Abstract
BackgroundThe 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.MethodsThis 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.DiscussionBetter 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 registrationNCT03940547, (April 24, 2019).
Highlights
The number of stunted children has fallen globally but continues to increase in Africa
We will collect contextual data about levels of AF contamination in infant foods and multiple human biomarkers and assess feeding practices and adherence to our intervention at multiple time points to better understand the pathways between AF ingestion and growth retardation. This two-group cluster randomized trial (CRT) is designed to test the hypothesis that provision of a complementary food porridge flour and separate groundnut flour, both with very low levels of AF (AFB1 < 5 ppb) will be associated with better linear growth in infants between 6 and 18 months of age compared to infants who consume complementary porridge and foods made with similar ingredients and groundnut flour, but acquired by the household
These Community health worker (CHW) were trained by Tanzanian Food and Nutrition Center trainers in March of 2019 in infant and young child feeding (IYCF) and lead IYCF education sessions for trial mothers in their communities
Summary
Aims This two-group cluster randomized trial (CRT) is designed to test the hypothesis that provision of a complementary food porridge flour and separate groundnut flour, both with very low levels of AF (AFB1 < 5 ppb) will be associated with better linear growth in infants between 6 and 18 months of age compared to infants who consume complementary porridge and foods made with similar ingredients and groundnut flour, but acquired by the household. 5. Assess the effect of an intervention to reduce AF exposure on the urinary biomarker AFM1 in a cohort of 600 infants at 9, 12, 15 and 18 months. Two community health workers (CHWs) per health facility were selected by the management of the facility to be employed part-time by the research project These CHWs were trained by Tanzanian Food and Nutrition Center trainers in March of 2019 in infant and young child feeding (IYCF) and lead IYCF education sessions for trial mothers in their communities. Babies > 6 weeks old and < 4 months old, who seek EPI from a randomized health facility and reside in Kongwa District. Exclusion criteria, assessed at recruitment and again at the 6-month visit: 1. A baby with a disability that preclude normal feeding and swallowing
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