts. To eliminate hunger, our global community should embrace integrated approaches and bring evidence-based policies and practices to scale.

Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm randomized controlled trial

BACKGROUND

Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol.

METHODS

This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ.

DISCUSSION

This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.

Anthropometric nutritional status of children (0-18 years) in South Africa 1997-2022: a systematic review and meta-analysis

OBJECTIVE

To conduct a comprehensive systematic review and meta-analysis of the available literature on the anthropometric nutritional status of South African infants and children, 0-18 years old and to report on trends of changes in nutritional status over the period 1997-2022.

DESIGN

Systematic review and meta-analysis.

SETTING

Review of the available literature on the anthropometric nutritional status of South African infants and children, 0-18 years old, over the period 1997-2022.

PARTICIPANTS

South African infants and children, 0-18 years old.

RESULTS

Only quantitative data from ninety-five publications that described the nutritional status in terms of anthropometry were included. Most recent studies applied the WHO 2006 and 2007 definitions for malnutrition among children 0-5 years old and 5-19 years old, respectively. Meta-analysis of all prevalence data shows the highest stunting prevalence of 25·1 % among infants and preschool children, compared to 11·3 % among primary school-age children and 9·6 % among adolescents. Furthermore, the overweight and obesity prevalence was similar among children younger than 6 years and adolescents (19 %), compared to 12·5 % among primary school-age children. In national surveys, adolescent overweight prevalence increased from 16·9 % in 2002 to 23·1 % in 2011. Meta-regression analysis shows a decrease in stunting among children 6-18 years old and an increase in combined overweight and obesity in the 10-19 years age group.

CONCLUSION

The double burden of malnutrition remains evident in South Africa with stunting and overweight/obesity the most prevalent forms of malnutrition among children.

Patterns in child stunting by age: A cross-sectional study of 94 low- and middle-income countries

Child stunting prevalence is primarily used as an indicator of impeded physical growth due to undernutrition and infections, which also increases the risk of mortality, morbidity and cognitive problems, particularly when occurring during the 1000 days from conception to age 2 years. This paper estimated the relationship between stunting prevalence and age for children 0-59 months old in 94 low- and middle-income countries. The overall stunting prevalence was 32%. We found higher stunting prevalence among older children until around 28 months of age-presumably from longer exposure times and accumulation of adverse exposures to undernutrition and infections. In most countries, the stunting prevalence was lower for older children after around 28 months-presumably mostly due to further adverse exposures being less detrimental for older children, and catch-up growth. The age for which stunting prevalence was the highest was fairly consistent across countries. Stunting prevalence and gradient of the rise in stunting prevalence by age varied across world regions, countries, living standards and sex. Poorer countries and households had a higher prevalence at all ages and a sharper positive age gradient before age 2. Boys had higher stunting prevalence but had peak stunting prevalence at lower ages than girls. Stunting prevalence was similar for boys and girls after around age 45 months. These results suggest that programmes to prevent undernutrition and infections should focus on younger children to optimise impact in reducing stunting prevalence. Importantly, however, since some catch-up growth may be achieved after age 2, screening around this time can be beneficial.

Causes and consequences of child growth faltering in low-resource settings

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

The Influence of Mother's Employment, Family Income, and Expenditure on Stunting Among Children Under Five: A Cross-Sectional Study in Indonesia

Introduction

It is widely acknowledged that the socioeconomic circumstances of a family income are correctly reflected in that family expenditures. The dietary habits of families are influenced by socioeconomic circumstances that may affect stunting. Therefore, this study aims to investigate the household economic predictor stunting (mother's employment, family income, and family expenditure) in children under five.

Methods

This study used a cross-sectional design. Six districts and cities have been chosen as study areas based on the areas with the highest incidence of stunting in West Java, Indonesia. This study conducted specifically from October to December 2018. Data were examined using descriptive statistics (frequency distribution) and a Spearman Rank bivariate test. A logistic regression was employed to determine the elements that serve as predictors of stunting.

Results

A total of 731 women with children under five participated in the study. A bivariate analysis showed that mother's employment had an association with stunting among children under five (p = 0.014). Meanwhile, family income and expenditure are not statistically significant associated with stunting (p > 0.05). A multivariate analysis showed that mother's employment was a stunting predictor with odd ratio (OR) 1.810 (p = 0.017). The OR value means that mothers who do not work have a 1.810 chance for their children to experience stunting compared with mothers who have work. However, family income and expenditure have negative projected values (p = 0.580 and p = 0.398, respectively).

Conclusion

Children under five who are stunted are potentially predictive with mothers' employment, with a chance is higher in mother who do not work. However, family income and expenditure are not predictive of stunting.

Development and validation of the Teen Moms Child Feeding Questionnaire for Sub-Saharan Africa

BACKGROUND

In Sub-Saharan Africa, the nutritional status of children born to teenage mothers deserves critical attention. Maternal knowledge and attitudes concerning infant and young child feeding (IYCF) may predict actual practices and child nutritional status. This study created and validated the Teen Moms Child Feeding Questionnaire for Sub-Saharan Africa.

METHODS

A literature search on IYCF knowledge and attitude gaps in teenage mothers generated scale items. Ten nutrition experts and six teenage mothers assessed content validity and comprehensibility, respectively. Construct validation was conducted by item response theory (IRT) and confirmatory factor analysis (CFA), in 150 teenage mothers in rural communities of Abuja, Nigeria. Model fit parameters were estimated by standardized chi-square tests. Internal consistency reliability was determined by marginal reliability and Cronbach's alpha. In a sub-sample of 40 women who completed the questionnaire two weeks later, test-retest reliability was assessed via intraclass correlations.

RESULTS

The IRT analysis retained 23 knowledge items on infant food type, breastfeeding and complementary feeding, with acceptable discrimination and difficulty. CFA produced a six-factor solution (exclusive breastfeeding, breast milk expression, meal frequency, responsive feeding, dietary diversity, and barriers) with 17 attitude items. Confirmatory fit and Tucker Lewis indices > 0.9; Root Mean Square Errors of Approximation and Standardized Root Mean Square Residuals < 0.08, showed good model fit. Overall Cronbach's alpha of the attitude scale (0.843), subscales (≥ 0.6) and high intraclass correlation coefficients (> 0.75) indicated reliability.

CONCLUSION

The Teen Moms Child Feeding Questionnaire for Sub-Saharan Africa is a valid assessment tool for IYCF knowledge and attitudes of teenage mothers.

Evaluation of YOUTUBE videos on complementary feeding: Content quality and reliability analysis

YouTube is an online platform that parents frequently use to access information on child health. Parents' watching YouTube videos to have information on complementary feeding requires evaluation of the videos regarding child health. This study which was conducted in descriptive design, aimed to analyze YouTube videos' content quality and reliability on complementary feeding. Searched by matching keywords "starting", "beginning", "introducing", "solid food", and "complementary feeding" through boolean operators in the English language on YouTube, on August 2022. The search identified 528 videos related to complementary feeding. Two independent researchers analyzed the content of 61 videos that met the inclusion criteria. The content quality of the videos was evaluated using the Checklist for Complementary Feeding (CCF), which was prepared by researchers in line with international guidelines, the reliability of the videos was analyzed using the DISCERN, and the content quality was evaluated using the Global Quality Score (GQS). Of the 61 videos included, 38 (62.3%) were informative, and 23 (37.7%) were misleading. The kappa value among independent observers was 0.96. The mean GQS, DISCERN, and CCF scores of the videos grouped as informative were significantly higher than the videos grouped as misleading (p = 0.000, p = 0.000, p = 0.000, respectively). There was a significant difference between the mean scores of GQS and DISCERN according to the publication source of the videos (p = 0.033 and p = 0.023, respectively). The GQS and DISCERN mean scores of the Ministrial/Academic/Hospital/Healthcare Institution channel videos were higher than the mean scores of the Individual/Parents content channel videos. Videos on YouTube about complementary feeding have high viewing rates, but also videos that are low in terms of quality and reliability.

The Effects of Yogurt Supplementation and Nutritional Education on Malnourished Infants: A Pilot RCT in Dhaka's Slums

Our objective was to quantify the effects of yogurt supplementation and nutrition education over three months on the linear growth of infants at risk of stunting. We conducted a three-arm pilot randomized controlled trial: (1) nutrition education for mothers; (2) nutrition education plus a daily yogurt supplement (50 g) for the index child; and (3) usual care (control). Dyads of children aged 4-6 months and at risk of stunting [length-for-age z-score (LAZ) ≤ -1 SD and >-2 SD] and their mothers with ≤10 years of education were eligible for the study. Participants were recruited from five slum areas in Dhaka, Bangladesh. Intention-to-treat (N = 162) and complete-case analyses (N = 127) showed no between-group statistically significant differences in LAZ or weight-for-age (WAZ). However, the yogurt group showed greater change in linear growth compared to the control (LAZ: mean difference 0.20, 95% CI: -0.06, 0.47, p-value 0.13), which was also slightly greater than the education-only group. Children in the yogurt plus group were five times (95% CI: 0.80, 31.80, p-value 0.09) more likely to meet the minimum dietary diversity (MDD) score compared to the control. A 3-month follow-up of this pilot study did not demonstrate that yogurt was beneficial to linear growth. However, there were encouraging trends that merit replication of the intervention with larger samples and longer follow-ups.

Effect of milk protein and whey permeate in large quantity lipid-based nutrient supplement on linear growth and body composition among stunted children: A randomized 2 × 2 factorial trial in Uganda

BACKGROUND

Despite possible benefits for growth, milk is costly to include in foods for undernourished children. Furthermore, the relative effects of different milk components, milk protein (MP), and whey permeate (WP) are unclear. We aimed to assess the effects of MP and WP in lipid-based nutrient supplement (LNS), and of LNS itself, on linear growth and body composition among stunted children.

METHODS AND FINDINGS

We performed a randomized, double-blind, 2 × 2 factorial trial among 12 to 59 months old stunted children in Uganda. Children were randomized to 4 formulations of LNS with MP or soy protein isolate and WP or maltodextrin (100 g/day for 12 weeks) or no supplementation. Investigators and outcome assessors were blinded; however, participants were only blinded to the ingredients in LNS. Data were analyzed based on intention-to-treat (ITT) using linear mixed-effects models adjusted for age, sex, season, and site. Primary outcomes were change in height and knee-heel length, and secondary outcomes included body composition by bioimpedance analysis (ISRCTN13093195). Between February and September 2020, we enrolled 750 children with a median age of 30 (interquartile range 23 to 41) months, with mean (± standard deviation) height-for-age z-score (HAZ) -3.02 ± 0.74 and 12.7% (95) were breastfed. The 750 children were randomized to LNS (n = 600) with or without MP (n = 299 versus n = 301) and WP (n = 301 versus n = 299), or no supplementation (n = 150); 736 (98.1%), evenly distributed between groups, completed 12-week follow-up. Eleven serious adverse events occurred in 10 (1.3%) children, mainly hospitalization with malaria and anemia, all deemed unrelated to the intervention. Unsupplemented children had 0.06 (95% confidence interval, CI [0.02, 0.10]; p = 0.015) decline in HAZ, accompanied by 0.29 (95% CI [0.20, 0.39]; p < 0.001) kg/m2 increase in fat mass index (FMI), but 0.06 (95% CI [-0.002; 0.12]; p = 0.057) kg/m2 decline in fat-free mass index (FFMI). There were no interactions between MP and WP. The main effects of MP were 0.03 (95% CI [-0.10, 0.16]; p = 0.662) cm in height and 0.2 (95% CI [-0.3, 0.7]; p = 0.389) mm in knee-heel length. The main effects of WP were -0.08 (95% CI [-0.21, 0.05]; p = 220) cm and -0.2 (95% CI [-0.7; 0.3]; p = 403) mm, respectively. Interactions were found between WP and breastfeeding with respect to linear growth (p < 0.02), due to positive effects among breastfed and negative effects among non-breastfed children. Overall, LNS resulted in 0.56 (95% CI [0.42, 0.70]; p < 0.001) cm height increase, corresponding to 0.17 (95% CI [0.13, 0.21]; p < 0.001) HAZ increase, and 0.21 (95% CI [0.14, 0.28]; p < 0.001) kg weight increase, of which 76.5% (95% CI [61.9; 91.1]) was fat-free mass. Using height-adjusted indicators, LNS increased FFMI (0.07 kg/m2, 95% CI [0.0001; 0.13]; p = 0.049), but not FMI (0.01 kg/m2, 95% CI [-0.10, 0.12]; p = 0.800). Main limitations were lack of blinding of caregivers and short study duration.

CONCLUSIONS

Adding dairy to LNS has no additional effects on linear growth or body composition in stunted children aged 12 to 59 months. However, supplementation with LNS, irrespective of milk, supports linear catch-up growth and accretion of fat-free mass, but not fat mass. If left untreated, children already on a stunting trajectory gain fat at the expense of fat-free mass, thus nutrition programs to treat such children should be considered.

TRIAL REGISTRATION

ISRCTN13093195.

Maternal and child nutrition in the Lives Saved Tool: Results of a recent update

Background

The Lives Saved Tool (LiST) is a mathematical modelling tool for estimating the survival, health, and nutritional impacts of scaling intervention coverage in low- and middle-income countries (LMICs). Various nutrition interventions are included in LiST and are regularly (and independently) reviewed and updated as new data emerge. This manuscript describes our latest in-depth review of nutrition evidence, focusing on intervention efficacy, appropriate population-affected fractions, and new interventions for potential inclusion in the LiST model.

Methods

An external advisory group (EAG) was assembled to review evidence from systematic reviews on intervention-outcome (I-O) pairs for women and children under five years of age. GRADE quality was assigned to each pair based on a LiST-specific checklist to facilitate consistent decisions during the consideration. For existing interventions with new information, the EAG was asked to recommend whether to update the default efficacy values and population-affected fractions. For the new interventions, the EAG decided whether there was sufficient evidence of benefit, and in affirmative cases, information on the efficacy and affected fraction values that could be used. Decisions were based on expert group consensus.

Results

Overall, the group reviewed 53 nutrition-related I-O pairs, including 25 existing and 28 new ones. Efficacy and population-affected fractions were updated for seven I-O pairs; three pairs were updated for efficacy estimates only, three were updated for population-affected fractions only; and nine new I-O pairs were added to the model, bringing the total of nutrition-related I-O pairs to 34. Included in the new I-O pairs were two new nutrition interventions added to LIST: zinc fortification and neonatal vitamin A supplementation.

Conclusions

For modelling tools like LiST to be useful, it is crucial to update interventions, efficacy and population-affected fractions as new evidence becomes available. The present updates will enable LiST users to better estimate the potential health, nutrition, and survival benefits of investing in nutrition.

Mitigating Infectious morbidity and Growth deficits in HIV-exposed uninfected infanTs with human Milk Oligosaccharide (MIGH-T MO): a randomised trial protocol

INTRODUCTION

Children who are HIV-exposed uninfected (HEU), that is, children who do not acquire HIV infection despite being born to mothers with HIV, have a higher risk of mortality, infectious morbidity and growth deficits than children who are HIV-unexposed uninfected (HUU). Prior research has focused on breast feeding and has pointed to changes in human milk oligosaccharides (HMOs) associated with maternal HIV that may influence the infant microbiome and thereby lead to these adverse outcomes. However, to our knowledge, no study has attempted to intervene along this pathway to reduce the occurrence of the adverse outcomes in children HEU. We will conduct a double-blind, randomised trial of a synbiotic intervention, which combines an HMO and probiotic, in breastfed infants HEU in South Africa to evaluate whether this intervention has promise to reduce excess infectious morbidity and growth faltering compared with controls.

METHODS AND ANALYSIS

One hundred and forty-four breastfed infants HEU, aged 4 weeks, will be 1:1 randomised to receive either a daily synbiotic or an identical-looking placebo through age 24 weeks. Infants will be followed until age 48 weeks and outcomes of infectious morbidity, growth and biological measurements (eg, microbiota, inflammation and metabolome) will be assessed. Analyses will follow intention-to-treat principles comparing the cohorts as randomised. Infants HEU will be compared across arms with respect to the occurrence of infectious morbidity and growth outcomes through 4-24 weeks and 4-48 weeks using appropriate parametric and non-parametric statistical tests. Additionally, an observational cohort of 40 breastfed infants HUU will be recruited as a comparator group with no intervention.

ETHICS AND DISSEMINATION

Ethical approval for this study has been obtained from the ethics committees at Columbia University and Stellenbosch University. The findings will be disseminated in publications.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05282485. SANCTR ID number: DOH-27-122021-6543.

Human Breast Milk Contamination with Aflatoxins, Impact on Children's Health, and Possible Control Means: A Review

Aflatoxins are natural toxicants produced mainly by species of the Aspergillus genus, which contaminate virtually all feeds and foods. Apart from their deleterious health effects on humans and animals, they can be secreted unmodified or carried over into the milk of lactating females, thereby posing health risks to suckling babies. Aflatoxin M1 (AFM1) is the major and most toxic aflatoxin type after aflatoxin B1 (AFB1). It contaminates human breast milk upon direct ingestion from dairy products or by carry-over from the parent molecule (AFB1), which is hydroxylated in the liver and possibly in the mammary glands by cytochrome oxidase enzymes and then excreted into breast milk as AFM1 during lactation via the mammary alveolar epithelial cells. This puts suckling infants and children fed on this milk at a high risk, especially that their detoxifying activities are still weak at this age essentially due to immature liver as the main organ responsible for the detoxification of xenobiotics. The occurrence of AFM1 at toxic levels in human breast milk and associated health conditions in nursing children is well documented, with developing countries being the most affected. Different studies have demonstrated that contamination of human breast milk with AFM1 represents a real public health issue, which should be promptly and properly addressed to reduce its incidence. To this end, different actions have been suggested, including a wider and proper implementation of regulatory measures, not only for breast milk but also for foods and feeds as the upstream sources for breast milk contamination with AFM1. The promotion of awareness of lactating mothers through the organization of training sessions and mass media disclosures before and after parturition is of a paramount importance for the success of any action. This is especially relevant that there are no possible control measures to ensure compliance of lactating mothers to specific regulatory measures, which can yet be appropriate for the expansion of breast milk banks in industrialized countries and emergence of breast milk sellers. This review attempted to revisit the public health issues raised by mother milk contamination with AFM1, which remains undermined despite the numerous relevant publications highlighting the needs to tackle its incidence as a protective measure for the children physical and mental health.

Promoting weaning practices and growth of Egyptian infants by using communication for behavioral development approach

Background

Access to various affordable and nutritious foods is considered a challenging factor for households with limited resources affecting the proper weaning practices. In order to motivate communities to adhere to the right and proper weaning practices, the social aspect should be considered through close communication with the targeted communities. This study aimed to evaluate how impactful the use of the principles of Communication for Development (C4D) that respect parents’ beliefs and their cultural norms is in improving the weaning practices and growth of infants in an Egyptian village.

Methods

An interventional three-phase study was conducted for three years. The intervention targeted 464 mothers of infants up to 2 years of age. C4D interventions encouraged each mother to provide her baby with nutritious and varied options through age-appropriate introduction and diversification of nutrient-rich complementary foods under the slogan “ enjoy meals like a baby”. The effectiveness of the approach was measured by five essential weaning practices: Introduction of solid, semi-solid, or soft foods, Minimum dietary diversity, minimum meal frequency, Minimum acceptable diet, and consumption of iron-rich foods.

Results

There was marked and significant improvement in the awareness and of the majority of the weaning practices’ indicators as a result of the interventions. This was noticed for the timely introduction of complementary foods which increased from 36.7% to 82.0%, the minimum meal frequency indicator (3–5) which increased from 25.3% to 67.3%, iron-rich or fortified food (68.0% to 82%) as well as a regular checkup for baby health at the health unit (71.3%). Indicators that were improved but failed to achieve the target were the “Minimum Dietary Diversity” (reached 32%) and the minimum acceptable diet (reached 22.0%). A significant effect on linear growth especially for females is evidenced by the remarkable decrease in wasting (from 31.5% to 11.1%) and obesity (from 12.0% to 0%) associated with a considerable decrease in underweight (from 40% to 16.7%).

Conclusion

Targeting caregivers through the C4D approach have succeeded in providing them with the support required for the provision of adequate nutrition for their infants that had significantly marked improvement in growth indices of their infants.

Impact of a package of health, nutrition, psychosocial support, and WaSH interventions delivered during preconception, pregnancy, and early childhood periods on birth outcomes and on linear growth at 24 months of age: factorial, individually randomised controlled trial

OBJECTIVE

To determine the effect of integrated and concurrent delivery of health, nutrition, water, sanitation and hygiene (WaSH), and psychosocial care interventions during the preconception period alone, during pregnancy and early childhood, and throughout preconception, pregnancy, and early childhood on birth outcomes and linear growth at 24 months of age compared with routine care.

DESIGN

Individually randomised factorial trial.

SETTING

Low and middle income neighbourhoods of Delhi, India.

PARTICIPANTS

13 500 women were randomised to receive preconception interventions (n=6722) or routine care (n=6778). 2652 and 2269 pregnant women were randomised again to receive pregnancy and early childhood interventions or routine care. The analysis of birth outcomes included 1290 live births for the preconception, pregnancy, and early childhood interventions (group A), 1276 for the preconception intervention (group B), 1093 for the pregnancy and early childhood interventions (group C), and 1093 for the control (group D). Children aged 24 months by 30 June 2021 were included in the 24 month outcome analysis (453 in group A, 439 in B, 293 in C, and 271 in D).

INTERVENTIONS

Health, nutrition, psychosocial care and support, and WaSH interventions were delivered during preconception, pregnancy, and early childhood periods.

MAIN OUTCOME MEASURES

The primary outcomes were low birth weight, small for gestational age, preterm, and mean birth weight. At 24 months, the outcomes were mean length-for-age z scores and proportion stunted. Three prespecified comparisons were made: preconception intervention groups (A+B) versus no preconception intervention groups (C+D); pregnancy and early childhood intervention groups (A+C) versus routine care during pregnancy and early childhood (B+D) and preconception, pregnancy, and early childhood interventions groups (A) versus control group (D).

RESULTS

The proportion with low birth weight was lower in the preconception intervention groups (506/2235) than in the no preconception intervention groups (502/1889; incidence rate ratio 0.85, 98.3% confidence interval 0.75 to 0.97; absolute risk reduction -3.80%, 98.3% confidence interval -6.99% to -0.60%). The proportion with low birth weight was lower in the pregnancy intervention groups (502/2096) than in the no pregnancy intervention groups (506/2028) but the upper limit of the confidence interval crossed null effect (0.87, 0.76 to 1.01; -1.71%, -4.96% to 1.54%). There was a larger effect on proportion with low birth weight in the group that received interventions in the preconception and pregnancy periods (267/1141) compared with the control group (267/934; 0.76, 0.62 to 0.91; -5.59%, -10.32% to -0.85%). The proportion stunted at 24 months of age was substantially lower in the pregnancy and early childhood intervention groups (79/746) compared with the groups that did not receive these interventions (136/710; 0.51, 0.38 to 0.70; -8.32%, -12.31% to -4.32%), and in the group that received preconception, pregnancy, and early childhood interventions (47/453) compared with the control group (51/271; 0.49, 0.32 to 0.75; -7.98%, -14.24% to -1.71%). No effect on stunting at 24 months was observed in the preconception intervention groups (132/892) compared with the no preconception intervention groups (83/564).

CONCLUSIONS

An intervention package delivered during preconception, pregnancy, and early childhood substantially reduced low birth weight and stunting at 24 months. Pregnancy and early childhood interventions alone had lower but important effects on birth outcomes and 24 month outcomes. Preconception interventions alone had an important effect on birth outcomes but not on 24 month outcomes.

TRIAL REGISTRATION

Clinical Trial Registry-India CTRI/2017/06/008908.

Effectiveness of nutritional supplementation during the first 1000-days of life to reduce child undernutrition: A cluster randomized controlled trial in Pakistan

BACKGROUND

Childhood stunting can start in the womb and continue for two years. Therefore, the first 1000 days of life between a woman's pregnancy and her child's 2nd birthday offer a unique window of opportunity to build healthier and more prosperous futures. Therefore, we aimed to assess the effectiveness of nutritional supplementation during the first 1000-days to reduce the prevalence of stunting in children at 24 months of age.

METHODS

In this cluster randomized controlled trial, we enrolled women during their pregnancy from two rural districts of Sindh, Pakistan. A cluster was one union council with a population of ∼25000 residents. Out of 29 clusters, we randomly allocated 6 clusters to the intervention and control groups each. Pregnant women received a monthly supply of 5 kg (i.e., 165 grams/day) of wheat soya blend plus (WSB+) during pregnancy and the first six months of their lactation period. In addition, their children received lipid-based nutrient supplement - medium-quantity (LNS-MQ) between 6-23 months of age. The primary outcome was a reduction in the prevalence of stunting in children at 24 months of age. Analysis was an intention to treat. The trial is registered on ClinicalTrial.gov, number NCT02422953.

FINDINGS

Two thousand thirty pregnant women (1017 in the intervention group and 1013 in the control group) were enrolled between August 30, 2014, and May 25, 2016. Monthly follow-ups were conducted between October 1, 2014, and October 25, 2018. At 24 months of age, we captured data from 699 (78%) of 892 live births in the intervention group and 653 (76%) of 853 live births in the control group. There was a significant difference in mean length (49.4 cm vs 48.9 cm, p =0.027), weight (3.1 kg vs 3.0 kg, p =0.013), length for age z-scores (-1.2 vs -1.5, p =0.004) and weight for age z-scores (-1.2 vs -1.5, p =0.015) among infants in the intervention compared to control group. At 24 months of age, a significant difference in the prevalence of stunting (absolute difference, 10.2%, 95% CI 18.2 to 2.3, p =0.017) and underweight (absolute difference, 13.7%, 95% CI 20.3 to 7.0, p =0.001) were observed in the intervention as compared to the control group. The prevalence of wasting was not significantly different between the intervention and control groups (absolute difference, 6.9%, 95% CI 14.1 to 0.3, p =0.057).

INTERPRETATION

Provision of WSB+ and LNS-MQ during the first 1000-days of life improved child linear growth and reduced stunting in children at 24 months. This study can be scaled-up in similar settings to lower the prevalence of stunting in children under two years of age.

FUNDING

World Food Programme, Pakistan.

Age Distribution of All-Cause Mortality Among Children Younger Than 5 Years in Low- and Middle-Income Countries

Importance

Coverage of essential child health and nutrition interventions in low- and middle-income countries remains suboptimal. Adverse exposures, such as undernutrition and infections, are particularly harmful during the 1000 days from conception until 2 years of age.

Objective

To investigate whether deaths in children younger than 5 years-which also reflect adverse exposures faced by children more broadly-are concentrated in the first 2 years after birth.

Design, Setting, and Participants

This cross-sectional study used a synthetic cohort probability method with Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 77 low- and middle-income countries, with the earliest survey starting data collection in March 2010 and the most recent survey ending data collection in December 2019. Participants included 2 827 515 children who were younger than 5 years at any point 10 years before survey. Data were analyzed from March 11 to 21, 2022.

Main Outcomes and Measures

Share of deaths among children younger than 5 years occurring before 1 month, at 1 to 23 months, and at 24 to 59 months of age.

Results

Among the 2 827 515 children included in the analysis, 81.5% (95% CI, 81.0%-82.0%) of deaths occurred in the first 2 years after birth ranging from 63.7% (95% CI, 61.6%-65.7%) in Niger to 97.8% (95% CI, 85.9%-99.7%) in Albania. An estimated 18.5% (95% CI, 18.0%-19.0%) of child deaths occurred at 24 to 59 months of age. Countries with higher mortality rates among children younger than 5 years had a lower share of deaths occurring in the neonatal period.

Conclusions and Relevance

In this sample of 77 low- and middle-income countries, a large majority of deaths among children younger than 5 years occurred before 2 years of age in all countries among boys and girls and in households with the worst and best living standards. Research has highlighted perinatal complications, infections, and undernutrition as primary causes of death among children younger than 5 years. Therefore, coverage of interventions to reduce these adverse exposures should be ensured during pregnancy and the first 2 years after birth, which is also a crucial period for human development.

Epithelial Abnormalities in the Small Intestine of Zambian Children With Stunting

Background

Environmental enteropathy (EE) contributes to impaired linear growth (stunting), in millions of children worldwide. We have previously reported that confocal laser endomicroscopy (CLE) shows fluorescein leaking from blood to gut lumen in vivo in adults and children with EE. We set out to identify epithelial lesions which might explain this phenomenon in Zambian children with stunting non-responsive to nutritional support.

Methods

We performed confocal laser endomicroscopy (CLE) in 75 children and collected intestinal biopsies for histology in 91 children. CLE videos were evaluated, employing the Watson score to determine severity of leakiness. Morphometry was carried out on well-orientated mucosa and 3 biopsies were examined by electron microscopy.

Results

Confocal laser endomicroscopy demonstrated substantial leakage from circulation to gut lumen in 73 (97%) children. Histology consistently showed characteristic changes of EE: villus blunting, lamina propria and epithelial inflammation, and depletion of secretory cells (Paneth cells and goblet cells). Epithelial abnormalities included marked variability in epithelial height, disorganised and shortened microvilli, dilated intercellular spaces, pseudostratification, formation of synechiae between epithelium on adjacent villi, crypt destruction, and abundant destructive lesions which may correspond to the microerosions identified on CLE.

Conclusion

Epithelial abnormalities were almost universal in Zambian children with non-responsive stunting, including epithelial microerosions, cell-cell adhesion anomalies, and defects in secretory cells which may all contribute to impairment of mucosal barrier function and microbial translocation.

Improvement in Anthropometric Measurements of Malnourished Children by Means of Complementary Food and Nutritional Education in Fars Province, Iran: A Community-Based Intervention

Background

Childhood malnutrition could have adverse impacts on the growth of child and eventually on fertility and general economic growth, and still, this issue remains a worldwide priority and a concern. This study aimed to evaluate the effectiveness of the national nutritional interventions program on the improvement and nutritional status of malnourished children children aged 6–59 months.

Methods

This community-based intervention study was conducted with 1288 acute and moderately malnourished children aged 6–59 months referred to health centers. Children received combined nutritional education and counseling with the provision of affordable complementary food for 10 months. Anthropometric measurements were assessed monthly according to the standard protocols.

Results

Our results showed the reduction in the risk of malnutrition among children after nutritional interventions for weight-for-height (WHZ) (P < 0.001), height-for-age (HAZ) (P < 0.001), and weight-for-age (WAZ) (P = 0.008). Total malnourished children indicated improvement in HAZ (<-3 SD: OR = 1.10, P = 0.026), WAZ (<-2SD: OR = 1.21, P < 0.001; <-3SD: OR = 1.60, P < 0.001), and WHZ (<-3SD: OR = 1.10, P = 0.030). Controlling potential confounders (socioeconomic status, childrens' birth supine length, and weight) showed a significant amelioration in HAZ (<-2 SD: OR = 6.20, P = 0.020; <-3 SD: OR = 9, P = 0.003) and WAZ (<-2 SD: OR = 5.85, P = 0.010; <-3 SD: OR = 7.50, P = 0.004). In urban areas, significant amelioration was observed in HAZ (<-3 SD: OR = 1.22, P = 0.010) and WAZ (<-2 SD: OR = 1.24, P = 0.003; <-3 SD: OR = 1.64, P < 0.001). In rural, considerable amelioration was observed in WAZ (<-2 SD: OR = 1.20, P = 0.010; <-3 SD: OR = 1.50, P < 0.001) and WHZ (<-3 SD: OR = 1.20, P = 0.020).

Conclusion

Nutritional training and counseling as well as complementary food intervention among the malnourished children significantly improved the nutritional status of children. So community-based intervention is recommended to reduce the malnutrition among children.

Nutrition-sensitive agriculture programs increase dietary diversity in children under 5 years: A review and meta-analysis

Background

Low-quality diets contribute to the burden of malnutrition and increase the risk of children not achieving their developmental potential. Nutrition-sensitive agriculture programs address the underlying determinants of malnutrition, though their contributions to improving diets do not factor into current nutrition impact modeling tools.

Objective

To synthesize the evidence on the effectiveness of nutrition-sensitive agriculture programs in improving dietary diversity in young children (6-23.9 months and 6-60 months).

Methods

A literature search was conducted for published trials through existing systematic reviews and individual database search of the ISI Web of Science. All dietary diversity measures in the studies selected to be in the analysis were extracted. Estimation of main pooled effects were conducted on outcomes of minimum diet diversity (MDD) and diet diversity score (DDS) using random-effects meta-regression models. We report pooled effect sizes as standardized mean differences (SMDs) or odds ratios (ORs).

Results

Nutrition-sensitive agricultural interventions have a significant positive impact on the diet diversity scores of children aged 6-23.9 months (SMD = 0.22, 95% confidence interval (CI) = 0.09-0.36) and on the odds of reaching minimum diet diversity (OR = 1.45, 95% CI = 1.20, 1.76). Similar impacts are found when analyses are expanded to include studies for children aged 6-60 months (DDS SMD = 0.22, 95% CI = 0.12-0.32) (MDD OR = 1.64, 95% CI:  = 1.38-1.94).

Conclusion

Nutrition-sensitive agriculture interventions consistently have a positive impact on child dietary diversity. Incorporating this evidence in nutrition modeling tools can contribute to decision-making on the relative benefits of nutrition-sensitive interventions as compared with other maternal, newborn, child health and nutrition (MNCHN) interventions.

Consumption of Vitamin-A-Rich Foods and Vitamin A Supplementation for Children under Two Years Old in 51 Low- and Middle-Income Countries

Vitamin A supplementation for children 6-59 months old is an important intervention that boosts immune function, especially where children do not consume enough vitamin-A-rich foods. However, the low coverage of vitamin A supplementation is a persistent problem in low- and middle-income countries. We first estimated the percentage of children 6-23 months old receiving the minimum dietary diversity, vitamin-A-rich foods, and vitamin A supplementation, and second, the difference in the percentage receiving vitamin A supplementation between children 6-23 months old and children 24-59 months old using nationally representative cross-sectional household surveys, namely, the Demographic and Health Surveys, conducted from 2010 to 2019 in 51 low- and middle-income countries. Overall, 22% (95% CI: 22, 23) of children received the minimum dietary diversity, 55% (95% CI: 54, 55) received vitamin-A-rich foods, 59% (95% CI: 58, 59) received vitamin A supplementation, and 78% (95% CI: 78, 79) received either vitamin-A-rich foods or supplementation. A wide variation across countries was observed; for example, the percentage of children that received either vitamin-A-rich foods or supplementation ranged from 53% (95% CI: 49, 57) in Guinea to 96% (95% CI: 95, 97) in Burundi. The coverage of vitamin A supplementation should be improved, especially for children 6-23 months old, in most countries, particularly where the consumption of vitamin-A-rich foods is inadequate.

Gut Microbiota-Targeted Nutritional Interventions Improving Child Growth in Low- and Middle-Income Countries: A Systematic Review

The objective of this systematic literature review was to evaluate the efficacy of probiotic, prebiotic, and synbiotic interventions compared with control on improving growth outcomes of children living in low- and middle-income countries (LMICs). Probiotics had a beneficial effect on ≥1 of the growth outcomes in 5 out of the 11 included studies. Of these, 3 studies were conducted in undernourished children, 1 in healthy children, and 1 in children without a described health status. No effect of prebiotics on growth outcomes was seen in the 4 included studies. Synbiotics had a beneficial effect on growth outcomes in 3 out of 4 studies. Although a limited number of studies with high heterogeneity indicate that probiotics and synbiotics may have the potential to improve the growth of both undernourished and healthy children living in LMICs, more research is needed to confirm the observed effects. This review was registered at www.crd.york.ac.uk/prospero/ as CRD42020212998.

Effectiveness of Specialized Nutritious Foods and Social and Behavior Change Communication Interventions to Prevent Stunting among Children in Badakhshan, Afghanistan: Protocol for a Quasi-Experimental Study

Stunting predominantly occurs during the first 1000 days of life and continues to the age of five years. We will aim to assess the effectiveness of specialized nutritious foods (SNF)and social and behavior change communication (SBCC) strategies during the first 1000 days of life to prevent stunting among children in two rural districts of Badakhshan, Afghanistan. This will be a quasi-experimental pre-post study with the control group utilizing qualitative and quantitative methods. Before launching the program, formative research will be conducted on the acceptability, appropriate use and SBCC strategies needed to support the introduction of intervention package. Repeated cross-sectional baseline and endline surveys will be conducted in both the intervention and the control districts. After the formative research and baseline household survey, an intervention focusing on the provision of SNF, targeting pregnant and lactating women and children 6-23 months, and SBCC strategies will be implemented for at least 12 months. The primary outcome will be a reduction in the prevalence of stunting among children under two years in the intervention group compared to the control group. We will aim to compare the intervention and control group between the pre- and post-intervention assessments to isolate the effect of the intervention by difference-in-differences estimates. The program monitoring and evaluation component will examine the quality of implementation, acceptability of intervention, identification of potential barriers and to learn how to enhance the program's effectiveness through ongoing operational improvements. The results will be beneficial to design interventions to prevent stunting within Afghanistan and other low-middle-income countries.

Another voice in the crowd: the challenge of changing family planning and child feeding practices through mHealth messaging in rural central India

Introduction

Kilkari is one of the world’s largest mobile phone-based health messaging programmes. Developed by BBC Media Action, it provides weekly stage-based information to pregnant and postpartum women and their families, including on infant and young child feeding (IYCF) and family planning, to compliment the efforts of frontline health workers. The quantitative component of a randomised controlled trial (RCT) in the Indian state of Madhya Pradesh found that exposure to Kilkari increased modern contraceptive uptake but did not change IYCF practices. This qualitative research complements the RCT to explore why these findings may have emerged.

Methods

We used system generated data to identify households within the RCT with very high to medium Kilkari listenership. Mothers (n=29), as well as husbands and extended family members (n=25 interviews/family group discussions) were interviewed about IYCF and family planning, including their reactions to Kilkari’s calls on these topics. Analysis was informed by the theory of reciprocal determinism, which positions behaviour change within the interacting domains of individual attributes, social and environmental determinants, and existing practices.

Results

While women who owned and controlled their own phones were the Kilkari listeners, among women who did not own their own phones, it was often their husbands who listened. Spouses did not discuss Kilkari messages. Respondents retained and appreciated Kilkari messages that aligned with their pre-existing worldviews, social norms, and existing practices. However, they overlooked or de-emphasised content that did not. In this way, they reported agreeing with and trusting Kilkari while persisting with practices that went against Kilkari’s recommendations, particularly non-exclusive breastfeeding and inappropriate complementary feeding.

Conclusion

To deepen impact, digital direct to beneficiary services need to be complimented by wider communication efforts (e.g., sustained face-to-face, media, community engagement) to change social norms, taking into account the role of socio-environmental, behavioural, and individual determinants.

Effect of complementary feeding behaviour change communication delivered through community-level actors on infant growth and morbidity in rural communities of West Gojjam Zone, Northwest Ethiopia: A cluster-randomized controlled trial

Attaining the recommended level of adequacy of the infants' diet remains a serious challenge in developing countries. On the other hand, the incidence of growth faltering and morbidity increases significantly at 6 months of age when complementary foods are being introduced. This trial aimed to evaluate the effect of complementary feeding behaviour change communication delivered through community-level actors on infant growth and morbidity. We conducted a cluster-randomized controlled trial in rural communities of Ethiopia. Trial participants in the intervention clusters (eight clusters) received complementary feeding behaviour change communication for 9 months, whereas those in the control clusters (eight clusters) received only the usual care. A pre-tested, structured interviewer-administered questionnaire was used for data collection. Generalized estimating equations regression analyses adjusted for baseline covariates and clustering were used to test the effects of the intervention on infant growth and morbidity. Infants in the intervention group had significantly higher weight gain (MD: 0.46 kg; 95% CI: 0.36-0.56) and length gain (MD: 0.96 cm; 95% CI: 0.56-1.36) as compared with those in the control group. The intervention also significantly reduced the rate of infant stunting by 7.5 percentage points (26.5% vs. 34%, RR = 0.68; 95% CI: 0.47-0.98) and underweight by 8.2 percentage points (17% vs. 25.2%; RR = 0.55; 95% CI: 0.35-0.87). Complementary feeding behaviour change communication delivered through community-level actors significantly improved infant weight and length gains and reduced the rate of stunting and underweight.

The Role of Milk Protein and Whey Permeate in Lipid-based Nutrient Supplements on the Growth and Development of Stunted Children in Uganda: A Randomized Trial Protocol (MAGNUS)

Stunting is associated with cognitive impairment and later chronic disease. Previous trials to prevent stunting have had little effect, and no trials seem to have provided larger amounts of energy and high-quality proteins to already stunted children. We aimed to assess the effects of milk protein (MP) and whey permeate (WP) in large-quantity lipid-based nutrient supplements (LNS-LQ), among stunted children, on linear growth and child development. This was a randomized, double-blind, 2-by-2 factorial trial. Stunted children aged 12-59 mo from eastern Uganda (n = 750) were randomly assigned to receive 100 g LNS-LQ with or without MP and WP (n = 4 × 150) or no supplement (n = 150) for 3 mo. The primary outcomes were change in knee-heel and total length. Secondary outcomes included child development, body composition, anthropometry, and hemoglobin. Micronutrient status, intestinal function, and microbiota were also assessed. Our findings will contribute to an understanding of the role of milk ingredients and LNS in linear catch-up growth. This trial was registered at www.isrctn.com as ISRCTN13093195.

Affordability of nutritious foods for complementary feeding in South Asia

The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6-23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children's diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.

Affordability of nutritious foods for complementary feeding in Eastern and Southern Africa

Low intake of diverse complementary foods causes critical nutrient gaps in the diets of young children. Inadequate nutrient intake in the first 2 years of life can lead to poor health, educational, and economic outcomes. In this study, the extent to which food affordability is a barrier to consumption of several nutrients critical for child growth and development was examined in Ethiopia, Mozambique, South Africa, Tanzania, Uganda, and Zambia. Drawing upon data from nutrient gap assessments, household surveys, and food composition tables, current consumption levels were assessed, the cost of purchasing key nutritious foods that could fill likely nutrient gaps was calculated, and these costs were compared with current household food expenditure. Vitamin A is affordable for most households (via dark leafy greens, orange-fleshed vegetables, and liver) but only a few foods (fish, legumes, dairy, dark leafy greens, liver) are affordable sources of iron, animal-source protein, or calcium, and only in some countries. Zinc is ubiquitously unaffordable. For unaffordable nutrients, approaches to reduce prices, enhance household production, or increase household resources for nutritious foods are needed.

Tubaramure, a Food-Assisted Integrated Health and Nutrition Program, Reduces Child Wasting in Burundi: A Cluster-Randomized Controlled Intervention Trial

BACKGROUND

Little is known about the impact of food-assisted maternal and child health programs (FA-MCHN) on child wasting.

OBJECTIVES

We assessed the impact of Tubaramure, a FA-MCHN program in Burundi, on child (0 to 24 months) wasting and the differential impacts by socio-economic characteristics and age. The program targeted women and their children during the first 1000 days and included 1) food rations, 2) strengthening and promotion of use of health services, and 3) behavior change communication (BCC).

METHODS

We conducted a 4-arm, cluster-randomized, controlled trial (2010-2012). Clusters were defined as "collines" (communities). Impact was estimated using repeated cross-sectional data (n = ∼2620 children in each round). Treatment arms received household and individual (mother or child in the first 1000 days) food rations (corn-soy blend and micronutrient-fortified vegetable oil) from pregnancy to 24 months (T24 arm), from pregnancy to 18 months (T18), or from birth to 24 months (TNFP). All beneficiaries received the same BCC for the first 1000 days. The control arm received no rations or BCC.

RESULTS

Wasting (weight-for-length Z-score <2 SD) increased from baseline to follow-up in the control group (from 6.5% to 8%), but Tubaramure had a significant (P < 0.05) protective effect on wasting [treatment arms combined, -3.3 percentage points (pp); T18, -4.5 pp] and on the weight-for-length z-score (treatment arms combined, +0.15; T24, +0.20; T18, +0.17). The effects were limited to children whose mother and household head had no education, and who lived in the poorest households. The largest effect was found in children 6 to 12 months of age: the group with the highest wasting prevalence.

CONCLUSIONS

FA-MCHN programs in highly food-insecure regions can protect the most disadvantaged children from wasting. These findings are particularly relevant in the context of the economic crisis due to the coronavirus disease 2019 pandemic, which is expected to dramatically increase child wasting.

The Gut Microbiota: A Promising Target in the Relation between Complementary Feeding and Child Undernutrition

Child undernutrition is a major public health challenge that is persistent and disproportionately prevalent in low- and middle-income countries. Undernourished children face adverse health, economic, and social consequences that can be intergenerational. The first 1000 days of life, from conception until the child's second birthday, constitute the period of greatest vulnerability to undernutrition. The transition process from milk-based diets to solid, semi-solid, and soft food and liquids other than milk, referred to as complementary feeding (CF), occurs between the age of 6 mo and 2 y. CF practices that do not meet the WHO's guiding principles and are lacking in both quality and quantity increase susceptibility to undernutrition, restrict growth, and jeopardize child development and survival. The gut microbiota develops toward an adult-like configuration within the first 2-3 y of life. Recent studies suggest that significant changes in the gut microbial composition and functional capacity occur during the CF period, but these studies were conducted in high-income countries. Research in low- and middle-income countries, on the other hand, has implicated a disrupted gut microbiota in child undernutrition, and animal experiments reveal the potential for a causal relation. Given the growing body of evidence for a plausible role of the gut microbiota in the link between CF and undernutrition, microbiota-targeted complementary food may be a promising treatment modality for undernutrition management. The aims of this paper are to review the evidence for the relation between CF and undernutrition and to highlight the potential of the gut microbiota to be a promising target in this relation. Our summary of the current state of the knowledge in this area provides a foundation for future research and helps inform the design of interventions targeting the gut microbiota to combat child undernutrition and promote healthy growth.

Ending malnutrition in all its forms requires scaling up proven nutrition interventions and much more: a 129-country analysis

BACKGROUND

Sustainable Development Goal (SDG) 2.2 calls for an end to all forms of malnutrition, with 2025 targets of a 40% reduction in stunting (relative to 2012), for wasting to occur in less than 5% of children, and for a 50% reduction in anaemia in women (15-49 years). We assessed the likelihood of countries reaching these targets by scaling up proven interventions and identified priority interventions, based on cost-effectiveness.

METHODS

For 129 countries, the Optima Nutrition model was used to compare 2019-2030 nutrition outcomes between a status quo (maintained intervention coverage) scenario and a scenario where outcome-specific interventions were scaled up to 95% coverage over 5 years. The average cost-effectiveness of each intervention was calculated as it was added to an expanding package of interventions.

RESULTS

Of the 129 countries modelled, 46 (36%), 66 (51%) and 0 (0%) were on track to achieve the stunting, wasting and anaemia targets respectively. Scaling up 18 nutrition interventions increased the number of countries reaching the SDG 2.2 targets to 50 (39%), 83 (64%) and 7 (5%) respectively. Intermittent preventative treatment of malaria during pregnancy (IPTp), infant and young child feeding education, vitamin A supplementation and lipid-based nutrition supplements for children produced 88% of the total impact on stunting, with average costs per case averted of US$103, US$267, US$556 and US$1795 when interventions were consecutively scaled up, respectively. Vitamin A supplementation and cash transfers produced 100% of the total global impact on prevention of wasting, with average costs per case averted of US$1989 and US$19,427, respectively. IPTp, iron and folic acid supplementation for non-pregnant women, and multiple micronutrient supplementation for pregnant women produced 85% of the total impact on anaemia prevalence, with average costs per case averted of US$9, US$35 and US$47, respectively.

CONCLUSIONS

Prioritising nutrition investment to the most cost-effective interventions within the country context can maximise the impact of funding. A greater focus on complementing nutrition-specific interventions with nutrition-sensitive ones that address the social determinants of health is critical to reach the SDG targets.

Combined infant and young child feeding with small-quantity lipid-based nutrient supplementation is associated with a reduction in anemia but no changes in anthropometric status of young children from Katanga Province of the Democratic Republic of Congo: a quasi-experimental effectiveness study

BACKGROUND

Small-quantity lipid-based nutrient supplements (SQ-LNS) are efficacious in controlled settings; data are scarce on the effectiveness utilizing health care delivery platforms.

OBJECTIVE

We evaluated the impact of an infant young child feeding (IYCF)-SQ-LNS intervention on anemia and growth in children aged 6-18 mo in the Democratic Republic of Congo following a quasi-experimental effectiveness design.

METHODS

An intervention health zone (HZ) received enhanced IYCF including improved counseling on IYCF during pregnancy until 12 mo after birth and daily use of SQ-LNS for infants 6-12 mo; the control HZ received the standard IYCF package. We analyzed data from 2995 children, collected in repeated cross-sectional surveys. We used adjusted difference-in-difference analyses to calculate changes in anemia, iron and vitamin A deficiencies, stunting, wasting, and underweight.

RESULTS

Of mothers, 70.5% received SQ-LNS at least once in the intervention HZ, with 99.6% of their children consuming SQ-LNS at least once. The mean number of batches of SQ-LNS (28 sachets per batch, 6 batches total) received was 2.3 ± 0.8 (i.e., 64.4 ± 22.4 d of SQ-LNS). The enhanced program was associated with an 11.0% point (95% CI: -18.1, -3.8; P < 0.01) adjusted relative reduction in anemia prevalence and a mean +0.26-g/dL (95% CI: 0.04, 0.48; P = 0.02) increase in hemoglobin but no effect on anthropometry or iron or vitamin A deficiencies. At endline in the intervention HZ, children aged 8-13 mo who received ≥3 monthly SQ-LNS batch distributions had higher anthropometry z scores [length-for-age z score (LAZ): +0.40, P = 0.04; weight-for-age z score (WAZ): +0.37, P = 0.04] and hemoglobin (+0.65 g/dL, P = 0.007) and a lower adjusted prevalence difference of stunting (-16.7%, P = 0.03) compared with those who received none.

CONCLUSIONS

The enhanced IYCF-SQ-LNS intervention using the existing health care delivery platform was associated with a reduction in prevalence of anemia and improvement in mean hemoglobin. At endline among the subpopulation receiving ≥3 mo of SQ-LNS, their LAZ, WAZ, and hemoglobin improved. Future research could explore contextual tools to maximize coverage and intake adherence in programs using SQ-LNS.

Stunting among Preschool Children in India: Temporal Analysis of Age-Specific Wealth Inequalities

Adequate nutritional intake for mothers during pregnancy and for children in the first two years of life is known to be crucial for a child's lifelong physical and neurodevelopment. In this regard, the global nutrition community has focused on strategies for improving nutritional intake during the first 1,000 day period. This is largely justified by the observed steep decline in children's height-for-age z scores from birth to 23 months and presumed growth faltering at later ages as a reflection of earlier deprivation that is accumulated and irreversible. Empirical evidence on the age-stratified burden of child undernutrition is needed to re-evaluate the appropriate age for nutrition interventions to target among children. Using data from two successive rounds of National Family Health Surveys conducted in 2006 and 2016, the objective of this paper was to analyze intertemporal changes in the age-stratified burden of child stunting across socioeconomic groups in India. We found that child stunting in India was significantly concentrated among children entering preschool age (24 or above months). Further, the temporal reduction in stunting was relatively higher among children aged 36-47 months compared to younger groups (below 12 and 12-23 months). Greater socioeconomic inequalities persisted in stunting among children from 24 months or above age-groups, and these inequalities have increased over time. Children of preschool age (24 or above months) from economically vulnerable households experienced larger reductions in the prevalence of stunting between 2006 and 2016, suggesting that policy research and strategies beyond the first 1000 days could be critical for accelerating the pace of improvement of child nutrition in India.

How do nutrition professionals working in low-income countries perceive and prioritize actions to prevent wasting? A mixed-methods study

Despite a shared commitment to achieving global nutrition targets, development and emergency‐humanitarian actors tend to prioritize different nutrition outcomes and actions. New approaches are needed to bridge the divide between these communities and to strengthen the overall evidence base for prevention of wasting. To better understand how these different groups perceive and prioritize actions for wasting prevention, key informant interviews (n = 21) were conducted, and an online survey was fielded among nutrition professionals working in low‐income countries (n = 107). Additionally, nutrition policy and strategy documents for select global and country institutions (n = 12) were analysed to identify interventions and approaches for addressing different forms of undernutrition. The findings of this study suggest that at both global and country levels, development actors tend to prioritize stunting prevention, and emergency‐humanitarian actors tend to prioritize treatment of acute malnutrition. It was less common for wasting prevention to be mentioned as an explicit priority. Many interventions were perceived by respondents to influence both stunting and wasting despite limited published evidence of effectiveness on wasting for water, sanitation and hygiene, growth monitoring and promotion, breastfeeding promotion and micronutrient supplementation. To help unify the nutrition community around prevention of wasting, the discourse about priority interventions should shift from ‘stunting versus wasting’ and ‘prevention versus treatment’ to a life‐course framing around child survival, growth and development. Respondents identified a need for more programme and research funding that prioritizes both wasting and stunting as outcomes. They also suggest leveraging existing national coordination bodies that bring development and emergency‐humanitarian partners together.

Protocol for the trial to establish a causal linkage between mycotoxin exposure and child stunting: a cluster randomized trial

Background

The number of stunted children has fallen globally but continues to increase in Africa. Stunting is estimated to contribute to 14–17% of child deaths under 5 years of age and is a risk factor for poor cognitive and motor development and educational outcomes. Inadequate dietary intake and disease are thought to be the immediate causes of undernutrition and stunting. However, improving infant diets through complementary feeding interventions has been shown to only modestly reduce stunting. Multiple observational studies demonstrate a dose response relationship between fetal and post-natal aflatoxin exposure and reduced linear growth.

Methods

This community-based cluster randomized trial will measure the effect of a reduced aflatoxin diet on length-for-age Z scores at 18 months in central Tanzania. All 52 health facilities in the Kongwa District of Dodoma Region were randomized into two groups. Starting at 6 months of age, participants in the intervention group receive a low-aflatoxin pre-blended porridge flour containing maize and groundnut (ratio 4:1 respectively) and low-aflatoxin groundnut flour, whereas in the control group the same porridge mix and groundnut flour are promoted through education but acquired by the household. Both groups will receive the same infant and young child feeding education and a thermos flask. A total of 3120 infants between 6 weeks and 3 months of age will be recruited into the study over 1 year. Data will be collected four times – at recruitment and when the infants are 6, 12 and 18 months of age. In a cohort of 600 infants, additional data will be collected at 9 and 15 months of age. The primary outcome is length-for-age at 18 months. Secondary outcomes include the Z scores for weight-for-age, middle upper arm circumference and head circumference, and the blood biomarker aflatoxin-albumin in the full sample, with the urine biomarker aflatoxin M1 analyzed in the cohort only.

Discussion

Better understanding the etiology of childhood stunting can lead to more appropriate interventions and policies to further reduce linear growth faltering and meet the Sustainable Development Goals.

Trial registration

NCT03940547, (April 24, 2019).

Progress in reducing child mortality and stunting in India: an application of the Lives Saved Tool

The Lives Saved Tool (LiST) has been used to estimate the impact of scaling up intervention coverage on undernutrition and mortality. Evidence for the model is largely based on efficacy trials, raising concerns of applicability to large-scale contexts. We modelled the impact of scaling up health programs in India between 2006 and 2016 and compared estimates to observed changes. Demographics, intervention coverage and nutritional status were obtained from National Family and Health Survey 2005–6 (NFHS-3) for the base year and NHFS-4 2015–16 for the endline. We used the LiST to estimate the impact of changes in coverage of interventions over this decade on child mortality and undernutrition at national and subnational levels and calculated the gap between estimated and observed changes in 2016. At the national level, the LiST estimates are close to the actual values of mortality for children <1 year and <5 years in 2016 (at 41 vs 42.6 and 50 vs 56.4, respectively, per 1000 live births). National estimates for stunting, wasting and anaemia at are also close to the actual values of NFHS-4. At the state level, actual changes were higher than the changes from the LiST projections for both mortality and stunting. The predicted changes using the LiST ranged from 33% to 92% of the actual change. The LiST provided national projections close to, albeit slightly below, actual performance over a decade. Reasons for poorer performance of state-specific projections are unknown; further refinements to the LiST for subnational use would improve the usefulness of the tool.

Impact of Water Quality, Sanitation, Handwashing, and Nutritional Interventions on Enteric Infections in Rural Zimbabwe: The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial

BACKGROUND

We assessed the impact of water, sanitation, and hygiene (WASH) and infant and young child feeding (IYCF) interventions on enteric infections in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe.

METHODS

We tested stool samples collected at 1, 3, 6, and 12 months of age and during diarrhea using quantitative molecular diagnostics for 29 pathogens. We estimated the effects of the WASH, IYCF, and combined WASH + IYCF interventions on individual enteropathogen prevalence and quantity, total numbers of pathogens detected, and incidence of pathogen-attributable diarrhea.

RESULTS

WASH interventions decreased the number of parasites detected (difference in number compared to non-WASH arms, -0.07 [95% confidence interval, -.14 to -.02]), but had no statistically significant effects on bacteria, viruses, or the prevalence and quantity of individual enteropathogens after accounting for multiple comparisons. IYCF interventions had no significant effects on individual or total enteropathogens. Neither intervention had significant effects on pathogen-attributable diarrhea.

CONCLUSIONS

The WASH interventions implemented in SHINE (improved pit latrine, hand-washing stations, liquid soap, point-of-use water chlorination, and clean play space) did not prevent enteric infections. Transformative WASH interventions are needed that are more efficacious in interrupting fecal-oral microbial transmission in children living in highly contaminated environments.

Smartphone-Based Maternal Education for the Complementary Feeding of Undernourished Children Under 3 Years of Age in Food-Secure Communities: Randomised Controlled Trial in Urmia, Iran

The mothers’ nutritional literacy is an important determinant of child malnourishment. We assessed the effect of a smartphone-based maternal nutritional education programme for the complementary feeding of undernourished children under 3 years of age in a food-secure middle-income community. The study used a randomised controlled trial design with one intervention arm and one control arm (n = 110; 1:1 ratio) and was performed at one well-child clinic in Urmia, Iran. An educational smartphone application was delivered to the intervention group for a 6-month period while the control group received treatment-as-usual (TAU) with regular check-ups of the child’s development at the well-child centre and the provision of standard nutritional information. The primary outcome measure was change in the indicator of acute undernourishment (i.e., wasting) which is the weight-for-height z-score (WHZ). Children in the smartphone group showed greater wasting status improvement (WHZ +0.65 (95% Confidence Interval (CI) ± 0.16)) than children in the TAU group (WHZ +0.31 (95% CI ± 0.21); p = 0.011) and greater reduction (89.6% vs. 51.5%; p = 0.016) of wasting caseness (i.e., WHZ < −2; yes/no). We conclude that smartphone-based maternal nutritional education in complementary feeding is more effective than TAU for reducing undernourishment among children under 3 years of age in food-secure communities.

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.

Factors that May Influence the Effectiveness of 4 Specialized Nutritious Foods in the Prevention of Stunting and Wasting in Children Aged 6-23 Months in Burkina Faso

BACKGROUND

A trial in Burkina Faso compared the cost-effectiveness of 4 specialized nutritious foods (SNFs) used to prevent stunting and wasting in children aged 6-23 mo.

OBJECTIVES

This article explores differences in SNF use that may have influenced effectiveness, specifically in relation to consumption by the recipient child and by any other person (i.e., sharing), other diversion from the recipient child, preparation, storage, and hygiene.

METHODS

Subsamples from a geographically clustered, longitudinal trial with random assignment to Corn Soy Blend Plus with oil (CSB+ w/oil), Corn Soy Whey Blend with oil (CSWB w/oil), Super Cereal Plus (SC+), or ready-to-use supplementary food (RUSF) were selected for in-depth interviews, in-home observations, and focus group discussions.

RESULTS

Sharing was common in all arms, with the highest reported in SC+ (73%) and highest observed in CSWB w/oil (36%). Some reported giving the ration away (highest in SC+ at 17%) or using it for other purposes (highest in CSWB w/oil at 17%). The recipient child was observed consuming the ration in 49% of households on average (38-60% by arm in CSB+ w/oil and RUSF, respectively). Qualitative reports of bitterness and spoilage emerged in the CSWB w/oil arm. Most observed households (excluding RUSF) did not prepare porridge daily as instructed (35-46% by arm). Household water samples showed either high-risk or unsafe contamination with Escherichia coli (72-78% by arm). Low percentages were observed handwashing (both child and server) before consuming the porridge.

CONCLUSIONS

The SNFs were not prepared or served as intended and diversion from the recipient was common. Storage conditions may have resulted in spoilage of the ration containing whey before reaching recipients. This article provides context about factors that may have influenced the effectiveness of these SNFs. Programming and household use of SNFs are as important as their nutrient composition. This trial was registered at clinicaltrials.gov as NCT02071563.

Exploring the Nutritional Ecology of Stunting: New Approaches to an Old Problem

Despite a declining prevalence, stunting remains an elusive target for the global health community. The perception is that stunting represents chronic undernutrition (i.e., due to inadequate nutrient intake associated with food insecurity, low-quality diet, and suboptimal infant feeding practices in the first two years of life). However, other causes include maternal–fetal interactions leading to intrauterine growth retardation, poor maternal nutrition during pregnancy and lactation, and maternal and pediatric infections. Moreover, physical, economic, demographic, and social environments are major contributors to both food insecurity and conditions that limit linear growth. Overall, factors representing both the internal and external “nutritional ecologies” need to be considered in efforts to reduce stunting rates. Nutritional assessment requires better understanding of the mechanism and role of nutrition in growth, clear expectations about the sensitivity and specificity of the tools used, and inclusion of bio-indicators reflecting the extent and nature of the functional effect of poor nutrition and environmental factors contributing to human physical growth. We provide a perspective on current knowledge about: (i) the biology and contribution of nutrition to stunting/poor growth; (ii) our current nutritional assessment toolkit; (iii) the implications of current assessment approaches for clinical care and public interventions; and (iv) future directions for addressing these challenges in a changing global health environment.

The Impact of an mHealth Voice Message Service (mMitra) on Infant Care Knowledge, and Practices Among Low-Income Women in India: Findings from a Pseudo-Randomized Controlled Trial

Objectives mHealth interventions for MNCH have been shown to improve uptake of antenatal and neonatal services in low- and middle-income countries (LMICs). However, little systematic analysis is available about their impact on infant health outcomes, such as reducing low birth weight or malnutrition among children under the age of five. The objective of this study is to determine if an age- and stage-based mobile phone voice messaging initiative for women, during pregnancy and up to 1 year after delivery, can reduce low birth weight and child malnutrition and improve women's infant care knowledge and practices. Methods We conducted a pseudo-randomized controlled trial among pregnant women from urban slums and low-income areas in Mumbai, India. Pregnant women, 18 years and older, speaking Hindi or Marathi were enrolled and assigned to receive mMitra messages (intervention group N = 1516) or not (Control group N = 500). Women in the intervention group received mMitra voice messages two times per week throughout their pregnancy and until their infant turned 1 year of age. Infant's birth weight, anthropometric data at 1 year of age, and status of immunization were obtained from Maternal Child Health (MCH) cards to assess impact on primary infant health outcomes. Women's infant health care practices and knowledge were assessed through interviews administered immediately after women enrolled in the study (Time 1), after they delivered their babies (Time 2), and after their babies turned 1 year old (Time 3). 15 infant care practices self-reported by women (Time 3) and knowledge on ten infant care topics (Time 2) were also compared between intervention and control arms. Results We observed a trend for increased odds of a baby being born at or above the ideal birth weight of 2.5 kg in the intervention group compared to controls (odds ratio (OR) 1.334, 95% confidence interval (CI) 0.983-1.839, p = 0.064). The intervention group performed significantly better on two infant care practice indicators: giving the infant supplementary feeding at 6 months of age (OR 1.4, 95% CI 1.08-1.82, p = 0.009) and fully immunizing the infant as prescribed under the Government of India's child immunization program (OR 1.531, 95% CI 1.141-2.055, p = 0.005). Women in the intervention group had increased odds of knowing that the baby should be given solid food by 6 months (OR 1.89, 95% CI 1.371-2.605, p < 0.01), that the baby needs to be given vaccines (OR 1.567, 95% CI 1.047-2.345, p = 0.028), and that the ideal birth weight is > 2.5 kg (OR 2.279, 95% CI 1.617-3.213, p < 0.01). Conclusions for Practice This study provides robust evidence that tailored mobile voice messages can significantly improve infant care practices and maternal knowledge that can positively impact infant child health. Furthermore, this is the first prospective study of a voice-based mHealth intervention to demonstrate a positive impact on infant birth weight, a health outcome of public health importance in many LMICs.