Supplementation With Iron Syrup or Iron-Containing Multiple Micronutrient Powders Alters Resting Brain Activity in Bangladeshi Children

BACKGROUND

Anemia and iron deficiency have been associated with poor child cognitive development. A key rationale for the prevention of anemia using supplementation with iron has been the benefits to neurodevelopment. However, little causal evidence exists for these gains.

OBJECTIVES

We aimed to examine effects of supplementation with iron or multiple micronutrient powders (MNPs) on brain activity measures using resting electroencephalography (EEG).

METHODS

Children included in this neurocognitive substudy were randomly selected from the Benefits and Risks of Iron Supplementation in Children study, a double-blind, double-dummy, individually randomized, parallel-group trial in Bangladesh, in which children, starting at 8 mo of age, received 3 mo of daily iron syrup, MNPs, or placebo. Resting brain activity was recorded using EEG immediately after intervention (month 3) and after a further 9-month follow-up (month 12). We derived EEG band power measures for delta, theta, alpha, and beta frequency bands. Linear regression models were used to compare the effect of each intervention with that of placebo on the outcomes.

RESULTS

Data from 412 children at month 3 and 374 at month 12 were analyzed. At baseline, 43.9% were anemic and 26.7% were iron deficient. Immediately after intervention, iron syrup, but not MNPs, increased the mu alpha-band power, a measure that is associated with maturity and the production of motor actions (iron vs. placebo: mean difference = 0.30; 95% CI: 0.11, 0.50 μV²; P = 0.003; false discovery rate adjusted P = 0.015). Despite effects on hemoglobin and iron status, effects were not observed on the posterior alpha, beta, delta, and theta bands, nor were effects sustained at the 9-month follow-up.

CONCLUSIONS

The effect size for immediate effects on the mu alpha-band power is comparable in magnitude with psychosocial stimulation interventions and poverty reduction strategies. However, overall, we did not find evidence for long-lasting changes in resting EEG power spectra from iron interventions in young Bangladeshi children. This trial was registered at www.anzctr.org.au as ACTRN12617000660381.

High adherence and its influencing factors on multiple micronutrient powders (MNPs)

Adherence to home fortification of foods with multiple micronutrient powders (MNPs) is an essential indicator of effective implementation of MNP programmes. A meta‐analysis was conducted to evaluate the high adherence rate (HAR) to MNPs and further investigate the factors that influence HAR. We searched PubMed, Web of Science, Embase, CAB Abstracts, MEDLINE (OVID), Cochrane Library, China National Knowledge Infrastructure, Wanfang and VP, from the date of database inception to 9 November 2020. We included peer‐reviewed observational studies that investigated adherence to MNPs. Data on the HAR to MNPs and influencing factors on HAR were extracted and then pooled together. A total of 10 studies were included. The pooled HAR to MNPs was 63.28% (51.12%–74.64%). Among HARs, rates were higher in middle‐income countries (65.21%) than low‐income countries (55.23%). Parental age over 30 years (maternal age OR = 1.25, 95% CI: 1.08–1.44; paternal age OR = 1.17, 95% CI: 1.04–1.32), children aged 18–36 months (OR = 1.45, 95% CI: 1.12–1.88), maternal educational attainment of college or above (OR = 1.38, 95% CI:1.10–1.73), caregiver with the perception that other mothers use MNPs (OR = 1.52, 95% CI:1.19–1.95), caregiver being aware of the importance of iron (OR = 1.42, 95% CI: 1.18–1.71), caregiver having correct knowledge of MNPs (OR = 1.36, 95% CI:1.19–1.57) and caregiver reporting children have no side effects from MNPs (OR = 2.77, 95% CI: 2.46–3.11) were contributing factors to high adherence to MNPs. The overall HAR to MNPs was relatively low; hence, effective and trusted communication channels need to be established, along with more thorough dissemination of the knowledge of MNPs to caregivers, to improve MNPs adherence rates, especially in low‐income countries.

A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency

BACKGROUND

Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools.

OBJECTIVES

This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity.

METHODS

We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools.

RESULTS

At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity.

CONCLUSIONS

Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.

Home Fortification of Complementary Foods Reduces Anemia and Diarrhea among Children Aged 6-18 Months in Bihar, India: A Large-Scale Effectiveness Trial

BACKGROUND

Home fortification of complementary foods with multiple micronutrient powders (MNPs) is recommended to reduce child anemia in resource-poor settings. However, evidence of program effectiveness in India to guide policies and programs is lacking.

OBJECTIVES

We implemented a large-scale intervention of MNPs in Bihar, India. The primary outcome was MNP consumption and change in hemoglobin concentration among children aged 6-18 mo between baseline and endline (12 mo). Secondary outcomes were change in child weight and length and infant and young child feeding (IYCF) practices (initiation, diversity, and feeding frequency). Ad hoc analyses included changes in anemia; stunting; underweight; wasting; and reported diarrhea, fever, and hospitalization.

METHODS

We conducted a cluster-randomized, effectiveness trial in >4000 children within the context of ongoing health and nutrition programs implemented by CARE, India. Seventy health subcenters were randomly assigned to receive either MNPs with IYCF counseling (intervention) or IYCF counseling only (control). We used an adjusted difference-in-difference approach using repeat cross-sectional surveys at baseline and endline to evaluate impact.

RESULTS

At baseline, 75% of intervention and 69% of control children were anemic and 33% were stunted. By endline, 70% of intervention households reported their child had ever consumed MNPs, and of those, 64% had consumed MNPs in the past month. Relative to control, hemoglobin concentration increased (0.22 g/dL; 95% CI: 0.00, 0.44 g/dL) and anemia declined by 7.1 percentage points (pp) (95% CI: -13.5, -0.7 pp). There was no impact on anthropometry nor IYCF practices. However, there was a decline of 8.0 pp (95% CI: -14.9, -1.1 pp) in stunting among children aged 12-18 mo. Diarrhea prevalence in the past 2 wk was reduced by 4.0 pp (95% CI: -7.6, -0.4 pp).

CONCLUSIONS

Home fortification of complementary foods within a government-run program in Bihar had moderate compliance and caused modest improvements in hemoglobin and reductions in anemia and diarrhea prevalence.

Using formative research to design context-specific animal source food and multiple micronutrient powder interventions to improve the consumption of micronutrients by infants and young children in Tanzania, Kenya, Bangladesh and Pakistan

Optimal complementary feeding practices including consumption of multiple micronutrient powders (MNP) are recommended to improve micronutrient intake by infants and young children (IYC) 6-23 months. Formative research was used to design the behaviour change strategy to improve IYC micronutrient intake for the multicountry ENRICH project in rural impoverished areas of Tanzania, Kenya, Bangladesh and Pakistan. Employing a qualitative approach with multiple methods and guided by a social ecological framework, the study was conducted in several phases: data collection in the community, household and health facilities, initial analysis and household trials (HHT). Results found limited use of animal source foods (ASF) for feeding IYC and MNP largely unavailable. Although cost constrained access to ASF, potential more affordable context-specific ASF options were identified in each setting. Caregivers associated ASF with many positive attributes for IYC, but barriers to feeding them included lack of caregiver time and knowledge of specific preparation techniques, and limited advice from health workers. Feeding practices were identified that used time-efficient, specific preparations for eggs and other ASF, and demonstrated good initial acceptability and feasibility during HHT. Testing MNP in HHT found good initial feasibility and acceptability and provided an understanding of the facilitators and constraints for preparing, feeding and promoting MNP. In conclusion, formative research led to the design of context-specific ASF and MNP complementary feeding promotion strategies to improve IYC consumption of micronutrients by identifying the practices, benefits, motivations and alternative actions to overcome the barriers in each setting.

Acceptability of multiple micronutrient powders and iron syrup in Bihar, India

Nearly two thirds of young children are anaemic in Bihar, India. Paediatric iron and folic acid syrup (IFAS) and multiple micronutrient powders (MNPs) are two evidence‐based interventions to prevent anaemia. Using a randomized crossover design, we examined the acceptability of IFAS versus MNPs for children 6–23 months. In a catchment area of 2 health centres in Bihar, health front‐line workers (FLWs) delivered either (a) IFAS twice weekly or (b) MNPs for 1 month followed by the other supplementation strategy for 1 month to the same families (NCT02610881). Household surveys were conducted at baseline (N = 100), 1 month after receiving the first intervention (1 month; N = 95), and 1 month after the second intervention (2 months; N = 93). Focus group discussions (10 FLWs) and in‐depth interviews (20 mothers) were held at 1 and 2 months. We used chi‐square and Fisher exact tests to test mothers' product preferences. Qualitative data were analysed using MaxQDA and Excel employing a thematic analysis approach. There was high adherence and acceptability for both products (>80%). There was no significant difference in preference (p < .05) on perceived benefits (39% MNPs, 40% IFAS), side effects (30% MNPs, 30% IFAS), ease of use (42% IFAS, 31% MNPs), child preference (45% IFAS, 37% MNPs), and maternal preference (44% IFAS, 34% MNPs). Mothers and FLWs indicated that the direct administration of IFAS ensured that children consumed the full dose, and MNPs intake depended on the quantity of food consumed, especially among younger children, which emphasizes the need to integrate supplementation with the promotion of optimal child feeding practices.