Food-based approaches to improve nutritional quality of the complementary diet to address stunting

Integrating small‐quantity lipid‐based nutrient supplements (SQ‐LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ‐LNS programmes on IYCF practices. A 2‐year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices, plus monthly SQ‐LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility‐based IYCF counselling with no SQ‐LNS distributions). Cross‐sectional preintervention and postintervention surveys (n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to introduce water (+66.9% [60.6, 73.2], P < 0.001) and complementary foods (+56.4% [49.3, 63.4], P < 0.001), feeding the minimum meal frequency the previous day (+9.2% [2.7, 15.7], P = 0.005); feeding the child in a separate bowl (+9.7% [2.2, 17.2], P = 0.01); awareness of anaemia (+16.9% [10.4, 23.3], P < 0.001); owning soap (+14.9% [8.3, 21.5], P < 0.001); and washing hands after defecating and before cooking and feeding the child the previous day (+10.5% [5.8, 15.2], +12.5% [9.3, 15.6] and +15.0% [11.2, 18.8], respectively, P < 0.001 for all). The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ‐LNS, may be an important source of micronutrients and macronutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF–SQ‐LNS to improve IYCF practices, and ultimately children's nutritional status.

Achieving dietary micronutrient adequacy in a finite world

An Egg Feeding Intervention Increased Protein Quantity and Quality Among Young Malawian Children

Micronutrient deficiencies remain common among women and children in Sub‐Saharan Africa (SSA); in pregnant/lactating women, the intakes of essential fatty acids may also be low. Enriching home‐prepared foods with small‐quantity lipid‐based nutrient supplements (SQ‐LNSs) is a promising new strategy of delivering additional micronutrients, essential fatty acids and good quality protein to women and children. This narrative review aimed to examine the impact of SQ‐LNSs supplementation among women and infants and young children in SSA, and to discuss the differential impact of SQ‐LNS consumption across different settings.Papers reporting randomized trials conducted in SSA in which apparently healthy women and/or ≥6‐mo‐old children received SQ‐LNSs were identified through electronic and manual searches.Prenatal SQ‐LNS consumption reduced the prevalence of low gestational weight gain in Ghana when compared with multiple micronutrients supplementation, and was associated with poorer iron/hemoglobin status when compared with iron‐plus‐folic acid supplementation. SQ‐LNSs received alone or as intervention package improved infant/child growth in two trials in Ghana and one trial each in Burkina Faso, Kenya, Zimbabwe and South Africa, but had no impact on growth in two trials in Malawi. SQ‐LNSs supplementation improved motor development in Ghana, Burkina Faso, Malawi, Kenya, and South Africa, but had no impact on language, socio‐emotional, and executive functions in Ghana and Malawi and on Griffiths’ developmental scores in Malawi.SQ‐LNSs may contribute to improving child growth in SSA. More research is needed to determine the iron level in SQ‐LNSs effective for improving both maternal hemoglobin/iron status and birth outcomes.

Protein-quality evaluation of complementary foods in Indian children

To introduce practices for improving complementary feeding and evaluate their adoption and association with improved dietary intakes. A quasiexperimental pilot study comparing dietary intakes from complementary foods among three intervention communities and one control community before and after the intervention, and adoption of new complementary feeding practices among intervention communities following the intervention. Rural subsistence communities in southern Malawi, Central Africa. Mothers and their children aged 6 to 23 months receiving complementary foods. A participatory, nutrition education intervention based on four locally adapted lessons for complementary feeding practices designed to increase: (i) total complementary food intake; (ii) energy and nutrient density of the complementary diet, and; (iii) iron and zinc bioavailability of the complementary diet. Adoption rates for the four practices ranged from 25% for preparation of enriched porridges, to 10% for preparing soaked, pounded maize. The amount of complementary foods (g/day) and intakes of energy, animal protein, niacin, riboflavin, calcium, iron, and zinc, but not vitamin A, were significantly greater (P<0.05) in the intervention compared to control group, as were the energy, iron, and riboflavin density, and the estimated amount of bioavailable iron and zinc. Several intervention practices were well accepted and adopted and were associated with improved adequacy of energy and nutrient intakes from the complementary diet. Such improvements were attributed mainly to greater total intakes and, to a lesser extent, enhanced dietary quality of the complementary foods.

Objectives: A study was undertaken to determine whether benefits gained by providing small-quantity lipid-based nutrient supplements (SQ-LNS) from age 6–12 months were maintained at age 18 months compared with a delayed intervention. Design: Children who completed a randomised controlled trial were enrolled at age 12 months (n = 392) and followed-up until age 18 months (n = 252; dropout rate 35.7%). Two previously exposed (PE and PE-plus) groups (received SQ-LNS from 6–12 months, but no supplement from 12–18 months) were compared with the delayed intervention (DI) group (received no supplement from 6–12 months, but received SQ-LNS from 12–18 months). Methods and outcome measures: At age 12 and 18 months, weight, length, haemoglobin (Hb) and psychomotor development were measured. Setting: The study was carried out in peri-urban Jouberton area, Klerksdorp, South Africa. Subjects: Children aged 12–18 months. Results: Compared with DI, negative effects (either a trend or statistically significant) were observed for PE and PE-plus for length-for-age Z-scores (LAZ) (p = 0.091 and p = 0.075, respectively), PE-plus for weight-for-age Z-scores (WAZ) (p = 0.027), and PE and PE-plus for Hb (p = 0.080 and p = 0.033, respectively); and a positive effect for PE-plus for eye–hand coordination (p = 0.086). The odds for anaemia were higher for PE-plus compared with DI (OR = 1.68; 95% CI 0.91, 3.09). Regardless of group, prevalence of anaemia and stunting increased from age 12 to age 18 months. Conclusions Benefits of providing SQ-LNS from age 6–12 months were not sustained at age 18 months, compared with providing SQ-LNS from age 12–18 months. Studies to determine the optimum supplementary period to achieve sustainable benefits of SQ-LNS on linear growth and iron status are warranted.

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 In The Gambia, many children consume diets that are lacking in nutrients that are essential for their growth and development. This study aims to explore Gambian mothers' and grandmothers' perceptions around animal source foods (meat, eggs, milk etc.) in order to inform future interventions focused on improving child feeding practices. Methods In July and August 2023, nine semi – structured focus group discussions were conducted with mothers and grandmothers in two settings in The Gambia. A purposeful sample of participants were recruited with the support of each local Medical Research Council clinic. Data were analysed using the framework method and thematic analysis. Participants included 19 mothers and 12 grandmothers in a semi-rural area and 12 mothers and 12 grandmothers in a rural area, caring for children 6-24 months. Mothers and grandmothers were in separate groups. Results Knowledge gaps were identified in both settings regarding aspects of complementary feeding, such as the appropriate timing and methods for introducing animal source foods to children’s diets. Differences were noted in the availability and dissemination of infant and young child feeding information in the two settings, emphasising the crucial role of contextual factors in shaping future programmes. The accessibility and affordability of animal source foods, was found to be a key determinant of their inclusion into children’s diets. A reliance on commercially available complementary foods was common in both settings. Conclusion This study reveals disparities between current complementary feeding practices and guidelines in this setting. It also underscores context-specific barriers caregivers encounter in offering diverse complementary foods, including animal source foods. A high reliance on commercially available complementary foods was also uncovered, particularly in Keneba. Further research is recommended to aid the development of context- specific interventions.

In The Gambia, many children consume diets that are lacking in nutrients that are essential for their growth and development. This study aims to explore Gambian mothers' and grandmothers' perceptions around animal source foods (meat, eggs, milk etc.) in order to inform future interventions focused on improving child feeding practices. In July and August 2023, nine semi - structured focus group discussions were conducted with mothers and grandmothers in two settings in The Gambia. A purposeful sample of participants were recruited with the support of each local Medical Research Council clinic. Data were analysed using the framework method and thematic analysis. Participants included 19 mothers and 12 grandmothers in a semi-rural area and 12 mothers and 12 grandmothers in a rural area, caring for children 6-24 and grandmothers were in separate groups. Knowledge gaps were identified in both settings regarding aspects of complementary feeding, such as the appropriate timing and methods for introducing animal source foods to children's diets. Differences were noted in the availability and dissemination of infant and young child feeding information in the two settings, emphasising the crucial role of contextual factors in shaping future programmes. The accessibility and affordability of animal source foods, was found to be a key determinant of their inclusion into children's diets. A reliance on commercially available complementary foods was common in both settings. This study reveals disparities between current complementary feeding practices and guidelines in this setting. It also underscores context-specific barriers caregivers encounter in offering diverse complementary foods, including animal source foods. A high reliance on commercially available complementary foods was also uncovered, particularly in Keneba. Further research is recommended to aid the development of context- specific interventions.

BackgroundIn The Gambia, many children consume diets that are lacking in nutrients that are essential for their growth and development. This study aims to explore Gambian mothers' and grandmothers' perceptions around animal source foods (meat, eggs, milk etc.) in order to inform future interventions focused on improving child feeding practices.MethodsIn July and August 2023, nine semi – structured focus group discussions were conducted with mothers and grandmothers in two settings in The Gambia. A purposeful sample of participants were recruited with the support of each local Medical Research Council clinic. Data were analysed using the framework method and thematic analysis. Participants included 19 mothers and 12 grandmothers in a semi-rural area and 12 mothers and 12 grandmothers in a rural area, caring for children 6–24 and grandmothers were in separate groups.ResultsKnowledge gaps were identified in both settings regarding aspects of complementary feeding, such as the appropriate timing and methods for introducing animal source foods to children’s diets. Differences were noted in the availability and dissemination of infant and young child feeding information in the two settings, emphasising the crucial role of contextual factors in shaping future programmes. The accessibility and affordability of animal source foods, was found to be a key determinant of their inclusion into children’s diets. A reliance on commercially available complementary foods was common in both settings.ConclusionThis study reveals disparities between current complementary feeding practices and guidelines in this setting. It also underscores context-specific barriers caregivers encounter in offering diverse complementary foods, including animal source foods. A high reliance on commercially available complementary foods was also uncovered, particularly in Keneba. Further research is recommended to aid the development of context- specific interventions.

The objectives of this study were to estimate the quantity and nutritive quality of the complementary diet in rural Malawi, and to identify feeding practices, nutrients and dietary modifiers of iron and zinc bioavailability that may limit the quality of the diet. This cross-sectional study design included an anthropometric survey, a feeding practices questionnaire, and an interactive, 24 h recall dietary data survey. Four rural villages in Balaka district, southern Malawi. Mothers resident in the study communities with breastfed children aged up to 24 months were eligible. Stunting was prevalent among these weanlings. Maize was the predominant food source, with limited contribution of animal foods. Deficits in dietary energy and several nutrients were found when compared to estimated needs. When expressed per kg body weight, energy intakes appeared adequate. The bioavailability of zinc was low due to a high phytate:zinc molar ratio. Iron bioavailability was also low due to low intake of absorption enhancers such as meat/fish/poultry protein and ascorbic acid. Dietary quality was poorest for 6 to 8-month-old infants. Iron, zinc and calcium were the most limiting nutrients to the quality of the diet, partly exacerbated by the poor bioavailability of iron and zinc. Increased total intake and bioavailability of iron and zinc would improve the complementary diets. This study was funded by the Thrasher Research Fund, Salt Lake City, Utah, USA.

In South Africa, approximately one in four children under the age of five is stunted (NDoH, Stats SA, SAMRC & ICF, 2019) – a rate that has remained persistently high. The enduring social and economic impact of stunting, coupled with rising food prices, underscores the need for interventions that are both effective and affordable. This review synthesises global evidence on strategies for children aged 6–24 months and evaluates their suitability within South Africa’s social, fiscal, and institutional realities. Two approaches emerge as most promising short-term strategies: (i) nutrition education that equips caregivers and communities to adopt age-appropriate complementary feeding, and (ii) small-quantity lipid-based nutrient supplements (SQ-LNS) – 100-kcal, minimally processed nutrient-dense pastes rich in healthy fats, vitamins and minerals. Evidence indicates that these approaches can prevent undernutrition and foster linear growth when delivered at scale. These measures could yield rapid, affordable gains, but they must operate alongside longer-term structural reforms.

Recent meta-analyses demonstrate that small-quantity lipid-based nutrient supplements (SQ-LNS) for young children significantly reduce child mortality, stunting, wasting, anaemia and adverse developmental outcomes. Cost considerations should inform policy decisions. We developed a modelling framework to estimate the cost and cost-effectiveness of SQ-LNS and applied the framework in the context of rural Uganda. We adapted costs from a costing study of micronutrient powder (MNP) in Uganda, and based effectiveness estimates on recent meta-analyses and Uganda-specific estimates of baseline mortality and the prevalence of stunting, wasting, anaemia and developmental disability. Rural Uganda. Not applicable. Providing SQ-LNS daily to all children in rural Uganda (> 1 million) for 12 months (from 6 to 18 months of age) via the existing Village Health Team system would cost ∼$52 per child (2020 US dollars) or ∼$58·7 million annually. SQ-LNS could avert an average of > 242 000 disability-adjusted life years (DALYs) annually as a result of preventing 3689 deaths, > 160 000 cases of moderate or severe anaemia and ∼6000 cases of developmental disability. The estimated cost per DALY averted is $242. In this context, SQ-LNS may be more cost-effective than other options such as MNP or the provision of complementary food, although the total cost for a programme including all age-eligible children would be high. Strategies to reduce costs, such as targeting to the most vulnerable populations and the elimination of taxes on SQ-LNS, may enhance financial feasibility.

Small-quantity, lipid-based nutrient supplements (SQ-LNS) show promise to improve the quality of maternal and child diets, particularly during the first 1000 days of life. The potential of SQ-LNS to impact positively upon nutritional status relies on numerous factors, including complementary dietary intake, disease prevalence and dynamics of household utilization, including sharing practices. Therefore, this study sought to elucidate the patterns and determinants of SQ-LNS utilization among children 6-23 months and potential sharing practices of other household members prior to intervention development. In Ntchisi, Malawi and Cabo Delgado, Mozambique, both rural, agricultural settings, we conducted two home-feeding trials of 8 and 6 weeks, respectively, nested within a larger multi-phase, emergent formative research design. Multiple methods, including in-depth interviews (n = 38), direct meal observations (n = 80), full-day child observations (n = 38) and spot checks of SQ-LNS supply (n = 23), were conducted with households (n = 35 in Malawi; n = 24 in Mozambique). Overall, the SQ-LNS was utilized contrary to its recommended use, with 50% of households in Malawi reporting running out of stock too early and 87% of households in Mozambique either overusing or underusing the product. Utilization of SQ-LNS was manifested in four patterns of overuse and two of underuse and was determined by factors at multiple levels of influence. Maternal and child health efforts need to consider the reasons behind choices by households to overuse or underuse SQ-LNS and design intervention strategies to increase the likelihood of its appropriate utilization.