Abstract
Small-quantity lipid-based nutrient supplements (SQ-LNS) are promising home fortification products, but the optimal zinc level needed to improve growth and reduce morbidity is uncertain. We aimed to assess the impact of providing SQ-LNS with varied amounts of zinc, along with illness treatment, on zinc-related outcomes compared with standard care. In a placebo-controlled, cluster-randomized trial, 34 communities were stratified to intervention (IC) or non-intervention cohorts (NIC). 2435 eligible IC children were randomly assigned to one of four groups:1) SQ-LNS without zinc, placebo tablet; 2) SQ-LNS containing 5mg zinc, placebo tablet; 3) SQ-LNS containing 10mg zinc, placebo tablet; or 4) SQ-LNS without zinc and 5mg zinc tablet from 9–18 months of age. During weekly morbidity surveillance, oral rehydration salts were provided for reported diarrhea and antimalarial therapy for confirmed malaria. Children in NIC (n = 785) did not receive SQ-LNS, tablets, illness surveillance or treatment. At 9 and 18 months, length, weight and hemoglobin were measured in all children. Reported adherence was 97±6% for SQ-LNS and tablets. Mean baseline hemoglobin was 89±15g/L. At 18 months, change in hemoglobin was greater in IC than NIC (+8 vs -1g/L, p<0.0001), but 79.1% of IC were still anemic (vs. 91.1% in NIC). Final plasma zinc concentration did not differ by group. During the 9-month observation period, the incidence of diarrhea was 1.10±1.03 and of malaria 0.54±0.50 episodes per 100 child-days, and did not differ by group. Length at 18 months was significantly greater in IC compared to NIC (77.7±3.0 vs. 76.9±3.4cm; p<0.001) and stunting prevalence was significantly lower in IC (29.3%) than NIC (39.3%; p<0.0001), but did not differ by intervention group within IC. Wasting prevalence was also significantly lower in IC (8.7%) than in NIC (13.5%; p = 0.0003). Providing SQ-LNS daily with or without zinc, along with malaria and diarrhea treatment, significantly increased growth and reduced stunting, wasting and anemia prevalence in young children.Trial RegistrationClinicalTrials.gov NCT00944281
Highlights
Growth stunting in early life continues to be a critical public health concern in low-income countries [1,2]
Provision of Small quantity lipid-based nutrient supplements (SQ-LNS) along with simple feeding advice and treatment of confirmed cases of malaria and reported diarrhea resulted in significantly greater growth velocity and lower prevalence of stunting, wasting and anemia among children in the IC compared to children in the NIC
This reduction in stunting prevalence is of public health significance considering that stunting is associated with increased risk of morbidity and mortality, impaired cognition and educational performance, lower adult wages, and, when accompanied by excessive weight gain later in childhood, increased risk of nutrition-related chronic diseases [1,2]
Summary
Growth stunting in early life continues to be a critical public health concern in low-income countries [1,2]. Diarrhea and pneumonia are leading causes of morbidity and mortality among young children in low income countries and the case fatality for these illnesses is increased in undernourished children [3,4]. SQ-LNS provide ~20 g or ~110–120 kcal per day along with additional protein, essential fatty acids and 22 micronutrients, including zinc. Trials investigating the potential of SQ-LNS and mediumquantity LNS (MQ-LNS; at ~50 g or ~250–280 kcal per day) to prevent malnutrition and promote growth have yielded mixed results [12,13,14,15,16,17]. The beneficial impact of zinc on growth and morbidity is less clear when provided mixed with food, such as point-ofuse fortification of complementary foods with SQ-LNS or multiple micronutrient powders (MNP), possibly because of insufficient zinc content
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