The effect of adding ready-to-use supplementary food to a general food distribution on child nutritional status and morbidity: a cluster-randomized controlled trial

Effectiveness of locally produced ready-to-use supplementary foods on the prevention of stunting in children aged 6-23 months: a community-based trial from Pakistan

Undernutrition is a major public health problem in developing countries. Around 40·2 % of children are stunted in Pakistan. This longitudinal study aimed to assess the effectiveness of locally produced ready-to-use supplementary foods in the prevention of stunting by detecting change in of children in intervention v. control arm against the 2006 WHO growth reference. A community-based non-randomised cluster-controlled trial was conducted from January 2018 to December 2020 in the district of Kurram, Khyber Pakhtunkhwa, Pakistan. A total of 80 clusters (each cluster comprising ≈ 250-300 households) were defined in the catchment population of twelve health facilities. Children aged 6-18 months were recruited n 1680. The intervention included a daily ration of 50 g - locally produced ready-to-use-supplementary food (Wawa-Mum). The main outcome of this study was a change in length for age z-score (LAZ) v. WHO growth standards. Comparison between the interventions was by t test and ANOVA. Cox proportional hazard models were used to assess the association between stunting occurrence and the utilisation of locally produced supplement. Out of the total 1680, fifty-one out of the total 1680, 51·1 out of the total 1680 and 51·1 % (n 859) were male. Mean age 13·9 months (sd + 859) were male. Mean age 13·9 months (sd + -4·4). At baseline, 36·9 % (n 618) were stunted. In the intervention group, mean LAZ score significantly increased from -1·13(2·2 sd) at baseline to -0·93(1·8 sd) at 6-month follow-up (P value 0·01) compared with the control group. The incidence rate of stunting in the intervention arm was 1·3 v. 3·4 per person year in the control arm. The control group had a significantly increased likelihood of stunting (Hazard Ratio (HR) 1·7, 95 % CI 1·46, 2·05, P value < 0·001) v. the intervention group. Locally produced ready-to-use supplementary food is an effective intervention for reducing stunting in children below 2 years of age. This can be provided as part of a malnutrition prevention package to overcome the alarming rates of stunting in Pakistan.

Current evidence on the effectiveness of Ready-to-Use Supplementary Foods in children with moderate acute malnutrition: a systematic review and meta-analysis

Moderate acute malnutrition (MAM) is defined by a weight-for-height Z-score (WHZ) between -3 and -2 of the WHO reference or by a mid-upper arm circumference (MUAC) of ≥11⋅5 and <12⋅5 cm. This study aimed to synthesise the evidence for the effectiveness of Ready-to-Use Supplementary Food (RUSF) compared to other dietary interventions or no intervention on functioning at different levels of the International Classification of Functioning, Disability, and Health (ICF) among children with MAM between 2 and12 years old. Three databases (PubMed, Scopus, and Web of Science) were systematically searched (last update: 20 November 2022). Pooled estimates of effect were calculated using random-effects meta-analyses. The level of evidence was estimated with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method. Seven studies were included. RUSF had a significant small-sized better effect (pooled mean: 0⋅38; 95 % CI = [0⋅10, 0⋅67], P = 0⋅01, I² = 97 %) on different anthropometric measurements compared to other dietary interventions among MAM children (n 6476). Comparing RUSF with corn-soy blend Plus Plus (CSB++) showed that RUSF had a small-sized but significantly better effect on the children's anthropometric measures compared to children who received CSB++ (pooled mean: 0⋅16; 95 % CI = [0⋅05, 0⋅27], P = 0⋅01; I2 = 35 %). MAM children treated with RUSF had a better recovery rate compared to those treated with CSB++ (pooled risk difference: 0⋅11; 95 % CI = [0⋅06, 0⋅11], P < 0⋅001; I2 = 0 %). The RUSF intervention seems promising in improving MAM children's nutritional outcomes and recovery rate compared to other dietary interventions.

Lipid-based nutrient supplements for prevention of child undernutrition: when less may be more

BACKGROUND

Both small-quantity and medium-quantity lipid-based nutrient supplements (LNS) have been used for the prevention of child undernutrition. A meta-analysis of 14 trials of small-quantity lipid-based nutrient supplements (SQ-LNS) - no LNS showed effects on length-for-age z-score {LAZ, +0.14 [95% confidence interval (CI): 0.11, 0.16]} and weight-for-length z-score [WLZ, +0.08 (0.06, 0.10)] z-scores, as well as prevalence ratios (95% CI) for stunting [LAZ < -2, 0.88 (0.85, 0.91)] and wasting [WLZ < -2, 0.86 (0.80, 0.93)]. However, little is known about the effects of medium-quantity lipid-based nutrient supplements (MQ-LNS) on growth.

OBJECTIVES

We aimed to examine the effects of preventive MQ-LNS (∼250-499 kcal/d) provided at ∼6-23 mo of age on growth outcomes - no LNS or provision of SQ-LNS.

METHODS

We conducted a systematic review of studies of MQ-LNS for prevention, and categorized them as providing <6 mo - ≥6 mo of supplementation; for the latter category, we conducted a meta-analysis, with the main outcomes being change in WLZ and LAZ, and prevalence of wasting and stunting.

RESULTS

Three studies provided MQ-LNS for 3-5 mo (seasonal) for children 6-36 mo of age, and did not show consistent effects on growth outcomes. Eight studies provided MQ-LNS for 6-18 mo, generally starting at 6 mo of age; in the meta-analysis (max total n = 13,954), MQ-LNS increased WLZ [+0.09 (95% CI: 0.05, 0.13)] and reduced wasting [0.89 (0.81, 0.97)], but had no effect on LAZ [+0.04 (-0.02, 0.11)] or stunting [0.97 (0.92, 1.02)] - no LNS. Two studies directly compared SQ-LNS and MQ-LNS and showed no significant differences in growth outcomes.

CONCLUSIONS

The current evidence suggests that MQ-LNS offer no added benefits over SQ-LNS, although further studies directly comparing MQ-LNS with SQ-LNS would be useful. One possible explanation is incomplete consumption of the MQ-LNS ration and thus lower than desirable intake of certain nutrients.

TRIAL REGISTRATION NUMBER

Registry and registry number for systematic reviews or meta-analyses: Registered with PROSPERO as CRD42022382448 on December 18, 2022: =https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022382448.

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

Background

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

Methodology

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

Results

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

Conclusion

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

Effects of Oral Lipid-Based nutritional supplements on appetite, energy intake, and lipid profile of moderately underweight children

Oral lipid-based nutritional supplements (LNS) are designed to ensure dietary adequacy and to improve malnourishment in children. Therefore, this study investigated the effects of 4 weeks of LNS on appetite, energy intake, and lipid profile of moderately underweight children (5-10 years old) with BMI-Z score between -2 and - 3 SDS, recruited in a single-blind randomized control trial. In addition to the regular dietary intake, fasting blood samples, anthropometric measurements, energy intake, and appetite responses were obtained before and after 4 weeks of LNS (535 kcal) or PLACEBO (92 kcal). After 4 weeks of supplementation mean energy intake (kcal) (p < .001), body weight (kg) (p < .001), BMI (kg/m2) (p < .01), mid-upper arm circumference (cm) (p < .01), total cholesterol (mg/dl) (p < .01) and fasting glucose (mg/dl) (p < .01) were raised significantly in the LNS group as compared to the PLACEBO group. No significant changes were detected in appetite responses (p > 0.05). In conclusion, LNS increases the overall energy intake, but does not affect the appetite but may induce hyperglycemia and hyperlipidemia.

Fortified balanced energy-protein supplementation during pregnancy and lactation and infant growth in rural Burkina Faso: A 2 × 2 factorial individually randomized controlled trial

BACKGROUND

Optimal nutrition is crucial during the critical period of the first 1,000 days from conception to 2 years after birth. Prenatal and postnatal supplementation of mothers with multimicronutrient-fortified balanced energy-protein (BEP) supplements is a potential nutritional intervention. However, evidence on the long-term effects of BEP supplementation on child growth is inconsistent. We evaluated the efficacy of daily fortified BEP supplementation during pregnancy and lactation on infant growth in rural Burkina Faso.

METHODS AND FINDINGS

A 2 × 2 factorial individually randomized controlled trial (MISAME-III) was implemented in 6 health center catchment areas in Houndé district under the Hauts-Bassins region. From October 2019 to December 2020, 1,897 pregnant women aged 15 to 40 years with gestational age <21 completed weeks were enrolled. Women were randomly assigned to the prenatal intervention arms receiving either fortified BEP supplements and iron-folic acid (IFA) tablets (i.e., intervention) or IFA alone (i.e., control), which is the standard of care during pregnancy. The same women were concurrently randomized to receive either of the postnatal intervention, which comprised fortified BEP supplementation during the first 6 months postpartum in combination with IFA for the first 6 weeks (i.e., intervention), or the postnatal control, which comprised IFA alone for 6 weeks postpartum (i.e., control). Supplements were provided by trained village-based project workers under direct observation during daily home visits. We previously reported the effect of prenatal BEP supplementation on birth outcomes. The primary postnatal study outcome was length-for-age z-score (LAZ) at 6 months of age. Secondary outcomes were anthropometric indices of growth (weight-for length and weight-for-age z-scores, and arm and head circumferences) and nutritional status (prevalence rates of stunting, wasting, underweight, anemia, and hemoglobin concentration) at 6 months. Additionally, the longitudinal prevalence of common childhood morbidities, incidence of wasting, number of months of exclusive breastfeeding, and trajectories of anthropometric indices from birth to 12 months were evaluated. Prenatal BEP supplementation resulted in a significantly higher LAZ (0.11 standard deviation (SD), 95% confidence interval (CI) [0.01 to 0.21], p = 0.032) and lower stunting prevalence (-3.18 percentage points (pp), 95% CI [-5.86 to -0.51], p = 0.020) at 6 months of age, whereas the postnatal BEP supplementation did not have statistically significant effects on LAZ or stunting at 6 months. On the other hand, postnatal BEP supplementation did modestly improve the rate of monthly LAZ increment during the first 12 months postpartum (0.01 z-score/month, 95% CI [0.00 to 0.02], p = 0.030), whereas no differences in growth trajectories were detected between the prenatal study arms. Furthermore, except for the trend towards a lower prevalence of underweight found for the prenatal BEP intervention at 6 months (-2.74 pp, 95% CI [-5.65 to 1.17], p = 0.065), no other secondary outcome was significantly affected by the pre- or postnatal BEP supplementation.

CONCLUSIONS

This study provides evidence that the benefits obtained from prenatal BEP supplementation on size at birth are sustained during infancy in terms of linear growth. Maternal BEP supplementation during lactation may lead to a slightly better linear growth towards the second half of infancy. These findings suggest that BEP supplementation during pregnancy can contribute to the efforts to reduce the high burden of child growth faltering in low- and middle-income countries.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03533712.

A nutrition programme using positive deviance approach to reduce undernutrition among urban poor children under-five in Malaysia: A cluster randomised controlled trial protocol

BACKGROUND

Childhood undernutrition remains a public health issue that can lead to unfavourable effects in later life. These effects tend to be more devastating among urban poor young children, especially in light of the recent COVID-19 pandemic. There is an immediate need to introduce interventions to reduce childhood undernutrition. This paper described the study protocol of a nutrition programme that was developed based on the positive deviance approach and the evaluation of the effectiveness of the programme among urban poor children aged 3 to 5 years old.

METHODS

This mixed-method study will be conducted in two phases at low-cost flats in Kuala Lumpur. Phase one will involve a focus group discussion with semi-structured interviews to explore maternal feeding practices and the types of food fed to the children. Phase two will involve a two-armed cluster randomised controlled trial to evaluate the effectiveness of a programme developed based on the positive deviance approach. The programme will consist of educational lessons with peer-led cooking demonstrations, rehabilitation, and growth monitoring sessions. Intervention group will participate in the programme conducted by the researcher for three months whereas the comparison group will only receive all the education materials and menus used in the programme after data collection has been completed. For both groups, data including height, weight, and dietary intake of children as well as the nutritional knowledge and food security status of mothers will be collected at baseline, immediate post-intervention, and 3-month post-intervention.

EXPECTED RESULTS

The positive deviance approach helps to recognise the common feeding practices and the local wisdom unique to the urban poor population. Through this programme, mothers may learn from and be empowered by their peers to adopt new feeding behaviours so that their children can achieve healthy weight gain.

TRIAL REGISTRATION

This study was registered with clinicaltrials.gov: NCT04688515 on 29 December 2020, https://www.clinicaltrials.gov/ct2/show/NCT04688515.

The Impact of Nutrition-Based Interventions on Nutritional Status and Metabolic Health in Small Island Developing States: A Systematic Review and Narrative Synthesis

Small island developing states (SIDS) have a high burden of nutrition-related disease associated with nutrient-poor, energy-dense diets. In response to these issues, we assessed the effectiveness of nutrition-based interventions on nutritional status (under-nutrition) and metabolic health (over-nutrition) among persons in SIDS. We included SIDS-based nutrition studies with change in nutrition status (e.g., markers of anaemia) or metabolic status (e.g., markers of glycaemia) as outcomes. The PRISMA framework was applied and MEDLINE, Embase, CINAHL, OARE library, Web of Science, Scopus, ASSIA, EconLit, AGORA, AGRICOLA, AGRIS, WHO-EMRO, and LILACS were searched (2000−2020). Cochrane risk of bias (ROB) and Cochrane ROBINS-I tools assessed ROB for randomised and non-randomised studies, respectively. PROSPERO registration (CRD42021236396) was undertaken. We included 50 eligible interventions, involving 37,591 participants: 14 trials reported on nutritional status, 36 on metabolic health. Effective interventions, evaluated at the individual level, took a multifaceted approach for metabolic outcomes; while nutrition outcomes utilised supplements. Most intervention types were suitable for issues related to ‘over’ nutrition versus ‘under’ nutrition. Twenty-six studies (nutrition status (six); metabolic health (twenty)) were effective (p < 0.05). With the current rise of nutrition-related public health challenges, there is a need for further development and evaluation of these and related interventions at the population level.

Design Factors for Food Supplementation and Nutrition Education Interventions That Limit Conclusions about Effectiveness for Wasting Prevention: A Scoping Review of Peer-Reviewed Literature

We conducted a scoping review to characterize the evidence base for the effectiveness of food supplementation (FS), nutrition education (NE), or FS/NE interventions to prevent wasting among children aged 6 to 59 mo. We aimed to identify gaps in peer-reviewed literature and to develop recommendations for strengthening study designs. We identified 56 unique studies (FS = 21, NE = 19, FS/NE = 16) for which we assessed intervention design factors, implementation context, evaluation methods, and wasting impact. Compared with studies focused on stunting, fewer wasting-focused studies reported weight-for-height z score (WHZ). Midupper arm circumference (MUAC) was more commonly reported in wasting-focused studies (71.4%) than those focused on stunting (36.8%) or wasting and stunting (30.4%). FS studies measured anthropometry (mean, 95% CI) more frequently at every 11.3 (7.8, 14.8) wk than NE interventions at 36.3 (8.8, 62.1) wk (P = 0.036), but not FS/NE interventions at 25.8 (5.6, 49.1) wk (P = 0.138). NE interventions tended to be of longer duration than FS or FS/NE interventions. Only 6 studies followed and measured children after the intervention period ended. Across all studies, 45% reported a significant effect on wasting; these included FS, NE, and FS/NE interventions. The lack of comparability across studies limits conclusions about the effectiveness of specific types of interventions. To build a more unified evidence base for wasting prevention we recommend that future studies 1) report on a consistent set of metrics, including MUAC; 2) attempt to measure change in wasting incidence using more frequent measures; 3) measure wasting prevalence among the general population; 4) follow children postintervention to assess relapse; 5) measure food insecurity and diet quality; and 6) use harmonized protocols across multiple settings. Such efforts to improve study comparability will strengthen the evidence base, may help unite divergent professional communities, and ultimately accelerate progress toward eliminating child undernutrition.

Effectiveness of unconditional cash transfers combined with lipid-based nutrient supplement and/or behavior change communication to prevent stunting among children in Pakistan: a cluster randomized controlled trial

BACKGROUND

In Pakistan, the prevalence of stunting among children younger than 5 y has remained above WHO critical thresholds (≥30%) over the past 2 decades.

OBJECTIVES

We hypothesized that an unconditional cash transfer (UCT) combined with lipid-based nutrient supplement (LNS) and/or social and behavior change communication (SBCC) will prevent stunting among children 6-23 mo of age.

METHODS

This was a 4-arm, community-based cluster randomized controlled trial conducted in the district of Rahim Yar Khan, Pakistan. A total of 1729 children (UCT, n = 434; UCT + SBCC, n = 433; UCT + LNS, n = 430; and UCT + LNS + SBCC, n = 432) were enrolled at 6 mo of age and measured monthly for 18 mo until the age of 24 mo.

RESULTS

At 24 mo of age, children who received UCT + LNS [rate ratio (RR): 0.85; 95% CI: 0.74, 0.97; P = 0.015) and UCT + LNS + SBCC (RR: 0.86; 95% CI: 0.77, 0.96; P = 0.007) had a significantly lower risk of being stunted compared with the UCT arm. No significant difference was noted among children who received UCT + SBCC (RR: 1.03; 95% CI: 0.91, 1.16; P = 0.675) in the risk of being stunted compared with the UCT arm. The pooled prevalence of stunting among children aged 6-23 mo was 41.7%, 44.8%, 38.5%, and 39.3% in UCT, UCT + SBCC, UCT + LNS, and UCT + LNS + SBCC, respectively. In pairwise comparisons, a significant impact on stunting among children in UCT + LNS (P = 0.029) and UCT + LNS + SBCC (P = <0.001) was noted compared with the UCT arm.

CONCLUSIONS

UCT combined with LNS and UCT + LNS + SBCC were effective in reducing the prevalence of stunting among children aged 6-23 mo in marginalized populations. UCT + SBCC was not effective in reducing the child stunting prevalence. This trial was registered at clinicaltrials.gov as NCT03299218.

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.

Trial Registration: Clinicaltrials.gov NCT04581993 [Registered: 8 October 2020].

Effectiveness of various methods of home fortification in under-5 children: where they work, where they do not. A systematic review and meta-analysis

CONTEXT

The common approaches of home fortification (HF) for prevention and/or treatment of micronutrient deficiencies are micronutrient powders (MNPs), foodlets, and lipid-based nutrient supplements (LNSs). There are mixed results for the impact of HF on growth and nutritional status of young children.

OBJECTIVE

This systematic review was prepared in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate current evidence from randomized controlled trials including children younger than 5 years to assess the effect of strategies of HF on growth and micronutrient status.

METHODS

The MEDLINE, PubMed, Embase, Cochrane Library, and Google Scholar databases were searched to July 2018. A total of 1301 studies were found in a preliminary search. After screening of titles and abstracts, 30 studies were selected.

RESULTS

Treatment with MNPs, foodlets, and LNSs effectively increased hemoglobin concentrations by at least 2.52 g/L, 4.59 g/L, and 4.4 g/dL, respectively, as compared with a control. There was a significant decrease in risk of anemia development after foodlet intervention compared with a control or iron drops (odds ratio, 0.27; 95%CI, 0.10-0.74; P = 0.01). However, these interventions did not result in any significant improvement in z-scores for changes of height for age, weight for age, and weight for height. The results indicated that MNP (7.16; 95%CI, 0.31-14.01; P = 0.04) and foodlet treatment (4.92; 95%CI, 0.28-9.57; P = 0.04) could increase serum zinc levels. However, none of the home fortification methods improved vitamin A status in the target group.

CONCLUSION

Home fortification can be used as an effective method to improve hemoglobin, iron, and zinc status, although in this study it had no effect on vitamin A or anthropometric indicators of the target population. More investigations are warranted for newer approaches of HF to improve a broader range of micronutrients as well as child growth indices and for evaluation of the coverage, compliance, and consistency of such interventions at the population level.

PROSPERO REGISTRATION NO

CRD42018109279.

Fortified blended flour supplements displace plain cereals in feeding of young children

Lipid-based nutritional supplements (LNS) and fortified blended flours (FBF) are widely used to increase the nutrient density of children's diets and improve their health, but their effectiveness could be modified by displacement of other foods. We reanalysed data from a cost-effectiveness trial comparing impacts on anthropometry of three FBFs (Corn Soy Blend Plus [CSB+], Corn Soy Whey Blend [CSWB], SuperCereal Plus [SC+]) and one LNS (Ready-to-use Supplementary Food [RUSF]) among infants aged 7-23 months in Burkina Faso. Using dietary diversity data from a single 24-h recall period (n = 1,591 children, observed once over 18-month study period), we fit logistic regression models to estimate differences in intake of each food group making up the infant and young child minimum dietary diversity score and linear models to test for differences in dietary diversity score among children in each supplement arm. We tested for differences in breastfeeding time using the subsample for which breastfeeding was observed (n = 176). Children who consumed one of the three FBFs had lower odds of consuming household grains, roots and tubers compared with the LNS consumers (odds ratios [ORs] = 0.35-0.47; 95% confidence intervals [CIs]: 0.20-1.05). Consumption of other foods, dietary diversity and breastfeeding did not differ significantly at the 5% significance level. FBFs displaced the household's own cereals more than LNS, with no difference in the child's consumption of other more nutrient-rich family foods. Given limited stomach capacity and feeding time, providing fortified cereals may help improve children's overall diet quality in settings where children would otherwise be fed nutrient-poor root crops or cereal grains.

Specialized Nutritious Food Combined With Cash Transfers and Social and Behavior Change Communication to Prevent Stunting Among Children Aged 6 to 23 Months in Pakistan: Protocol for a Cluster Randomized Controlled Trial

Background

In Pakistan, the prevalence of stunting in children younger than 5 years has remained above global critical levels over the past two decades, with the stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country—43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households.

Objective

The primary objective of this study is to determine the effect of a medium quantity of a lipid-based nutrient supplement (LNS) combined with unconditional cash transfers and social and behavior change communication (SBCC) on reduction of stunting in children aged 6 to 23 months.

Methods

A 5-arm cluster randomized controlled trial will be conducted in the district of Rahim Yar Khan in Punjab, Pakistan. The intervention packages will be (1) cash only, (2) cash with LNS, (3) cash with SBCC, and (4) cash with SBCC and LNS. The control arm will receive routine standard of care. We will enroll children at 6 months of age and follow up on a monthly basis up to 24 months of age. A total of 2000 children, 400 in each arm, will be enrolled to detect a 20% reduction in the prevalence of stunting among children aged 24 months. Length, weight, food intake, compliance to interventions, morbidities, and other relevant data will be collected at enrollment and on a monthly basis over the period of 18 months. The process evaluation will assess acceptability of the interventions and potential barriers to implementation through focus group discussions and in-depth interviews with the target population and relevant stakeholders. Furthermore, a cost analysis will be conducted to assess the cost-effectiveness of each intervention package.

Results

The study protocol was approved by the Ethics Review Committee of Aga Khan University in Pakistan on January 4, 2017. Data collection began in May 2017 and was completed in July 2019. Data analyses are yet to be completed. This study will explore the effectiveness of intervention packages comprised of cash transfers from Benazir Income Support Programme with or without additional LNS and SBCC in preventing childhood stunting. We expect the results to be published in peer-reviewed journals by autumn of 2020.

Conclusions

The findings of this trial will provide robust evidence as to which intervention packages can have significant effects on linear growth of children and design effective intervention packages to prevent stunting in children aged 6 to 23 months.

Trial Registration

ClinicalTrials.gov NCT03299218; https://clinicaltrials.gov/ct2/show/NCT03299218

International Registered Report Identifier (IRRID)

DERR1-10.2196/19001

Food supplements to reduce stunting in Pakistan: a process evaluation of community dynamics shaping uptake

Background

There is an increasing interest in use of food supplements to prevent childhood stunting, however the evidence on the process indicators is scarce. We in this study explore the barriers to the effective implementation of food supplementation programs and the possible mitigation strategies which can guide the design of future programs.

Methods

We undertook a process evaluation of a stunting prevention food supplementation pilot program in rural Pakistan that distributed Wheat Soy Blend (WSB) to pregnant & lactating women, and Lipid-based Nutrient Supplement (LNS) and micronutrient powder (MNP) to < 5 years children. We used a mixed methods approach through a quantitative survey of 800 households and conducted 18 focused group discussion (FGDs) (with male and female caregivers), 4 FGDs (with Community Health Workers (CHWs)) and 22 key informant interviews (with district stakeholders) to evaluate the community side factors affecting uptake through five parameters: value, acceptability, receipt of supplement, usage and correct dosage.

Results

The findings show that proportionately few beneficiaries consumed the full dose of supplements, despite reasonable knowledge amongst caregivers. Sharing of supplements with other household member was common, and the full monthly stock was usually not received. Qualitative findings suggest that caregivers did not associate food supplements with stunting prevention. WSB was well accepted as an extra ration, LNS was popular due its chocolaty taste and texture, whereas MNP sprinkles were perceived to be of little value. The cultural food practices led to common sharing, whereas interaction with CHWs was minimal for nutrition counselling. Qualitative findings also indicate CHWs related programmatic constraints of low motivation, multi-tasking, inadequate counselling skills and weak supervision.

Conclusion

We conclude that the community acceptability of food supplements does not translate into optimal consumption. Hence a greater emphasis is needed on context specific demand creation and focusing on the supply side constraints with improved logistical planning, enhanced motivation and supervision of community workers with involvement of multiple stakeholders. While, similar studies are needed in varying contexts to help frame universal guidelines.

Trial registration

ClinicalTrials.gov Identifier: NCT02422953. Registered on April 22, 2015.

Micronutrient and Inflammation Status Following One Year of Complementary Food Supplementation in 18-Month-Old Rural Bangladeshi Children: A Randomized Controlled Trial

Background: Four fortified complementary food supplements (CFSs) in a randomized controlled trial (RCT) were found to improve childhood linear growth in rural Bangladesh. We hypothesized children receiving these supplements would have improved micronutrient status. Methods: In the RCT, we assessed hemoglobin and serum ferritin, retinol, zinc, C-reactive protein (CRP), and α-1-acid glycoprotein (AGP) at endline (18 mo) in a subsample of children (n = 752). The impact of supplementation on mean concentrations and the prevalence of nutrient deficiency and inflammation were evaluated using adjusted generalized estimating equation (GEE) linear and log-binomial regression models. Results: In the control arm at age 18 months, 13% of children were anemic (hemoglobin < 110 g/L), and 6% were iron (inflammation-adjusted ferritin < 12 μg/L), 8% vitamin A (inflammation-adjusted retinol < 0.70 μmol/L), and 5% zinc (zinc < 9.9 μmol/L) deficient. The prevalence of inflammation by CRP (>5 mg/L) and AGP (>1 g/L) was 23% and 66%, respectively, in the control group. AGP trended lower in CFS groups (p = 0.04), while CRP did not. Mean ferritin (p < 0.001) and retinol (p = 0.007) were higher in all supplemented groups relative to control, whereas hemoglobin improved with two of the four CFSs (p = 0.001), and zinc was equal or lower in supplemented groups relative to control (p = 0.017). Conclusions: CFSs improved iron status and vitamin A concentrations and lowered inflammation in a context of low underlying nutrient deficiency but high inflammation.

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).

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.

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

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

Nutritional service needs of pregnant and lactating adolescent girls in Trans-Mara East Sub-County, Narok County: focus on access and utilization of nutritional advice and services

Background

An understanding of the association between adolescent nutrition, adolescent pregnancy and their quest for healthcare services may elucidate a basis for intervention and formulation of programs that enhance post-partum and increase the lifespan of the newborn, improve the quality of life and bridge morbidity, mortality and healthcare-associated cost. However, the nutritional needs of pregnant and lactating adolescent girls aged below 10 years resident in Trans Mara East Sub-County, Kenya remained unestablished. The objective of this study was to assess the nutritional needs of pregnant and lactating adolescent girls (under 19) when accessing and utilizing nutritional advice and services in Trans-Mara East Sub-County, Narok County.

Methods

The study adopted a cross-sectional approach that employed mixed methods with both quantitative and qualitative research approaches. Cochran formula was applied to arrive at a minimum of 291 households. Probability proportionate to size sampling techniques using cluster and simple random methods were used to practically access adolescents who are pregnant or lactating. Data was collected using questionnaires, in-depth interview and Focus Group Discussion. Quantitative data was analyzed descriptively using frequencies and inferentially using odds ratio and z-test. Framework analysis was employed to analyze qualitative data. p ≤ 0.05 was considered statistically significant.

Results

The study revealed that access of pieces of nutritional-related advice represented by 67.8% was significantly higher than expected frequency of 50%. Nutrition supplementation, food fortification or blending and complementary feeding were significantly below the expectant frequency (p < 0.01) of 50%. Nutrition service areas such as provision and collection of vitamin A and IFAS were significantly lower than expected frequency (p < 0.01).

Conclusions

The most widely utilized were nutrition services that falls within the preventive-focused services followed by curative-focused services. Nutritionist and nurse more likely to increase overall utilization of nutrition services.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2391-7) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Linear growth faltering and the role of weight attainment: Prospective analysis of young children recovering from severe wasting in Niger

Efforts to reduce the impact of stunting have been largely independent of interventions to reduce the impact of wasting, despite the observation that the conditions can coexist in the same child and increase risk of death. To optimize the management of malnourished children—who can be wasted, stunted, or both—the relationship between stunting and wasting should be elaborated. We aimed to describe the relationship between concurrent weight and height gain during and after rehabilitation from severe wasting. We conducted a secondary analysis of a randomized trial for the outpatient treatment of severe wasting, including 1,542 children who recovered and were followed for 12 weeks. We described the overlap of stunting and severe wasting and the change in stunting over time. We showed the relationship between concurrent weight and height gain using adjusted generalized estimating equations and calculated the mean rate of change in weight‐for‐height z score (WHZ) and height‐for‐age z score (HAZ) during and after rehabilitation. At baseline, 79% (n = 1,223/1,542) and 49% (n = 757/1,542) of children were stunted and severely stunted, respectively. Prevalence increased over time among children <24 months. During rehabilitation when weight was not yet fully recovered, we found rapid WHZ gain but limited HAZ gain. Following successful rehabilitation, WHZ gain slowed. The rate of HAZ gain was negative after rehabilitation but increased relative to the period during treatment. The potential relationship between weight and height gain calls for increased coverage of wasting treatment to not only prevent child mortality but also reduce linear growth faltering.

Seasonal malaria chemoprevention packaged with malnutrition prevention in northern Nigeria: A pragmatic trial (SMAMP study) with nested case-control

Integrating seasonal malaria chemoprevention (SMC), recommended by the WHO since 2012 to prevent malaria infection, with nutrition interventions may improve health outcomes and operational efficiencies. This study assessed the effects of co-packaging interventions on distribution coverage, nutrition, and clinical malaria outcomes in northern Nigeria. From August to November 2014, community volunteers delivered sulfadoxine-pyrimethamine and amodiaquine (SP-AQ) door-to-door each month to approximately 7,000 children aged 6–24 months in seven wards of Madobi, Kano State, Nigeria. In three of the wards children additionally received a lipid-based nutrient supplement (LNS–medium quantity), Plumpy Doz. Coverage, adherence, and anthropometric outcomes were assessed through baseline, midline, and endline household surveys. A facility-based case-control study was also conducted to estimate impact on clinical malaria outcomes. Coverage of SP-AQ was similar between arms at 89% (n = 2,409 child-months [88–90%]) in the SP-AQ only arm and 90% (n = 1,947 child-months [88–92%]) in the SP-AQ plus LNS arm (p = 0.52). Coverage of LNS was 83% (n = 2,409 child-months [81–84%]). Whilst there were marked changes in anthropometric status between baseline, midline and endline, these were largely accounted for by socioeconomic status and must be interpreted with care due to possible measurement issues, especially length-based indices. Overall nutritional status of our most robust measure, weight-for-age, does appear to have improved by endline, but was similar in the two study arms, suggesting no additional benefit of the LNS. While the odds of clinical malaria among those who received the intended intervention were lower in each study arm compared to children who did not receive interventions (SP-AQ only OR = 0.23 [0.09–0.6]; SP-AQ plus LNS OR = 0.22 [0.09–0.55]), LNS was not shown to have an additional impact. Coverage of SMC was high regardless of integrating LNS delivery into the SMC campaign. Supplementation with LNS did not appear to impact nutritional outcomes, but appeared to enhance the impact of SP-AQ on clinical odds of malaria. These results indicate that combining nutritional interventions with seasonal malaria chemoprevention in high-risk areas can be done successfully, warranting further exploration with other products or dosing.

Trial Registration: ISRCTN 11413895

Supplementation with Small-Quantity Lipid-Based Nutrient Supplements Does Not Increase Child Morbidity in a Semiurban Setting in Ghana: A Secondary Outcome Noninferiority Analysis of the International Lipid-Based Nutrient Supplements (iLiNS)-DYAD Randomized Controlled Trial

BACKGROUND

Adequate knowledge about the safety of consumption of small-quantity lipid-based nutrient supplements (SQ-LNSs) is needed.

OBJECTIVE

We aimed to test the hypothesis that SQ-LNS consumption is noninferior to control with respect to child morbidity.

METHODS

Women (n = 1320) ≤20 wk pregnant were assigned to iron and folic acid until delivery with no supplementation for offspring; or multiple micronutrient supplements until 6 mo postpartum with no supplementation for offspring; or SQ-LNSs until 6 mo postpartum, and SQ-LNSs for offspring (6 mg Fe/d) from 6 to 18 mo of age [the lipid-based nutrient supplement (LNS) group]. We assessed noninferiority (margin ≤20%) between any 2 groups during 0-6 mo of age, and between the non-LNS and LNS groups during 6-18 mo of age for caregiver-reported acute respiratory infection, diarrhea, gastroenteritis, fever/suspected malaria, poor appetite, and "other illnesses."

RESULTS

During 0-6 mo of age, 1197 infants contributed 190,503 infant-days. For all morbidity combined, overall mean incidence (per 100 infant-days) was 3.3 episodes, overall mean prevalence (percentage of infant-days) was 19.3%, and the 95% CIs of the incidence rate ratio (IRR) and longitudinal prevalence rate ratio (LPRR) between any 2 groups were ≤1.20. During 6-18 mo, there were 240,097 infant-days for the non-LNS group and 118,698 for the LNS group. For all morbidity combined, group mean incidences were 4.3 and 4.3, respectively (IRR: 1.0; 95% CI: 1.0, 1.1), and mean prevalences were 28.2% and 29.3%, respectively (LPRR: 1.0; 95% CI: 1.0, 1.1). Noninferiority was inconclusive for diarrhea, fever/suspected malaria, and poor appetite.

CONCLUSIONS

SQ-LNS consumption does not increase reported overall child morbidity in this population compared with the 2 other treatments.This trial was registered at clinicaltrials.gov as NCT00970866.

Effect of small-quantity lipid-based nutrient supplements on growth, psychomotor development, iron status, and morbidity among 6- to 12-mo-old infants in South Africa: a randomized controlled trial

Background

Evidence on the effect of small-quantity lipid-based nutrient supplements (SQ-LNSs) on early child growth and development is mixed.

Objective

This study assessed the effect of daily consumption of 2 different SQ-LNS formulations on linear growth (primary outcome), psychomotor development, iron status (secondary outcomes), and morbidity in infants from age 6 to 12 mo within the context of a maize-based complementary diet.

Methods

Infants (n = 750) were randomly assigned to receive SQ-LNS, SQ-LNS-plus, or no supplement. Both SQ-LNS products contained micronutrients and essential fatty acids. SQ-LNS-plus contained, in addition, docosahexaenoic acid, arachidonic acid (important for brain and eye development), lysine (limiting amino acid in maize), phytase (enhances iron absorption), and other nutrients. Infants' weight and length were measured bimonthly. At age 6 and 12 mo, psychomotor development using the Kilifi Developmental Inventory and South African Parent Rating Scale and hemoglobin, plasma ferritin, C-reactive protein, and α1-acid glycoprotein were assessed. WHO Motor Milestone outcomes, adherence, and morbidity were monitored weekly through home visits. Primary analysis was by intention-to-treat, comparing each SQ-LNS group with the control.

Results

SQ-LNS-plus had a positive effect on length-for-age zscore at age 8 mo (mean difference: 0.11; 95% CI: 0.01, 0.22; P = 0.032) and 10 mo (0.16; 95% CI: 0.04, 0.27; P = 0.008) but not at 12 mo (0.09; 95% CI: -0.02, 0.21; P = 0.115), locomotor development score (2.05; 95% CI: 0.72, 3.38; P = 0.003), and Parent Rating Score (1.10; 95% CI: 0.14, 2.07; P = 0.025), but no effect for weight-for-age zscore. Both SQ-LNS (P = 0.027) and SQ-LNS-plus (P = 0.005) improved hemoglobin concentration and reduced the risk of anemia, iron deficiency, and iron-deficiency anemia. Both SQ-LNS products reduced longitudinal prevalence of fever, coughing, and wheezing but increased incidence and longitudinal prevalence of diarrhea, vomiting, and rash/sores.

Conclusions

Point-of-use fortification with SQ-LNS-plus showed an early transient effect on linear growth and improved locomotor development. Both SQ-LNS products had positive impacts on anemia and iron status. This trial was registered at clinicaltrials.gov as NCT01845610.

Development and Acceptability of Locally Made Fish-Based, Ready-to-Use Products for the Prevention and Treatment of Malnutrition in Cambodia

BACKGROUND

Cambodia has a high prevalence of moderate acute malnutrition and severe acute malnutrition (SAM). The SAM treatment requires ready-to-use therapeutic foods (RUTFs), whereas ready-to-use supplementary foods (RUSFs) are used for prevention of acute malnutrition. Three locally produced fish-based products were developed: an RUTF paste (NumTrey-Paste) for treatment and 2 wafer versions, one for prevention (NumTrey-RUSF) and one for treatment (NumTrey-RUTF).

OBJECTIVE

To assess the acceptability of NumTrey-Paste and NumTrey-RUSF in comparison to a standard biscuit product (BP-100) used for the treatment of SAM.

METHODS

Acceptability of NumTrey-RUSF and NumTrey-Paste was tested in a nonblinded crossover taste trial among children (n = 52), aged ≥ 6 months to 18 years, and their caregivers. Eight organoleptic qualities were assessed on a 5-point hedonic scale, as well as a ranking test. A score of 1 to 3 was categorized as acceptable. The acceptability of NumTrey-RUTF was assessed using the caregivers' perception during an SAM treatment intervention.

RESULTS

Taste trial: The proportion of children categorizing products as overall acceptable was lowest for NumTrey-Paste compared to for BP-100 and NumTrey-RUSF (21% vs 43% [BP-100] and 36% [NumTrey-RUSF]). No difference was found in the proportion of children who ranked BP-100 or NumTrey-RUSF as "liked most" ( P > .05). Acceptability of NumTrey-RUSF ranked highest in appearance and taste (caregiver), whereas acceptability of NumTrey-Paste was ranked lowest in appearance and smell among the products. Intervention trial: The acceptability of NumTrey-RUTF increased from 72% to 86%.

CONCLUSIONS

The overall acceptability was ranked lowest for a pure paste product. However, filling the paste into a wafer made the product more acceptable.

Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review

BACKGROUND

Cluster randomised trials (CRTs) are a key instrument to evaluate public health interventions. Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned. Evaluation of implementation fidelity (IF) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions conducted in low- and middle-income countries (LMICs). However, current CRT reporting guidelines offer no guidance on IF assessment. The objective of this review was to study current practices concerning the assessment of IF in CRTs of public health interventions in LMICs.

METHODS

CRTs of public health interventions in LMICs that planned or reported IF assessment in either the trial protocol or the main trial report were included. The MEDLINE/PubMed, CINAHL and EMBASE databases were queried from January 2012 to May 2016. To ensure availability of a study protocol, CRTs reporting a registration number in the abstract were included. Relevant data were extracted from each study protocol and trial report by two researchers using a predefined screening sheet. Risk of bias for individual studies was assessed.

RESULTS

We identified 90 CRTs of public health interventions in LMICs with a study protocol in a publicly available trial registry published from January 2012 to May 2016. Among these 90 studies, 25 (28%) did not plan or report assessing IF; the remaining 65 studies (72%) addressed at least one IF dimension. IF assessment was planned in 40% (36/90) of trial protocols and reported in 71.1% (64/90) of trial reports. The proportion of overall agreement between the trial protocol and trial report concerning occurrence of IF assessment was 66.7% (60/90). Most studies had low to moderate risk of bias.

CONCLUSIONS

IF assessment is not currently a systematic practice in CRTs of public health interventions carried out in LMICs. In the absence of IF assessment, it may be difficult to determine if CRT results are due to the intervention design, to its implementation, or to unknown or external factors that may influence results. CRT reporting guidelines should promote IF assessment.

TRIAL REGISTRATION

Protocol published and available at: https://doi.org/10.1186/s13643-016-0351-0.

Effectiveness of the national food supplementary program on children growth and nutritional status in Iran

This study aimed to evaluate the effectiveness of the national food distribution program on the growth and nutritional status of malnourished or growth-retarded children in 2 provinces of Iran. A quasi-experimental design was used for the effectiveness evaluation. Qualitative data were gathered to explain the results. An intervention group consisted of 362 children aged 6-72 months who were under coverage of the program. These children received monthly food as foodstuff, food vouchers, or cash. A comparison group included 409 children aged 6-72 months who were selected from those covered by the Primary Health Care system. Children anthropometric indices were measured at the baseline and also 6 months later. Twelve focus group discussions were held with mothers who had at least 1 child under the coverage of the program. At the end of the study, the mean weight-for-age Z scores, height-for-age Z scores, and weight-for-height Z scores increased compared with the baselines in both groups (p < .001). The differences between 2 groups in weight-for-age Z scores, height-for-age Z scores, and weight-for-height Z scores were not significant at the end of the study (p = .62, p = .91, and p = .94, respectively). According to the mothers' reports, factors affected the program outcome, that is, children anthropometric indices were low income, intrahousehold food sharing, irregular distribution, quantity and quality of the distributed food, and insufficient training. Providing foods for the malnourished children living in low-income families helped to prevent a worsening of their nutritional status; however, it has not been effective in solving the problem, probably due to the weak implementation and lack of empowerment strategies.

A Randomized Controlled Trial of Two Ready-to-Use Supplementary Foods Demonstrates Benefit of the Higher Dairy Supplement for Reduced Wasting in Mothers, and Differential Impact in Infants and Children Associated With Maternal Supplement Response

BACKGROUND

There is no consensus over best approaches to reliably prevent malnutrition in rural communities in low-income countries.

OBJECTIVE

We compared the effectiveness of 2 lipid-based ready-to-use supplementary foods (RUSFs) differing in dairy protein content to improve the nutritional status of mothers and at-risk infants and young children in rural Guinea-Bissau.

METHODS

A 3-month cluster-randomized controlled pilot trial of 2 RUSFs was conducted with 692 mothers and 580 mildly or moderately malnourished infants (6-23 months) and children (24-59 months) from 13 villages. The RUSFs contained either 478 (mothers, children) or 239 kcal/d (infants) with 15% or 33% of protein from dairy and were distributed at community health centers 5 d/wk. Controls were wait-listed to receive RUSF. Primary outcomes were mid-upper arm circumference (MUAC) in mothers, and weight-for-age and height-for-age z-scores (WAZ and HAZ) in infants and children.

RESULTS

There was a significant effect of the RUSF-33% on MUAC in mothers ( P = .03). The WAZ and HAZ increased substantially, by ≈1 z-score, in infants and children ( P < .01) independent of group randomization. In children, but not infants, baseline WAZ and change in maternal MUAC were associated with change in WAZ (β = .07, P = .02).

CONCLUSION

Ready-to-use supplementary foods with higher dairy protein content had a significant benefit in village mothers, supporting a comparable recent finding in preschool children. In addition, supplementation of children <2 years resulted in improved growth independent of family nutritional status, whereas success in older children was associated with change in maternal nutrition, suggesting the need for community-level education about preventing malnutrition in older, as well as younger, children.

The effect of providing lipid-based nutrient supplements on morbidity in rural Malawian infants and young children: a randomized controlled trial

Objective

Safety of home fortificants in children is uncertain in areas where infections are common. We tested the hypothesis that provision of lipid-based nutrient supplements (LNS) containing Fe does not increase infectious morbidity in children.

Design

Randomized controlled trial. Infants were randomised to receive 10, 20 or 40 g LNS/d; or no supplement until age 18 months. All LNS contained 6 mg Fe/d. Morbidity outcomes (serious adverse events, non-scheduled visits and guardian-reported morbidity episodes) were compared between control and intervention groups using a non-inferiority margin of 20 %.

Setting

Namwera and Mangochi catchment areas in rural Malawi.

Subjects

Infants aged 6 months (n1932).

Results

The enrolled 1932 infants contributed 1306 child-years of follow-up. Baseline characteristics were similar across groups. Compared with the control group, the relative risk (95 % CI) of serious adverse events was 0·71 (0·48, 1·07), 0·67 (0·48, 0·95) and 0·91 (0·66, 1·25) in 10, 20 and 40 g LNS/d groups, respectively. The incidence rate ratio (95 % CI) of non-scheduled visits due to malaria was 1·10 (0·88, 1·37), 1·08 (0·89, 1·31) and 1·21 (1·00, 1·46), and of guardian-reported morbidity episodes was 1·04 (0·96, 1·11), 1·03 (0·97, 1·10) and 1·04 (0·97, 1·10), in the respective LNS groups.

Conclusions

Provision of 10 and 20 g LNS/d containing 6 mg Fe/d did not increase morbidity in the children. Provision of 40 g LNS/d did not affect guardian-reported illness episodes but may have increased malaria-related non-scheduled visits.

Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Uganda

BACKGROUND

Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food but also by illnesses and by poor infant and child feeding practices. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here, we report on the trial that took place in Kaabong, a poor agropastoral region of Karamoja, in east Uganda. While the region of Karamoja shows an acute malnutrition rate between 8.4% and 11.5% of which 2% to 3% severe malnutrition, more than half (58%) of the population in the district of Kaabong is considered food insecure.

METHODS AND FINDINGS

We investigated the effect of two types of nutritional supplementation on the incidence of malnutrition in ill children presenting at outpatient clinics during March 2011 to April 2012 in Kaabong, Karamoja region, Uganda, a resource-poor region where malnutrition is a chronic problem for its seminomadic population. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed with malaria, diarrhoea, or lower respiratory tract infection. Non-malnourished children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of ready-to-use therapeutic food (RUTF), two sachets/d of micronutrient powder (MNP), or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate progression to moderate or severe acute malnutrition; it was defined as weight-for-height z-score <-2, mid-upper arm circumference (MUAC) <115 mm, or oedema, whichever came first. Of the 2,202 randomised participants, 51.2% were girls, and the mean age was 25.2 (±13.8) mo; 148 (6.7%) participants were lost to follow-up, 9 (0.4%) died, and 14 (0.6%) were admitted to hospital. The incidence rates of NNO (first event/year) for the RUTF, MNP, and control groups were 0.143 (95% confidence interval [CI], 0.107-0.191), 0.185 (0.141-0.239), and 0.213 (0.167-0.272), respectively. The incidence rate ratio was 0.67 (95% CI, 0.46-0.98; p = 0.037) for RUTF versus control; a reduction of 33.3%. The incidence rate ratio was 0.86 (0.61-1.23; p = 0.413) for MNP versus control and 0.77 for RUTF versus MNP (95% CI 0.52-1.15; p = 0.200). The average numbers of study illnesses for the RUTF, MNP, and control groups were 2.3 (95% CI, 2.2-2.4), 2.1 (2.0-2.3), and 2.3 (2.2-2.5). The proportions of children who died in the RUTF, MNP, and control groups were 0%, 0.8%, and 0.4%. The findings apply to ill but not malnourished children and cannot be generalised to a general population including children who are not necessarily ill or who are already malnourished.

CONCLUSIONS

A 2-wk nutrition supplementation programme with RUTF as part of routine primary medical care to non-malnourished children with malaria, LRTI, or diarrhoea proved effective in preventing malnutrition in eastern Uganda. The low incidence of malnutrition in this population may warrant a more targeted intervention to improve cost effectiveness.

TRIAL REGISTRATION

clinicaltrials.gov NCT01497236.

Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Nigeria

BACKGROUND

Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food and poor infant and child feeding practices but also by illnesses. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here we report on the trial that took place in Goronyo, a rural region of northwest Nigeria with high morbidity and malnutrition rates.

METHODS AND FINDINGS

We investigated the effect of supplementation with ready-to-use therapeutic food (RUTF) and a micronutrient powder (MNP) on the incidence of malnutrition in ill children presenting at an outpatient clinic in Goronyo during February to September 2012. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed as having malaria, diarrhoea, or lower respiratory tract infection. Children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of RUTF; two sachets/d of micronutrients or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate occurrence of malnutrition; it was defined as low weight-for-height z-score (<-2 for non-malnourished and <-3 for moderately malnourished children), mid-upper arm circumference <115 mm, or oedema, whichever came first. Of the 2,213 randomised participants, 50.0% were female and the mean age was 20.2 (standard deviation 11.2) months; 160 (7.2%) were lost to follow-up, 54 (2.4%) were admitted to hospital, and 29 (1.3%) died. The incidence rates of NNO for the RUTF, MNP, and control groups were 0.522 (95% confidence interval (95% CI), 0.442-0.617), 0.495 (0.415-0.589), and 0.566 (0.479-0.668) first events/y, respectively. The incidence rate ratio was 0.92 (95% CI, 0.74-1.15; p = 0.471) for RUTF versus control; 0.87 (0.70-1.10; p = 0.242) for MNP versus control and 1.06 (0.84-1.33, p = 0.642) for RUTF versus MNP. A subgroup analysis showed no interaction nor confounding, nor a different effectiveness of supplementation, among children who were moderately malnourished compared with non-malnourished at enrollment. The average number of study illnesses for the RUTF, MNP, and control groups were 4.2 (95% CI, 4.0-4.3), 3.4 (3.2-3.6), and 3.6 (3.4-3.7). The proportion of children who died in the RUTF, MNP, and control groups were 0.8% (95% CI, 0.3-1.8), 1.8% (1.0-3.3), and 1.4% (0.7-2.8).

CONCLUSIONS

A 2-wk supplementation with RUTF or MNP to ill children as part of routine primary medical care did not reduce the incidence of malnutrition. The lack of effect in Goronyo may be due to a high frequency of morbidity, which probably further affects a child's nutritional status and children's ability to escape from the illness-malnutrition cycle. The duration of the supplementation may have been too short or the doses of the supplements may have been too low to mitigate the effects of high morbidity and pre-existing malnutrition. An integrated approach combining prevention and treatment of diseases and treatment of moderate malnutrition, rather than prevention of malnutrition by nutritional supplementation alone, might be more effective in reducing the incidence of acute malnutrition in ill children.

TRIAL REGISTRATION

clinicaltrials.gov NCT01154803.

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

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

A Randomized Controlled Trial Offering Higher- Compared with Lower-Dairy Second Meals Daily in Preschools in Guinea-Bissau Demonstrates an Attendance-Dependent Increase in Weight Gain for Both Meal Types and an Increase in Mid-Upper Arm Circumference for the Higher-Dairy Meal

BACKGROUND

Controversy remains over the most effective approaches to prevent childhood malnutrition.

OBJECTIVES

We tested the feasibility and effectiveness of delivering ready-to-use supplementary foods (RUSFs) as a second daily meal in preschool children aged 3-5 y in Guinea-Bissau, and compared RUSFs with different levels of dairy protein.

METHODS

This study was a 3 mo cluster-randomized controlled pilot trial of 2 RUSFs differing in dairy protein in 533 boys and girls from 9 preschools. Children receiving RUSFs were compared with wait-listed controls, and all students received a daily school lunch. The RUSFs were delivered 5 d/wk for 3 mo and contained 478 kcal and 11.5 g protein per 92-g daily serving. Deliveries included a ready-to-use supplementary food with 15% of protein from dairy sources (RUSF-15%) or one with 33% of protein from dairy sources (RUSF-33%). Intention-to-treat (ITT) and per-protocol analyses (>50 d of RUSF consumption) were conducted. Changes in the weight-for-age z score (WAZ) and height-for-age z score were primary outcomes. Additional outcomes included changes in mid-upper arm circumference (MUAC), hemoglobin, and retinol binding protein.

RESULTS

Baseline anthropometry was not different between groups (WAZ, -0.48 ± 1.04) and increased significantly over time (P < 0.01) with no effects of the RUSFs in ITT analyses. However, children consuming RUSFs for >50 d had a significantly greater increase in WAZ relative to the increase in controls (+0.40 and +0.32 for RUSF-15% and RUSF-33%, respectively, compared with +0.24 in controls, P < 0.01 and P < 0.05, respectively). RUSF-33%, but not RUSF-15%, also eliminated a decrease in MUAC observed in controls (-0.01 cm in RUSF-33% compared with -0.34 cm in controls, P < 0.05). The only difference between RUSF-15% and RUSF-33% was a mean decrease in hemoglobin in children receiving RUSF-15% (-0.5 compared with -0.002 g/dL, P = 0.05).

CONCLUSIONS

Implementation of 2-meal preschool feeding programs is feasible in low-income countries, and there are measurable benefits relative to 1-meal programs in children attending preschool regularly. In addition, MUAC and hemoglobin measurements indicate that meals with 33% compared with 15% of protein from dairy may help prevent wasting and anemia.

Considerations in developing lipid-based nutrient supplements for prevention of undernutrition: experience from the International Lipid-Based Nutrient Supplements (iLiNS) Project

The International Lipid-Based Nutrient Supplements (iLiNS) Project began in 2009 with the goal of contributing to the evidence base regarding the potential of lipid-based nutrient supplements (LNS) to prevent undernutrition in vulnerable populations. The first project objective was the development of acceptable LNS products for infants 6-24 months and for pregnant and lactating women, for use in studies in three countries (Burkina Faso, Ghana and Malawi). This paper shares the rationale for a series of decisions in supplement formulation and design, including those related to ration size, ingredients, nutrient content, safety and quality, and packaging. Most iLiNS supplements have a daily ration size of 20 g and are intended for home fortification of local diets. For infants, this ration size is designed to avoid displacement of breast milk and to allow for dietary diversity including any locally available and accessible nutrient-dense foods. Selection of ingredients depends on acceptability of flavour, micronutrient, anti-nutrient and essential fatty acid contents. The nutrient content of LNS designed to prevent undernutrition reflects the likelihood that in many resource-poor settings, diets of the most nutritionally vulnerable individuals (infants, young children, and pregnant and lactating women) are likely to be deficient in multiple micronutrients and, possibly, in essential fatty acids. During ingredient procurement and LNS production, safety and quality control procedures are required to prevent contamination with toxins or pathogens and to ensure that the product remains stable and palatable over time. Packaging design decisions must include consideration of product protection, stability, convenience and portion control.

Preventive Effects of Long-Term Supplementation with 2 Nutritious Food Supplements in Young Children in Niger

BACKGROUND

In nutritional crises, large-scale preventive distributions of specialized nutritious foods are recommended to prevent acute and chronic malnutrition in young children. Among the available specialized nutritious foods, the World Food Programme and UNICEF recommend lipid-based nutrient supplements (LNSs) and Super Cereal Plus (SC+). Although the effectiveness of short-term distributions for prevention of severe acute malnutrition (SAM) is well documented, evidence for long-term strategies and the role of distribution of specialized nutritious foods for prevention of stunting is weaker.

OBJECTIVE

The objective of this study was to compare long-term supplementation of LNSs and SC+ on the incidence of acute malnutrition and stunting in young children.

METHODS

We conducted two 15-mo-long supplementation interventions with the use of LNSs (500 kcal/d) and SC+ (810 kcal/d) and half rations during 5 mo of the nonlean season, for the prevention of acute malnutrition and stunting in children aged 6-23 mo. The study was designed as a prospective cohort in 11 villages in Madarounfa, Niger. We compared the incidence of acute malnutrition and stunting with the use of Cox proportional hazards models and report on sharing and use of these food supplements.

RESULTS

Characteristics of children at baseline were similar across groups. A total of 1967 children were included in the analysis (845 in the SC+ group and 1122 in the LNS group). No significant differences in the incidence of moderate acute malnutrition (SC+ compared with LNS: adjusted HR: 0.79; 95% CI: 0.61, 1.02) or SAM (HR: 0.84; 95% CI: 0.52, 1.34) were found. No difference in the incidence of stunting (HR: 1.08; 95% CI: 0.95, 1.24) or severe stunting (HR: 0.94; 95% CI: 0.71, 1.22) over the follow-up period were found.

CONCLUSIONS

These findings in young children in Niger suggest that both products should be considered when planning preventive distributions and choice of long-term supplementation should be guided by context-specific factors such as acceptability, cost, and operational feasibility, among others. Additional research is essential to improving child health. The study was registered at clinicaltrials.gov as NCT01828814.

The impact of stopping high-energy oral nutritional supplements on eating behaviour and weight gain

BACKGROUND AND AIMS

Many children referred to a tertiary feeding clinic are already taking high-energy oral nutritional supplements (HEOS), but these often seem not clinically useful. We undertook a retrospective review of all children on HEOS at the time of referral to the clinic in order to describe their subsequent progress in terms of growth and feeding behaviour.

RESULTS

A total of 48 children were on HEOS at referral and withdrawal of HEOS was attempted in 38 children, aged median 3.0 years (range 0.7-10 years) who were taking volumes equivalent to 2/3 of total daily energy requirements. The children tended to be very short and slim (median height SD score (SDS) -2.0 (range -5.7 to 1.9); body mass index -2.0 (-5.1 to 1.9)). Half had normal neurodevelopment (ND) but 4 (11%) had learning disability and 4 (11%) severe ND problems. By last follow-up after 0.86 (0-2.9) years, 30 (79%) had stopped all feeds. Those who stopped had a mean (SD) change in weight of 0.08 (0.6) SDS (range -0.88 to +1.59). Five children (17%) showed significant catch-up weight gain after stopping feeds, of whom three had been referred for weight faltering and possible tube feeding. Improvement in feeding behaviour was documented in 76% (29).

CONCLUSIONS

The use of HEOS in children suppresses appetite for solid food due to energy compensation. In some cases, HEOS may perpetuate or even cause weight faltering. It should not be assumed that failure to respond to HEOS is an indication for tube feeding.

Effect of fortified complementary food supplementation on child growth in rural Bangladesh: a cluster-randomized trial

Background: Growth faltering in the first 2 years of life is high in South Asia where prevalence of stunting is estimated at 40–50%. Although nutrition counselling has shown modest benefits, few intervention trials of food supplementation exist showing improvements in growth and prevention of stunting.

Methods: A cluster-randomized controlled trial was conducted in rural Bangladesh to test the effect of two local, ready-to-use foods (chickpea and rice-lentil based) and a fortified blended food (wheat-soy-blend++, WSB++) compared with Plumpy’doz, all with nutrition counselling vs nutrition counselling alone (control) on outcomes of linear growth (length and length-for-age z-score, LAZ), stunting (LAZ < −2), weight-for-length z-score (WLZ) and wasting (WLZ < −2) in children 6–18 months of age. Children (n = 5536) were enrolled at 6 months of age and, in the food groups, provided with one of the allocated supplements daily for a year.

Results: Growth deceleration occurred from 6 to 18 months of age but deceleration in LAZ was lower (by 0.02–0.04/month) in the Plumpy’doz (P = 0.02), rice-lentil (< 0.01), and chickpea (< 0.01) groups relative to control, whereas WLZ decline was lower only in Plumpy’doz and chickpea groups. WSB++ did not impact on these outcomes. The prevalence of stunting was 44% at 18 months in the control group, but lower by 5–6% (P ≤ 0.01) in those receiving Plumpy’doz and chickpea. Mean length and LAZ at 18 months were higher by 0.27–0.30 cm and 0.07–0.10 (all P < 0.05), respectively, in all four food groups relative to the control.

Conclusions: In rural Bangladesh, small amounts of daily fortified complementary foods, provided for a year in addition to nutrition counselling, modestly increased linear growth and reduced stunting at 18 months of age.

The MAM'Out project: a randomized controlled trial to assess multiannual and seasonal cash transfers for the prevention of acute malnutrition in children under 36 months in Burkina Faso

BACKGROUND

Wasting is a public health issue but evidence gaps remain concerning preventive strategies not primarily based on food products. Cash transfers, as part of safety net approach, have potential to prevent under-nutrition. However, most of the cash transfer programs implemented and scientifically evaluated do not have a clear nutritional objective, which leads to a lack of evidence regarding their nutritional benefits.

METHODS/DESIGN

The MAM'Out research project aims at evaluating a seasonal and multiannual cash transfer program to prevent acute malnutrition in children under 36 months, in terms of effectiveness and cost-effectiveness in the Tapoa province (Eastern region of Burkina Faso, Africa). The program is targeted to economically vulnerable households with children less than 1 year old at the time of inclusion. Cash is distributed to mothers and the transfers are unconditional, leading to beneficiaries' self-determination on the use of cash. The study is designed as a two-arm cluster randomized intervention trial, based on the randomization of rural villages. One group receives cash transfers via mobile phones and one is a control group. The main outcomes are the cumulative incidence of acute malnutrition and the cost-effectiveness. Child anthropometry (height, weight and MUAC) is followed, as well as indicators related to dietary diversity, food security, health center utilization, families' expenses, women empowerment and morbidities. 24 h-food recalls are also carried out. Individual interviews and focus group discussions allow collecting qualitative data. Finally, based on a theory framework built a priori, the pathways used by the cash to have an effect on the prevention of under-nutrition will be assessed.

DISCUSSION

The design chosen will lead to a robust assessment of the effectiveness of the proposed intervention. Several challenges appeared while implementing the study and discrepancies with the research protocol, mainly due to unforeseen events, can be highlighted, such as delay in project implementation, switch to e-data collection and implementation of a supervision process.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT01866124, registered May 7, 2013.

Ready-to-use supplementary food increases fat mass and BMI in Haitian school-aged children

BACKGROUND

In Haiti and other countries, large-scale investments in school feeding programs have been made with marginal evidence of nutrition outcomes.

OBJECTIVE

We aimed to examine the effectiveness of a fortified ready-to-use supplementary food (RUSF), Mamba, on reduced anemia and improved body composition in school-aged children compared to an unfortified cereal bar, Tablet Yo, and control groups.

METHODS

A cluster, randomized trial with children ages 3-13 y (n = 1167) was conducted in the north of Haiti. Six schools were matched and randomized to the control group, Tablet Yo group (42 g, 165 kcal), or Mamba group (50 g, 260 kcal, and >75% of the RDA for critical micronutrients). Children in the supplementation groups received the snack daily for 100 d, and all were followed longitudinally for hemoglobin concentrations, anthropometry, and bioelectrical impedance measures: baseline (December 2012), midline (March 2013), and endline (June 2013). Parent surveys were conducted at baseline and endline to examine secondary outcomes of morbidities and dietary intakes. Longitudinal regression modeling using generalized least squares and logit with random effects tested the main effects.

RESULTS

At baseline,14.0% of children were stunted, 14.5% underweight, 9.1% thin, and 73% anemic. Fat mass percentage (mean ± SD) was 8.1% ± 4.3% for boys and 12.5% ± 4.4% for girls. In longitudinal modeling, Mamba supplementation increased body mass index z score (regression coefficient ± SEE) 0.25 ± 0.06, fat mass 0.45 ± 0.14 kg, and percentage fat mass 1.28% ± 0.27% compared with control at each time point (P < 0.001). Among boys, Mamba increased fat mass (regression coefficient ± SEE) 0.73 ± 0.19 kg and fat-free mass 0.62 ± 0.34 kg compared with control (P < 0.001). Mamba reduced the odds of developing anemia by 28% compared to control (adjusted OR: 0.72; 95% CI: 0.57, 0.91; P < 0.001). No treatment effect was found for hemoglobin concentration.

CONCLUSION

To our knowledge, this is the first study to give evidence of body composition effects from an RUSF in school-aged children.

Food supplementation for improving the physical and psychosocial health of socio-economically disadvantaged children aged three months to five years

BACKGROUND

Undernutrition contributes to five million deaths of children under five each year. Furthermore, throughout the life cycle, undernutrition contributes to increased risk of infection, poor cognitive functioning, chronic disease, and mortality. It is thus important for decision-makers to have evidence about the effectiveness of nutrition interventions for young children.

OBJECTIVES

Primary objective1. To assess the effectiveness of supplementary feeding interventions, alone or with co-intervention, for improving the physical and psychosocial health of disadvantaged children aged three months to five years.Secondary objectives1. To assess the potential of such programmes to reduce socio-economic inequalities in undernutrition.2. To evaluate implementation and to understand how this may impact on outcomes.3. To determine whether there are any adverse effects of supplementary feeding.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, PsycINFO, and seven other databases for all available years up to January 2014. We also searched ClinicalTrials.gov and several sources of grey literature. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that provided supplementary food (with or without co-intervention) to children aged three months to five years, from all countries. Adjunctive treatments, such as nutrition education, were allowed. Controls had to be untreated.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data, and assessed risk of bias. We conducted meta-analyses for continuous data using the mean difference (MD) or the standardised mean difference (SMD) with a 95% confidence interval (CI), correcting for clustering if necessary. We analysed studies from low- and middle-income countries and from high-income countries separately, and RCTs separately from CBAs. We conducted a process evaluation to understand which factors impact on effectiveness.

MAIN RESULTS

We included 32 studies (21 RCTs and 11 CBAs); 26 of these (16 RCTs and 10 CBAs) were in meta-analyses. More than 50% of the RCTs were judged to have low risk of bias for random selection and incomplete outcome assessment. We judged most RCTS to be unclear for allocation concealment, blinding of outcome assessment, and selective outcome reporting. Because children and parents knew that they were given food, we judged blinding of participants and personnel to be at high risk for all studies.Growth. Supplementary feeding had positive effects on growth in low- and middle-income countries. Meta-analysis of the RCTs showed that supplemented children gained an average of 0.12 kg more than controls over six months (95% confidence interval (CI) 0.05 to 0.18, 9 trials, 1057 participants, moderate quality evidence). In the CBAs, the effect was similar; 0.24 kg over a year (95% CI 0.09 to 0.39, 1784 participants, very low quality evidence). In high-income countries, one RCT found no difference in weight, but in a CBA with 116 Aboriginal children in Australia, the effect on weight was 0.95 kg (95% CI 0.58 to 1.33). For height, meta-analysis of nine RCTs revealed that supplemented children grew an average of 0.27 cm more over six months than those who were not supplemented (95% CI 0.07 to 0.48, 1463 participants, moderate quality evidence). Meta-analysis of seven CBAs showed no evidence of an effect (mean difference (MD) 0.52 cm, 95% CI -0.07 to 1.10, 7 trials, 1782 participants, very low quality evidence). Meta-analyses of the RCTs demonstrated benefits for weight-for-age z-scores (WAZ) (MD 0.15, 95% CI 0.05 to 0.24, 8 trials, 1565 participants, moderate quality evidence), and height-for-age z-scores (HAZ) (MD 0.15, 95% CI 0.06 to 0.24, 9 trials, 4638 participants, moderate quality evidence), but not for weight-for-height z-scores MD 0.10 (95% CI -0.02 to 0.22, 7 trials, 4176 participants, moderate quality evidence). Meta-analyses of the CBAs showed no effects on WAZ, HAZ, or WHZ (very low quality evidence). We found moderate positive effects for haemoglobin (SMD 0.49, 95% CI 0.07 to 0.91, 5 trials, 300 participants) in a meta-analysis of the RCTs.Psychosocial outcomes. Eight RCTs in low- and middle-income countries assessed psychosocial outcomes. Our meta-analysis of two studies showed moderate positive effects of feeding on psychomotor development (SMD 0.41, 95% CI 0.10 to 0.72, 178 participants). The evidence of effects on cognitive development was sparse and mixed.We found evidence of substantial leakage. When feeding was given at home, children benefited from only 36% of the energy in the supplement. However, when the supplementary food was given in day cares or feeding centres, there was less leakage; children took in 85% of the energy provided in the supplement. Supplementary food was generally more effective for younger children (less than two years of age) and for those who were poorer/ less well-nourished. Results for sex were equivocal. Our results also suggested that feeding programmes which were given in day-care/feeding centres and those which provided a moderate-to-high proportion of the recommended daily intake (% RDI) for energy were more effective.

AUTHORS' CONCLUSIONS

Feeding programmes for young children in low- and middle-income countries can work, but good implementation is key.

Lipid-based nutrient supplements do not affect the risk of malaria or respiratory morbidity in 6- to 18-month-old Malawian children in a randomized controlled trial

BACKGROUND

There is evidence to support the use of lipid-based nutrient supplements (LNSs) to promote child growth and development in low-income countries, but there is also a concern regarding the safety of using iron-fortified products in malaria-endemic areas.

OBJECTIVE

The objective of this study was to test the hypothesis that 6- to 18-mo-old rural Malawian children receiving iron-containing (6 mg/d) LNSs would not have excess morbidity compared with infants receiving no supplementation.

METHODS

A randomized controlled trial allocated 840 children to receive daily supplementation with 54 g/d LNS with milk protein base (milk-LNS), 54 g/d LNS with soy protein base (soy-LNS), 71 g/d corn-soy blend (CSB), or no supplementation from 6 to 18 mo of age. Morbidity was compared using a non-inferiority margin set at 20% excess morbidity in supplemented groups compared with the nonsupplemented group.

RESULTS

Baseline characteristics were similar across groups. The proportion of days with febrile illness between 6 and 18 mo was 4.9%, and there were no differences between the groups: 4.9% (95% CI: 4.3, 5.5%), 4.5% (95% CI: 3.9, 5.1%), 4.7% (95% CI: 4.1, 5.3%), and 5.5% (95% CI: 4.7-6.3%) in the milk-LNS, soy-LNS, CSB, and control groups, respectively. The proportion of days with respiratory problems and diarrhea between 6 and 18 mo also did not differ between groups. Compared with controls, the incident rate ratio (95% CI) for clinical malaria was 0.80 (0.59, 1.09), 0.77 (0.56, 1.06), and 0.79 (0.58, 1.08) in milk-LNS, soy-LNS, and CSB, respectively, with 95% CIs confirming non-inferiority. The incidence of febrile episodes, diarrhea, respiratory problems or admission to hospital, prevalence of malaria parasitemia throughout the follow-up, and mean change in hemoglobin concentration from baseline were also similar between the groups.

CONCLUSIONS

Daily supplementation with 54 g of milk-based or soy protein-based LNS or 71 g of CSB did not result in increases in malaria or respiratory morbidity in children in a malaria-endemic setting. However, we could not conclude whether LNSs did or did not increase diarrheal morbidity. This trial was registered at clinicaltrials.gov as NCT00524446.

Preventing acute malnutrition among young children in crises: a prospective intervention study in Niger

BACKGROUND

Finding the most appropriate strategy for the prevention of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) in young children is essential in countries like Niger with annual "hunger gaps." Options for large-scale prevention include distribution of supplementary foods, such as fortified-blended foods or lipid-based nutrient supplements (LNSs) with or without household support (cash or food transfer). To date, there has been no direct controlled comparison between these strategies leading to debate concerning their effectiveness. We compared the effectiveness of seven preventive strategies-including distribution of nutritious supplementary foods, with or without additional household support (family food ration or cash transfer), and cash transfer only-on the incidence of SAM and MAM among children aged 6-23 months over a 5-month period, partly overlapping the hunger gap, in Maradi region, Niger. We hypothesized that distributions of supplementary foods would more effectively reduce the incidence of acute malnutrition than distributions of household support by cash transfer.

METHODS AND FINDINGS

We conducted a prospective intervention study in 48 rural villages located within 15 km of a health center supported by Forum Santé Niger (FORSANI)/Médecins Sans Frontières in Madarounfa. Seven groups of villages (five to 11 villages) were allocated to different strategies of monthly distributions targeting households including at least one child measuring 60 cm-80 cm (at any time during the study period whatever their nutritional status): three groups received high-quantity LNS (HQ-LNS) or medium-quantity LNS (MQ-LNS) or Super Cereal Plus (SC+) with cash (€38/month [US$52/month]); one group received SC+ and family food ration; two groups received HQ-LNS or SC+ only; one group received cash only (€43/month [US$59/month]). Children 60 cm-80 cm of participating households were assessed at each monthly distribution from August to December 2011. Primary endpoints were SAM (weight-for-length Z-score [WLZ]<-3 and/or mid-upper arm circumference [MUAC]<11.5 cm and/or bipedal edema) and MAM (-3≤WLZ<-2 and/or 11.5≤MUAC<12.5 cm). A total of 5,395 children were included in the analysis (615 to 1,054 per group). Incidence of MAM was twice lower in the strategies receiving a food supplement combined with cash compared with the cash-only strategy (cash versus HQ-LNS/cash adjusted hazard ratio [HR]=2.30, 95% CI 1.60-3.29; cash versus SC+/cash HR=2.42, 95% CI 1.39-4.21; cash versus MQ-LNS/cash HR=2.07, 95% CI 1.52-2.83) or with the supplementary food only groups (HQ-LNS versus HQ-LNS/cash HR=1.84, 95% CI 1.35-2.51; SC+ versus SC+/cash HR=2.53, 95% CI 1.47-4.35). In addition, the incidence of SAM was three times lower in the SC+/cash group compared with the SC+ only group (SC+ only versus SC+/cash HR=3.13, 95% CI 1.65-5.94). However, non-quantified differences between groups, may limit the interpretation of the impact of the strategies.

CONCLUSIONS

Preventive distributions combining a supplementary food and cash transfer had a better preventive effect on MAM and SAM than strategies relying on cash transfer or supplementary food alone. As a result, distribution of nutritious supplementary foods to young children in conjunction with household support should remain a pillar of emergency nutritional interventions. Additional rigorous research is vital to evaluate the effectiveness of these and other nutritional interventions in diverse settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01828814 Please see later in the article for the Editors' Summary.

Effect of 12-month intervention with lipid-based nutrient supplements on physical activity of 18-month-old Malawian children: a randomised, controlled trial

BACKGROUND/OBJECTIVES

This study measured the effects of dietary supplementation with lipid-based nutrient supplements (LNSs) on 18-month-old children's physical activity.

SUBJECTS/METHODS

In a randomised, controlled, outcome-assessor blinded trial 1932 six-month-old children from Malawi received one of five interventions daily from 6-18 months of age: 10-g milk-LNS, 20-g milk-LNS, 20-g non-milk-LNS, 40-g milk-LNS or 40-g non-milk-LNS, or received no intervention in the same period (control). The control group received delayed intervention with corn-soy blend from 18-30 months. Physical activity was measured over 1 week by ActiGraph GT3X+ accelerometer at 18 months. Main outcome was mean vector magnitude accelerometer counts/15 s. Analyses were restricted to children with valid accelerometer data on at least 4 days with minimum 6 h of wearing time per day.

RESULTS

Of the 1435 children recruited to this substudy, 1053 provided sufficient data for analysis. The mean (s.d.) vector magnitude accelerometer counts in the total sample were 307 (64). The difference (95% CI) in mean accelerometer counts, compared with the control group, was 8 (-6 to 21, P=0.258) in 10-g milk-LNS, 3 (-11 to 17, P=0.715) in 20-g milk-LNS, 5 (-8 to 19, P=0.445) in 20-g non-milk-LNS, 10 (-3 to 23, P=0.148) in 40-g milk-LNS and 2 (-12 to 16, P=0.760) in 40-g non-milk-LNS groups.

CONCLUSIONS

Provision of 10-40 g doses of LNS daily for 12 months did not increase physical activity of Malawian toddlers.

Severe Acute Malnutrition during Emergencies: Burden, Management, and Gaps

Natural and man-made disasters, including floods, droughts, earthquakes, and armed conflicts, create nutrition crises. Unfortunately, the frequency and severity of such disasters have been increasing since the beginning of the 20th century, and their contribution to the burden of acute malnutrition is increasing every year. However, their contribution to the burden of acute malnutrition is underrecognized due to the ways in which global statistics are built and causes of death are reported. Fortunately, the success of the current protocol for treatment of severe acute malnutrition (SAM) and the integrated approach to treatment has created a momentum allowing expanded coverage of treatment of SAM, especially in humanitarian emergency contexts. For this progress to be maintained and accelerated, changes in nutrition information systems at the national and global levels are needed, and the persisting barriers to the expansion and integration of treatment of SAM into routine health systems need to be removed. Emergency funding approaches and objectives have to include sustaining and amplifying the achievements of the short-term palliative interventions. Nutrition programs implemented in emergency contexts have the capacity to contribute to answering priority research questions, and this capacity should be more optimally utilized.

Supplemental feeding during pregnancy compared with maternal supplementation during lactation does not affect schooling and cognitive development through late adolescence

BACKGROUND

The long-term impact of early malnutrition on human capital outcomes remains unclear, and existing evidence has come largely from observational studies.

OBJECTIVE

We compared the impact of a nutritional supplement given during pregnancy or lactation in rural Gambia on educational performance and cognitive ability in offspring at their maturity.

DESIGN

This study was a follow-up of a randomized trial of prenatal high protein and energy supplementation conducted between 1989 and 1994. Subjects were 16-22 y of age at follow-up, and information was collected on schooling achievement and cognitive ability by using the Raven's progressive matrices test, Mill Hill vocabulary test, and forward and backward digit-span tests.

RESULTS

A total of 1459 individuals were traced and interviewed and represented 71% of the original cohort and 81% of the surviving cohort. There was no difference in cognitive ability or educational attainment between treatment groups by using any of the methods of assessment.

CONCLUSION

We have shown little evidence to support a long-term effect of prenatal protein-energy supplementation compared with supplementation during lactation on cognitive development in rural Gambians. This trial was registered at http://www.controlled-trials.com as ISRCTN72582014.