Multiple Micronutrient Powders Research Articles

Impact of Two Forms of Daily Preventive Zinc or Therapeutic Zinc Supplementation for Diarrhea on Hair Cortisol Concentrations Among Rural Laotian Children: A Randomized Controlled Trial.

Zinc supplementation has been shown to reduce the morbidity burden among young children, and may reduce chronic stress. Hair cortisol has been promoted as an indicator of chronic stress. We assessed the impact of different strategies for delivering supplementary zinc on hair cortisol concentrations (HCC) in young Laotian children and examined risk factors associated with HCC. In a randomized double-blind controlled trial (NCT02428647), children aged 6–23 mo were randomized to one of four intervention groups and followed for ~36 weeks: daily preventive zinc (PZ) tablets (7 mg/day), daily multiple micronutrient powder (MNP) sachets (containing 10 mg zinc and 14 other micronutrients), therapeutic zinc (TZ) supplements for diarrhea treatment (20 mg/day for 10 days) or daily placebo powder. HCC of 512 children was assessed at baseline and endline. ANCOVA and linear regression models were used to assess group differences in HCC and to examine the risk factors associated with HCC, respectively. At enrollment, mean HCC was 28.8 ± 43.9 pg/mg. In models adjusted for age at enrollment, health district, and baseline HCC there was no overall effect of the interventions on endline HCC and change in HCC. When controlling for additional predetermined covariates, there was a marginally significant effect on change in HCC (p = 0.075) with a slightly lower reduction of HCC in TZ compared to PZ (mean change (95% CI): −4.6 (−7.0; −2.3) vs. −9.4 (−11.7; −7.0) pg/mg; p = 0.053). At baseline, consumption of iron rich foods was negatively associated with HCC, whereas AGP (α1-acid glycoprotein) levels, elevated AGP and C-reactive protein and high soluble transferrin receptor were positively associated with HCC. In young Laotian children, MNP, PZ and TZ had no impact on HCC. The marginal difference in change in HCC between the PZ and TZ groups was too small to be considered of health significance.

Effects of Daily Zinc, Daily Multiple Micronutrient Powder, or Therapeutic Zinc Supplementation for Diarrhea Prevention on Physical Growth, Anemia, and Micronutrient Status in Rural Laotian Children: A Randomized Controlled Trial

ObjectivesTo evaluate the optimal zinc supplementation strategy for improving growth and hematologic and micronutrient status in young Laotian children.Study designIn total, 3407 children aged 6-23 months were randomized to receive either daily preventive zinc tablets (7 mg/d), high-zinc, low-iron micronutrient powder (10 mg/d zinc, 6 mg/d iron, and 13 other micronutrients), therapeutic zinc supplementation for diarrhea (20 mg/d for 10 days per episode), or daily placebo powder; all were followed for ~9 months. Anthropometry, hemoglobin, zinc, and iron status were assessed at baseline and endline. Analyses were by intention-to-treat, using linear and modified Poisson regression.ResultsAt baseline, mean (±SD) age was 14.2 ± 5.1 months and stunting and anemia prevalence were 37.9% and 55.6%, respectively. At endline, zinc deficiency in the preventive zinc (50.7%) and micronutrient powder (59.1%) groups were significantly lower than in the therapeutic zinc (79.2%) and control groups (78.6%; P < .001), with no impact on stunting (37.1%-41.3% across the groups, P = .37). The micronutrient powder reduced iron deficiency by 44%-55% compared with other groups (P < .001), with no overall impact on anemia (P = .14). Micronutrient powder tended to reduce anemia by 11%-16% among children who were anemic at baseline (P = .06).ConclusionsDespite improving zinc status, preventive zinc and micronutrient powder had no impact on growth. The micronutrient powder improved iron status and tended to reduce anemia among the subset of previously anemic children.Trial registrationClinicalTrials.govNCT02428647.

Use of monitoring data to improve implementation of a home fortification program in Bihar, India.

This paper describes the use of program‐monitoring data to track program performance and inform activities. Monitoring data were collected as part of an effectiveness trial of multiple micronutrient powders (MNPs) for children 6–18 months in Bihar, India. Communities (n = 70; reaching over 10,000 children) were randomized to receive either counselling on infant and young child feeding or both counselling and MNPs. Government frontline health workers (FLWs) implemented and monitored program activities with support from CARE India and university partners. Monitoring data were collected over the duration of the entire program to assess program impact pathways using various checklists, which captured information about (a) attendance and training of FLWs at health subcentre meetings, (b) distribution of MNPs, (c) receipt and use of MNPs at the household level, and (d) midline mixed methods survey. At the beginning of the program, 72% of households reported receiving and 53% reported currently consuming MNPs. These numbers fell to 40% and 43% at midline, respectively. The main barrier to use by household was a lack of MNPs, due in part to infrequent FLW distribution. However, FLWs rarely reported MNP shortages at Anganwadi centres. Side effects also emerged as a barrier and were addressed through revised recommendations for MNP use. Qualitative data indicated high community acceptance of MNPs and a good understanding of the program by FLWs. The use of real‐time program data allowed for recognition of key program issues and decision‐making to enhance program implementation.

Risk-Benefit and Cost-Effectiveness of Universal Iron Interventions for Public Health Control of Anemia in Young Children in 78 Countries: A Microsimulation Study

Almost 300 million children worldwide are anemic. Universal distribution of iron interventions (iron supplements or iron-containing multiple micronutrient powders, MNPs) to young children (e.g. <2 years of age) is a key World Health Organization recommendation to prevent anemia in low-income countries. However, concerns of iron-induced infection risk and limited effectiveness for anemia and broader child health outcomes have raised questions about whether iron interventions produce a net health benefit and are cost-effective. This has constrained implementation. Net effects likely differ in each country according to the epidemiology of anemia and infection, and local health care costs. Quality of implementation likely also affects net benefit. This means analyses must be country-specific. To help guide policymakers, we estimated country-specific net benefit-risk and cost-effectiveness of universal intervention with MNPs or iron supplements to young children. We developed a bespoke microsimulation model to estimate country-specific net Disability Adjusted Life Years (DALYs) attributable to anemia and infection in children from age 0-18 months who received MNPs, iron supplements or control from age 6-12 months. The model utilised publically available data on anemia, malaria, diarrhoea and respiratory infection epidemiology, and modified their risks according to effect sizes from the pivotal systematic reviews of randomised trials used to inform current guidelines. We next estimated corresponding cost/ DALY averted. We modeled all 78 countries (46 in Africa, 20 in Asia and 12 in Latin America) where WHO reported that anemia prevalence exceeded 40% in 2011, or where pilot iron intervention programmes have been reported to be in place. We found that MNPs and iron supplements produced a net benefit to health in all countries, though the magnitude was heterogeneous.DALYs averted/ 10,000 children in Africa ranged from 20.2 (Egypt) to 81.8 (Burkina Faso), median 49.8; in Asia/Pacific/the Middle East from 22.7 (China) to 110.1 (Yemen), median 33.4, and in Latin America from 14.1 (Ecuador) to 68.5 (Bolivia), median 26.5.The median benefit from iron supplements in Africa was 76.4 DALYs averted/10,000 children and ranged from 39.7 in Zimbabwe to 111.6 in Burkina Faso; in Asia/Pacific/Middle East the median benefit was 71.7, ranging from 36.9 in the Phillipines to 133.3 in Pakistan and 133.0 in Yemen; and in Latin America the median benefit was 59.1, ranging from 93.5 in Bolivia to 39.5 in Guatemala. The magnitude of net benefit from MNPs and iron supplements on DALYs was strongly positively associated with the prevalence of moderate anemia (e.g. for MNPs: r=0.82, P=2.3x10-20). In Africa, MNPs cost between $961-$4341/DALY averted; in Asia/Middle-East/Pacific between $844-$3975/DALY averted, and in Latin America between $1306-$6566/DALY averted. The 10 countries where MNPs are most cost-effective were Yemen ($844/DALY averted), Burkina Faso ($961), Mauritania ($1119), The Gambia ($1165), Guinea-Bissau ($1165), Senegal ($1193), Mali ($1197), Guinea ($1267), and Ghana ($1273). Suboptimal coverage markedly reduced both DALYs averted and cost-effectiveness. The severity, not just overall prevalence of anemia, should be considered when planning a programme. Optimisation of programme coverage is essential to maximise cost-effectiveness. Our results augment existing guidelines and identify locations where iron interventions have the greatest benefit and are most cost-effective.Figure LegendCaterpillar plots and regional maps demonstrating DALYs averted/ 10,000 children for A) Multiple Micronutrient Powders, and b) Iron Supplements. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Comparison of two forms of daily preventive zinc supplementation versus therapeutic zinc supplementation for diarrhea on young children\u2019s physical growth and risk of infection: study design and rationale for a randomized controlled trial

BackgroundZinc is an essential nutrient that is required for children’s normal growth and resistance to infections, including diarrhea and pneumonia, two major causes of child mortality. Daily or weekly preventive zinc supplementation has been shown to improve growth and reduce the risk of infection, while therapeutic zinc supplementation for 10–14 days is recommended for the treatment of diarrhea. The overall objective of the present study is to compare several regimens for delivering zinc to young children, both for the prevention of zinc deficiency and the treatment of diarrhea.MethodsThe present study is a community-based, randomized controlled trial in the Lao People’s Democratic Republic (PDR). Three thousand, four hundred children 6–23 months of age will be randomized to one of four intervention groups (daily preventive zinc dispersible tablet, daily preventive multiple micronutrient powder, therapeutic zinc dispersible tablet for diarrhea, or placebo control); interventions will be delivered for 9 months and outcomes measured at pre-determined intervals. Primary outcomes include physical growth (length and weight), diarrhea incidence, hemoglobin and micronutrient status, and innate and adaptive immune function. Secondary outcomes include mid-upper-arm circumference, neuro-behavioral development, hair cortisol concentrations, markers of intestinal inflammation and parasite burden. Incidence of adverse events and the modifying effects of inherited hemoglobin disorders and iron status on the response to the intervention will also be examined. We will estimate unadjusted effects and effects adjusted for selected baseline covariates using ANCOVA.DiscussionMany countries are now rolling out large-scale programs to include therapeutic zinc supplementation in the treatment of childhood diarrhea, but few have established programs demonstrated to be effective in the prevention of zinc deficiency. This study will address how best to deliver supplemental zinc to prevent zinc deficiency and reduce the severity of diarrhea-related health complications.Trial registrationTrial registration identifier (NCT02428647) ; Date of registration: April 29, 2015.

Understanding the impact of nutrition-sensitive social protection interventions on the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children.

Understanding the impact of nutrition-sensitive social protection interventions on the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children.

Effectiveness of a home fortification programme with multiple micronutrients on infant and young child development: a cluster-randomised trial in rural Bihar, India

Research demonstrates the importance of nutrition for early brain development. Few studies have examined the effectiveness of multiple micronutrient powders (MNP) on child development. This study examined the impacts of home fortification with MNP on motor and mental development, executive function and memory of children living in Bihar. This two-arm cluster-randomised effectiveness trial selected seventy health sub-centres to receive either MNP and nutrition counselling (intervention) or nutrition counselling alone (control) for 12 months. Front-line health workers delivered the intervention to all households in study communities with a child aged 6-18 months. Data were collected using cross-sectional surveys at baseline and endline by selecting households from intervention (baseline, n 2184; endline, n 2170) and control (baseline, n 2176; endline, n 2122) communities using a two-stage cluster-randomised sampling strategy. Children in the intervention group had a significantly larger improvement from baseline to endline compared with those in the control group on scores for motor and mental development (Cohen's d, motor=0·12; 95 % CI 0·03, 0·22; mental=0·15; 95 % CI 0·06, 0·25). Greater impacts of MNP on motor and mental development were observed in children from households with higher stimulation scores at baseline compared with those with lower stimulation (Cohen's d, motor=0·20 v. 0·09; mental=0·22 v. 0·14; P interaction<0·05). No significant treatment differences were seen for executive function or memory. Home fortification with MNP through the existing health infrastructure in Bihar was effective in improving motor and mental development and should be considered in combination with other child development interventions such as stimulation.

Low level aflatoxin exposure associated with greater linear growth in southern Mexico: A longitudinal study.

Aflatoxins are a group of naturally occurring mycotoxins, which can lead to death and are a known cause of hepatocellular carcinoma. AF exposure has been hypothesised to lead to stunted growth in children, but separating the AF effect from other determinants of linear growth retardation is difficult. The study used secondary data from an efficacy trial conducted in young children in southern Mexico to test the comparative efficacy of a milk-based multiple micronutrient-fortified food, a multiple micronutrient syrup, or a multiple micronutrient powder. The effect of serum AFB1 -lysine adduct level on incremental growth was tested using a longitudinal mixed model, controlling for key individual, maternal, and household-level covariates. AFB1 -lysine adduct was detectable in all but 2 of the 347 children in the study (median exposure: 0.82pg/mg albumin). AF exposure was associated (p<.05) with greater linear growth: an increase equivalent to the sample interquartile range (~0.5pg AFB1 -lysine/mg albumin) was associated (p<.05) with an increase in the child's height-for-age deficit of 1.5 to 2.0mm in the 4months from baseline (average age 8months) to follow-up (average age 12months); the magnitude of the difference in the 10-month follow-up was smaller and not statistically significant. This study documents that low-dose AF exposure was associated with greater child linear growth. Given its toxicity and carcinogenicity, our results do not change the urgent need to drastically reduce human AF exposure. Our findings show that the association between AF exposure and linear growth is more complex than previously thought.

Randomized control trials demonstrate that nutrition-sensitive social protection interventions increase the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children.

To examine the impact of a nutrition-sensitive social protection intervention on mothers' knowledge of Fe deficiency, awareness of multiple-micronutrient powders (MMP) and the consumption of MMP and other Fe supplements by their children aged 6-59 months. Two randomized controlled trials with treatment arms including cash transfers, food transfers, cash and food transfers, cash and nutrition behaviour change communication (BCC), and food and nutrition BCC were implemented over two years. Both included a control group that received no transfer or BCC. Transfer recipients were mothers living in poor households with at least one child aged less than 2 years at baseline. Probit models were used to analyse endline data. Rural areas in north-west and south Bangladesh. Mothers (n 4840) and children 6-59 months (n 4840). A transfer accompanied by nutrition BCC increased the share of mothers with knowledge of Fe deficiency (11·9 and 9·2 percentage points for North and South, respectively, P≤0·01), maternal awareness of MMP (29·0 and 22·2 percentage points, P≤0·01), the likelihood that their children 6-59 months had ever consumed MMP (32 and 11·9 percentage points, P≤0·01), consumed MMP in the preceding week (16·9 and 3·9 percentage points, P≤0·01) and consumed either MMP or an Fe supplement in the preceding week (22·3 and 7·1 percentage points, P≤0·01). Improvements were statistically significant relative to groups that received a transfer only. Nutrition-sensitive social protection (transfers with BCC added) may be a promising way to advance progress on micronutrient deficiencies.

The WHO recommendation of home fortification of foods with multiple-micronutrient powders in children under 2 years of age and its effectiveness on anaemia and weight: a pragmatic cluster-randomized controlled trial.

To assess under real community settings the effectiveness of the WHO strategy of home fortification of foods (HFF) with multiple-micronutrient powders on Hb change, anaemia and weight in children. A pragmatic cluster-randomized controlled trial. Forty villages in the Nioro Circle in Mali and 722 children aged 6-23 months were randomized to the intervention or control group. The intervention consisted of a daily dose of multiple-micronutrient powder for 3 months; in the control group, no supplement was given. In both groups, mothers received group education on child complementary feeding. Changes in weight, Hb concentration and anaemia were assessed as primary outcomes at baseline and 3 months. The HFF effect was determined using regression analyses and quantile regression with standard errors taking account of the cluster design. Children aged 6-23 months. Overall prevalence of anaemia in the sample was high: 90 %. HFF provided a modest but statistically significant Hb change v. no intervention (0·50 v. 0·09 g/dl, P=0·023). Prevalence of anaemia changed little: 91·3-85·8 % (P=0·04) in the intervention group v. 88·1-87·5 % % (P=0·86) in the control group. Proportion of severe anaemia was reduced by 84 % (from 9·8 to 1·6 %) in the intervention group, but increased in the control group (from 8·5 to 10·8 %). No effect was observed on weight. The WHO HFF strategy to fight anaemia showed a modest change on Hb concentration and significantly reduced the rate of severe anaemia.

PROTOCOL: Efficacy and effectiveness of micronutrient supplementation and fortification interventions on the health and nutritional status of children under-five in low and middle-income countries: a systematic review.

PROTOCOL: Efficacy and effectiveness of micronutrient supplementation and fortification interventions on the health and nutritional status of children under-five in low and middle-income countries: a systematic review.

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.

Benefits and risks of Iron interventions in children (BRISC): protocol for a three-arm parallel-group randomised controlled field trial in Bangladesh

IntroductionAnaemia is a major global health problem affecting about 43% of preschool children globally and 60% of 6–24-month-old children in rural Bangladesh, half of which is attributed to iron deficiency...

The effect of a micronutrient powder home fortification program on anemia and cognitive outcomes among young children in rural China: a cluster randomized trial

BackgroundAnemia early in life has been associated with delayed cognitive and motor development. The WHO recommends home fortification using multiple micronutrient powders (MNPs) containing iron as a strategy to address anemia in children under two. We evaluated the effects of a program freely distributing MNP sachets to caregivers of infants in rural China.MethodsWe conducted a cluster-randomized controlled trial in Shaanxi province, enrolling all children aged 6–11 months in target villages. Following a baseline survey, investigators randomly assigned each village/cluster to a control or treatment group. In the treatment group, caregivers were instructed to give MNPs daily. Follow-up was after 6, 12, and 18 months of intervention. Primary outcomes were hemoglobin concentrations and scores on the Bayley Scales of Infant Development.ResultsOne thousand, eight hundred and-two eligible children and their caregivers were enrolled. At baseline 48% (870) of children were anemic and 29% (529) were developmentally delayed. Six hundred and-ten children (117 villages) were assigned to the control group and 1192 children (234 villages) were assigned to the treatment group. Assignment to the treatment group was associated with an improvement in hemoglobin levels (marginal effect 1.77 g/L, 95% CI 0.017–3.520, p-value = 0.048) and cognitive development (marginal effect 2.23 points, 95% CI 0.061–4.399, p-value = 0.044) after 6 months but not thereafter. There were no significant effects on motor development. Zero effects after the first 6 months were not due to low compliance, low statistical power, or changes in feeding behavior. Hemoglobin concentrations improved in both the treatment and control groups over the course of the study; however, 22% (325) of children remained anemic at endline, and 48% (721) were cognitively delayed.ConclusionsProviding caregivers with MNP sachets modestly hastened improvement in hemoglobin levels that was occurring absent intervention; however, this improvement did not translate into improved developmental outcomes at endline.Trial registrationISRCTN44149146; prospectively registered on 15th April 2013.

Iron in Micronutrient Powder Promotes an Unfavorable Gut Microbiota in Kenyan Infants.

Iron supplementation may have adverse health effects in infants, probably through manipulation of the gut microbiome. Previous research in low-resource settings have focused primarily on anemic infants. This was a double blind, randomized, controlled trial of home fortification comparing multiple micronutrient powder (MNP) with and without iron. Six-month-old, non- or mildly anemic, predominantly-breastfed Kenyan infants in a rural malaria-endemic area were randomized to consume: (1) MNP containing 12.5 mg iron (MNP+Fe, n = 13); (2) MNP containing no iron (MNP−Fe, n = 13); or (3) Placebo (CONTROL, n = 7), from 6–9 months of age. Fecal microbiota were profiled by high-throughput bacterial 16S rRNA gene sequencing. Markers of inflammation in serum and stool samples were also measured. At baseline, the most abundant phylum was Proteobacteria (37.6% of rRNA sequences). The proteobacterial genus Escherichia was the most abundant genus across all phyla (30.1% of sequences). At the end of the intervention, the relative abundance of Escherichia significantly decreased in MNP−Fe (−16.05 ± 6.9%, p = 0.05) and CONTROL (−19.75 ± 4.5%, p = 0.01), but not in the MNP+Fe group (−6.23 ± 9%, p = 0.41). The second most abundant genus at baseline was Bifidobacterium (17.3%), the relative abundance of which significantly decreased in MNP+Fe (−6.38 ± 2.5%, p = 0.02) and CONTROL (−8.05 ± 1.46%, p = 0.01), but not in MNP-Fe (−4.27 ± 5%, p = 0.4445). Clostridium increased in MNP-Fe only (1.9 ± 0.5%, p = 0.02). No significant differences were observed in inflammation markers, except for IL-8, which decreased in CONTROL. MNP fortification over three months in non- or mildly anemic Kenyan infants can potentially alter the gut microbiome. Consistent with previous research, addition of iron to the MNP may adversely affect the colonization of potential beneficial microbes and attenuate the decrease of potential pathogens.

Informing infant and young child feeding programming in humanitarian emergencies: An evidence map of reviews including low and middle income countries.

Around 200million people were affected by conflict and natural disasters in 2015. Whereas those populations are at a particular high risk of death, optimal breastfeeding and complementary feeding practices could prevent almost 20% of deaths amongst children less than 5years old. Yet, coverage of interventions for improving infant and young child feeding (IYCF) practices in emergencies is low, partly due to lack of evidence. Considering the paucity of data generated in emergencies to inform programming, we conducted an evidence map from reviews that included low- and middle-income countries and looked at several interventions: (a) social and behavioural change interpersonal and mass communication for promoting breastfeeding and adequate complementary feeding; (b) provision of donated complementary food; (c) home-based fortification with multiple micronutrient powder; (d) capacity building; (e) cash transfers; (f) agricultural or fresh food supply interventions; and (g) psychological support to caretakers. We looked for availability of evidence of these interventions to improve IYCF practices and nutritional status of infants and young children. We identified 1,376 records and included 28 reviews meeting the inclusion criteria. The highest number of reviews identified was for behavioural change interpersonal communication for promoting breastfeeding, whereas no review was identified for psychological support to caretakers. We conclude that any further research should focus on the mechanisms and delivery models through which effectiveness of interventions can be achieved and on the influence of contextual factors. Efforts should be renewed to generate evidence of effectiveness of IYCF interventions during humanitarian emergencies despite the challenges.

Impact of Home Fortification of Complementary Foods Program on Child Anemia and Stunting in Bihar, India

Home fortification of complementary foods with multiple micronutrient powders (MMP) is recommended to reduce child anemia in resource‐poor settings. However, there is a lack of program effectiveness data in Bihar, India to guide policies. We conducted a cluster randomized effectiveness trial in West Champaran, Bihar in over 4000 children aged 6–18 months for a duration of one year, within the context of an ongoing program (CARE, India: Integrated Family Health Initiative) delivered by community front line workers. 70 health sub‐centers were randomized to intervention (MMPs and Infant and Young Child Feeding (IYCF) counseling) or control (only IYCF counseling). The MMPs included a daily RDA of iron, zinc, iodine, folic acid, and vitamins A, C and B12, for children. The study aimed to determine impact on measures of nutritional status (anemia, stunting, underweight and wasting) and child feeding practices and inform potential statewide scale‐up. A secondary objective was to examine potentially adverse outcomes (diarrhea, hospitalization and fever). We used a difference in difference approach using cross‐sectional baseline and endline surveys to evaluate impact and adjusted for caste, socioeconomic status, age, gender, maternal education, young mother status, and religion. The duration of the intervention was one year and at baseline, 72% of children were anemic and 33% were stunted. Although 86% of caretakers indicated that they would like to continue using the powders, only 38% of children had consumed MMPs in the last month and 24% were currently consuming MMP at endline. Anemia declined significantly by 7.8% (6.7% in adjusted models; p&lt;0.05) with a greater decline among children 12–18 months (9.3%, p&lt;0.05). There were no overall effects on the prevalence of stunting, underweight or wasting but there was a significant decline of 8.4% in stunting for children aged 12–18 months (7.2% in adjusted models; p&lt;0.05). There were no significant differences in IYCF (age of initiation of complementary feeding, feeding frequency, dietary diversity or minimum acceptable diet). There were no differences in severe morbidity (bloody diarrhea, severe diarrhea, persistent diarrhea, hospitalizations or fever) and there was a significant 4% decrease in the prevalence of any diarrhea self‐reported in past 2 weeks in the intervention communities. In conclusion, home fortification of complementary foods is a promising intervention associated with modest improvements in anemia and possibly stunting within the existing government run program context in Bihar, India.Support or Funding InformationFunding support provided by a BMGF grant through a subcontract with CARE‐India

Home fortification with multiple micronutrient powders improves infant and young child development in Bihar, India

Estimates based on stunting and extreme poverty show that, in South Asia, approximately 88 million children under five years of age fail to fulfill their developmental potential. Children in Bihar, India may be at particularly high risk because many experience chronic malnutrition with implications for brain development. This study examined the impacts of home fortification with multiple micronutrient powders (MMPs) (including iron, zinc, iodine, folic acid, and vitamins A, C and B12) on motor and mental development, memory, and executive function of children 6–18 months of age living in West Champaran, Bihar.Seventy health sub‐centers from West Champaran district were randomized to either MMPs and nutrition counseling (intervention) or nutrition counselling alone (control) for 12 months. Frontline health workers delivered MMPs and/or nutrition counseling to all households in study communities with a child 6–18 months of age. Data were collected using cross‐sectional household surveys at study baseline (N=4359) and endline (N=4292) with households selected from intervention and control communities using a 2‐stage cluster randomized sampling strategy. The Developmental Milestones Checklist‐II was used to assess motor and mental development, Elicited Imitation tasks were used to assess memory, and the A‐Not‐B test was used to assess executive function. Impacts of the intervention on child development outcomes were estimated with linear mixed models adjusted for clustering, using restricted maximum likelihood estimation.At baseline, 72% of children were anemic and 33% were stunted. In adjusted analyses, children in the intervention group had a significantly (P&lt;0.01) larger increase from baseline to endline compared to those in the control group on scores for gross motor (difference in difference=0.47, SE=0.13), language (DiD=0.25, SE=0.09), and personal‐social development (DiD=0.37, SE=0.14) after adjusting for clustering, age of the child, baseline hemoglobin, and baseline household stimulation score. However, we noted significant effect modification of MMP impacts on language and personal‐social development (PSD) by household stimulation scores at baseline such that impacts were greater for children from households with higher stimulation scores at baseline compared to those from households with lower stimulation scores at baseline (Cohen's d, language =0.13 v. 0.07; Cohen's d, PSD=0.09 v. 0.07; P‐interaction &lt;0.05). No significant impacts were seen for MMP on memory or executive function.Home fortification with multiple micronutrient powders through the existing health infrastructure in Northern India was effective in improving child motor and mental development and should be considered in combination with other household stimulation initiatives.Support or Funding InformationFunding for this work was obtained from the Bill and Melinda Gates Foundation and the Thrasher Research Fund. NCT02593136

Acceptability and Feasibility of Multiple Micronutrient Powders vs. Iron Syrup in Young Children in Bihar, India

Nearly 80% of children under 5 are anemic in Bihar, India. Pediatric iron/folic‐acid syrup (IFAS) and multiple micronutrient powders (MMPs) are two of the evidence‐based interventions to prevent anemia. India's current policy solution includes IFAS for children, but there are limited data on the use and effectiveness of MMPs. We examined the acceptability and feasibility of IFAS versus MMPs, using a longitudinal randomized cross‐over design (NCT02610881). Informed consent was obtained from caregivers of children 6–23 mo (N=100) covered under two health centers (HCs) in West Champaran district, Bihar. In one HC, five trained Accredited Social Health Activists (ASHAs), a cadre of front line workers, delivered MMPs to 10 eligible households for one month, and then IFAS for one month. In the second HC, ASHA's delivered IFAS in the first month followed by MMPs. Crossovers were separated by a 2‐week washout. Per Government of India guidelines, ASHAs administered 1 ml IFAS via standardized and calibrated droppers to children twice per week. For MMPs, ASHAs delivered 30 sachets to families once with instructions to use one sachet per day and followed‐up after 2 weeks. Household surveys were conducted at baseline (N=100), midline (1 mo; N= 95) and endline (2 mo; N= 93). Focus group discussions and in‐depth interviews were held at baseline and endline with 10 participating ASHAs and 10 mothers per HC, respectively. For both products there was high compliance (&gt; 80% reported taken as instructed) and high acceptability (&gt; 90% consumed product and would continue using). Mothers reported IFAS and MMPs to be beneficial for their children (39% MMPs, 40% IFAS, 18% both, 2% neither), and to have few side effects (30% MMPs, 30% IFAS, 2% both, 38% neither). There was no significant preference for either product based on ease of use (42% IFAS, 31% MMPs, 25% both, 2% neither), preferred by the child (45% IFA syrup, 37% MMPs, 16% both, 2% neither), preferred by caregiver (44% IFAS, 34% MMPs, 19% both, 2% neither), and preference for continued use (38% IFAS, 37% MMPs, 24% both, 2% neither). ASHAs were willing to distribute either product but reported concerns about increased work load and need for incentives. Mothers and ASHAs indicated that the direct delivery of IFAS ensured that the child received and consumed the full dose whereas MMPs consumption depended on quantity of food consumed, especially among younger children. Preference for IFAS may also be related to a belief that the child would “waste less.” Another perceived advantage was that administration did not involve food. Our study highlights that IFAS and MMPs were highly acceptable for consumption by children and for delivery by ASHAs, thus offering additional policy options for preventing pediatric anemia, and emphasizing the need to integrate supplementation with the promotion of optimal infant and young child feeding practices.Support or Funding InformationFunding: Bill &amp; Melinda Gates Foundation, through POSHAN, led by IFPRI

Provision of 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

Provision of 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