Multiple Micronutrient Powders Research Articles

Simulated effects of home fortification of complementary foods with micronutrient powders on risk of inadequate and excessive intakes in West Gojjam, Ethiopia

Home fortification of complementary foods (CFs) with multiple micronutrient powders (MNPs) is being scaled up in various countries, but little is known about the prevailing complementary feeding practices and the type and nutrient gaps to be filled with MNPs. The present study evaluated the complementary feeding practices of young children and simulated the risk of inadequate and excessive intakes associated with home fortification with MNPs. We have assessed the sociodemographic status, anthropometry, and complementary feeding practices of young children (N=122) in Mecha district, rural Ethiopia. Using a 2-day, quantitative 24-hr recall, usual intakes of energy, protein, iron, zinc, and calcium were estimated. The risks of inadequate and excessive iron and zinc intakes with or without home fortification scenarios were assessed. The simulations considered intakes from CFs assuming average breast milk contributions and additional nutrients provided by the MNPs. Stunting was highly prevalent (50%) and was associated with a lower dietary diversity (P=.009) and nutrient intakes from the CFs. Median energy, zinc, and calcium intakes were below the estimated needs from CFs; protein needs were met. Median dietary iron intake appeared adequate, but 76%, 95% CI [68%, 84%], of children had inadequate intake (assuming low bioavailability), whereas another 8%, 95% CI: [3%, 13%], had excessive intakes. Simulation of daily and alternative day's fortification with MNP decreased the prevalence of inadequate iron and zinc intake but significantly increased the risk of excessive intakes that remained unacceptably high for iron (>2.5%). Untargeted MNP interventions may lead to excessive intakes, even in settings where poor complementary feeding practices are prevalent.

Effectiveness of UNICEF Multiple Micronutrient Powder on Child Stunting Rate and Influencing Factors in Kisangani

Effectiveness of UNICEF Multiple Micronutrient Powder on Child Stunting Rate and Influencing Factors in Kisangani

A Combined Intervention of Zinc, Multiple Micronutrients, and Albendazole Does Not Ameliorate Environmental Enteric Dysfunction or Stunting in Rural Malawian Children in a Double-Blind Randomized Controlled Trial

Environmental enteric dysfunction (EED) and linear growth stunting affect many rural agrarian children in the developing world and contribute to the persistently high rates of stunting that are observed worldwide. Effective interventions to consistently ameliorate EED are lacking. We tested whether a bundle of safe and affordable interventions would decrease EED and stunting over 12-24 wk in a cohort of rural Malawian children 12-35 mo old. This was a randomized, double-blind, placebo-controlled clinical trial in which the intervention group received a single dose of albendazole and 14 d of zinc at enrollment and after 20 wk. The intervention group also received a daily multiple micronutrient powder throughout the 24 wk of study. The primary outcomes were improvements in EED, as measured by the urinary lactulose-to-mannitol ratio (L:M ratio) from dual-sugar absorption testing, and linear growth. Urinary L:M ratios and anthropometric measurements were evaluated after 12 and 24 wk of intervention and compared with a placebo group that did not receive any of these interventions. A total of 254 children were enrolled at a mean age of 24 mo; 55% were female. Their mean weight-for-age z score was -1.5, and their mean length-for-age z score was -0.9. After 12 and 24 wk of study, increases in the L:M ratio did not differ between the intervention group (0.071 and 0.088 units, respectively) and the placebo group (0.073 and 0.080 units, respectively) (P = 0.87 and 0.19, respectively). Relative changes in length and weight also did not differ significantly between groups at any time point. The combined usage of albendazole, zinc, and a daily multiple micronutrient powder did not decrease EED or stunting in this population of agrarian children 12-35 mo old in rural Malawi. Alternative interventions to improve these diseases should be investigated. This trial was registered at clinicaltrials.gov as NCT02253095.

The impact of home fortification with multiple micronutrient powder on vitamin A status in young children: A multicenter pragmatic controlled trial in Brazil.

Home fortification with multiple micronutrient powder (MNP) is effective in the prevention of anemia in young children. However, the impact on their vitamin A status remains controversial. This study aimed to evaluate the effect of MNP on vitamin A status in young Brazilian children. A multicenter pragmatic, controlled trial was carried out in primary health centers in four Brazilian cities. In the beginning of the study, the control group (CG) consisted of children 11-14months old (n=395) attending in routine pediatric health care. In parallel, the intervention group (IG) was composed of children 6-8months old (n=399), in the same health centers, who followed the intervention with MNP for 2-3months. The analysis of the effect of MNP on vitamin A status was performed by comparing the IG with the CG after a 4- to 6-month follow-up when IG children had reached the age of the controls. The prevalence of vitamin A deficiency (VAD; serum retinol <0.70μmol/L) in the CG was 16.2%, while in the IG was 7.5%-a 55% reduction in the VAD [prevalence ratio (95% confidence interval)=0.45 (0.28; 0.72)]. This reduction was also significant when stratifying the study centers by coverage of the Brazilian Vitamin A Supplementation Program. The adjusted mean of vitamin A serum concentrations improved in the IG compared with CG children, with a shift to the right in the vitamin A distribution. Home fortification with MNP was effective in reducing VAD among young Brazilian children.

Adherence to multiple micronutrient powders and associated factors in children aged 6 to 35 months treated in sentinel health facilities, Ministry of Health of Peru.

Anemia in children is a public health issue, and the current strategies include treatment and iron supplementation, but their level of adherence or compliance is unknown. To consider the adherence to multiple micronutrient powders and the associated factors. Epidemiological study of active surveillance through sentinel facilities in 2,024 children aged 6 to 35 months treated in health facilities of the Ministry of Health of Peru, from October to December 2014. Household visits were conducted in which counting of multiple micronutrient powders was applied and determined an adherence of consumption ≥ 90% envelopes, besides a form on the associated factors (anemia knowledge, iron-rich food, side effects, dosage regimen, drugs used, and motivation) was applied. Descriptive statistics, χ² test, Odds Ratio with a 95% confidence interval (CI), and binary logistic regression or adjusted Odds Ratio (aOR) were used. Of all, 79.1% participants were aged 6 to 23 months; 75.9% received multiple micronutrient powders; and the adherence was equivalent to 24.4% (95%CI 22.3 - 26.6). The factors: continue supplementation (OR = 3.5; 95%CI 1.7 - 7.5); no nausea (OR = 3.0; 95%CI 2.0 - 4.3); no use of antibiotics (OR = 2.5; 95%CI 1.7 - 3.6); and intention to continue treatment (OR = 2.3; 95%CI 1.3 - 4.1) were associated with adherence. The variables: thought of continuing treatment (aOR = 2.6; 95%CI 1.1 - 6.1); presence of side effects, but no discontinuation of the treatment (aOR = 2.5; 95%CI 1.4 - 4.3); no use of antibiotics (aOR = 2.0; 95%CI 1.1 - 3.4); and belief that not only drugs cure anemia (aOR = 1.6; 95%CI 1.0 - 2.6) were associated in the multivariate analysis. There was a low prevalence of adherence to a demanding cut-off point (≥ 90% of envelopes of multiple micronutrient powders), and the associated factors are associated with absence of infections, side effects, and mother's beliefs.

Effects of responsive stimulation and nutrition interventions on children's development and growth at age 4 years in a disadvantaged population in Pakistan: a longitudinal follow-up of a cluster-randomised factorial effectiveness trial.

A previous study in Pakistan assessed the effectiveness of delivering responsive stimulation and enhanced nutrition interventions to young children. Responsive stimulation significantly improved children's cognitive, language, and motor development at 2 years of age. Both interventions significantly improved parenting skills, with responsive stimulation showing larger effects. In this follow-up study, we investigated whether interventions had benefits on children's healthy development and care at 4 years of age. We implemented a follow-up study of the initial, community-based cluster-randomised effectiveness trial, which was conducted through the Lady Health Worker programme in Sindh, Pakistan. We re-enrolled 1302 mother-child dyads (87% of the 1489 dyads in the original enrolment) for assessment when the child was 4 years of age. The children were originally randomised in the following groups: nutrition education and multiple micronutrient powders (enhanced nutrition; n=311), responsive stimulation (n=345), combined responsive stimulation and enhanced nutrition (n=315), and routine health and nutrition services (control; n=331). The data collection team were masked to the allocated intervention. The original enrolment period included children born in the study area between April 1, 2009, and March 31, 2010, if they were up to 2·5 months old without signs of severe impairments. The primary endpoints for children were development and growth at 4 years of age. Interventions were given in monthly group sessions and in home visits. The primary endpoint for mothers was wellbeing and caregiving knowledge, practices, and skills when the child was 4 years of age. Analysis was by intention to treat. The original trial is registered with ClinicalTrials.gov, number NCT00715936. 1302 mother-child dyads were re-enrolled between Jan 1, 2013, and March 31, 2013, all of whom were followed up at 4 years of age. Children who received responsive stimulation (with or without enhanced nutrition) had significantly higher cognition, language, and motor skills at 4 years of age than children who did not receive responsive stimulation. For children who received responsive stimulation plus enhanced nutrition, effect sizes (Cohen's d) were 0·1 for IQ (mean difference from control 1·2, 95% CI -0·3 to 2·7), 0·3 for executive functioning (0·18, -0·07 to 0·29), 0·5 for pre-academic skills (7·53, 5·14 to 9·92) and 0·2 for pro-social behaviours (0·08, 0·03 to 0·13). For children who received responsive stimulation alone, effect sizes were 0·1 for IQ (mean difference with controls 1·7, -0·3 to 3·7), 0·3 for executive functioning (0·17, 0·07 to 0·27), 0·2 for pre-academic skills (3·86, 1·41 to 6·31), and 0·2 for pro-social behaviours (0·07, 0·02 to 0·12). Enhanced nutrition improved child motor development, with effect size of 0·2 for responsive stimulation plus enhanced nutrition (0·56, -0·03 to 1·15), and for enhanced nutrition alone (0·82, 0·18 to 1·46). Mothers who received responsive stimulation (with or without enhanced nutrition) had significantly better responsive caregiving behaviours at 4 years of child age than those who did not receive intervention. Effect size was 0·3 for responsive stimulation plus enhanced nutrition (1·95, 0·75 to 3·15) and 0·2 for responsive stimulation (2·01, 0·74 to 3·28). The caregiving environment had a medium effect size of 0·3 for all interventions (responsive stimulation plus enhanced nutrition 2·99, 1·50 to 4·48; responsive stimulation alone 2·82, 1·21 to 4·43; enhanced nutrition 3·52, 1·70 to 5·34). Responsive stimulation delivered in a community health service can improve child development and care, 2 years after the end of intervention. Future analyses of these data are needed to identify which children and families benefit more or less over time. Grand Challenges Canada.

Multiple micronutrients in powder delivered through primary health care reduce iron and vitamin A deficiencies in young Amazonian children.

We evaluated the effect of home fortification with multiple micronutrient powder (MNP) on anaemia and micronutrient status of young Amazonian children. A pragmatic controlled trial was performed. A control group (CG) of children aged 11-14 months was recruited in the routine of primary health-care centres for assessing anaemia and micronutrient status. At the same time, an intervention group (IG) of infants aged 6-8 months was recruited in the same health centres to receive MNP daily in complementary feeding for 2 months. The IG children were assessed 4-6 months after enrolment (n 112) when they had reached the age of the CG participants (n 128) for comparisons. Primary health centres in Rio Branco city, Brazilian Amazon. A total of 240 children aged<2 years. In the CG, the prevalence of anaemia (Hb8·3 mg/l) and vitamin A deficiency (VAD; serum retinol <0·70 μmol/l) was 20·3 %, 72·4 % and 18·6 %, respectively. Among the IG participants (aged 11-14 months), the prevalence of anaemia, ID and VAD was 15·2 %, 25·2 % and 4·7 %, respectively. The IG had a lower likelihood of ID (prevalence ratio (95 % CI): 0·34 (0·24, 0·49)) and VAD (0·25 (0·09, 0·64)). Home fortification of complementary feeding delivered through primary health care was effective in reducing iron and vitamin A deficiencies among young Amazonian children.

Effect of micronutrient powder supplementation for two and four months on hemoglobin level of children 6–23 months old in a slum in Dhaka: a community based observational study

Anemia is pervasive among children under the age of two years in Bangladesh. This study aimed to assess the effect of daily supplementation of multiple micronutrient powder (MNP) for 2 months and 4 months primarily on hemoglobin status of children aged 6–23 months living in a slum of Dhaka, Bangladesh. It was a community-based observational study where a total of 402 children and 578 children were enrolled for 2 months and 4 months MNP supplementation respectively. Venous blood was collected at enrollment and 5 months later. Hemoglobin level was measured and morbidity episodes recorded from twice weekly home visits. At enrollment, hemoglobin levels were 10.57 ± 1.28 g/dl and 10.78 ± 1.35 g/dl across 2 months and 4 months MNP supplementation groups respectively, compared to 10.65 ± 1.36 g/dl and 11.14 ± 1.11 g/dl at the end-line after MNP supplementation. Plasma hemoglobin increased only after 4 months supplementation in difference-in-difference analysis and this was significantly more in younger children after adjusting the confounding variables (p = 0.03). Prevalence of anemia had improved for both at 2 months (p = 0.015) and 4 months (p = 0.004) of MNP supplementation. Incidence rate ratios (IRR) for diarrhea, cough and fever were comparable across the groups during the supplementation periods and IRR for acute lower respiratory tract infection was significantly lower in 4 months supplementation group with a IRR of 0.30 (95 % CI; 0.22, 0.42). Four months MNP supplementation was relatively more effective in improving hemoglobin level in children 6–24 months.

A Changing Landscape for Vitamin A Programs: Implications for Optimal Intervention Packages, Program Monitoring, and Safety.

Vitamin A deficiency (VAD) remains a widespread public health problem in the developing world, despite changes in under-5 mortality rates, morbidity patterns, and intervention options. This article considers the implications of a changing epidemiologic and programmatic landscape for vitamin A (VA) programs. We review progress to prevent VAD and its health consequences, assess gaps in VA status and intervention coverage data, and assess data needed to guide decisions regarding the optimal mix, targeting, and dose of VA interventions to maximize benefit and minimize risk. Vitamin A supplementation programs have contributed to the reduction in under-5 mortality rates, but alone, do not address the underlying problem of inadequate dietary VA intakes and VAD among preschool-aged children in the developing world. A combination of VA interventions (eg, supplementation, fortified foods, multiple micronutrient powders, and lipid-based nutrient supplements) will be required to achieve VA adequacy in most settings. Current efforts to measure the coverage of multiple VA interventions, as well as whether and how much VA children are receiving, are few and fragmented. Where intervention overlap exists, further effort is needed to monitor VA intakes, ensuring that targeted groups are consuming adequate amounts but not exceeding the tolerable upper intake level. Vitamin A status data will also be critical for navigating the changing landscape of VA programs. Data from these monitoring efforts will help to guide decisions on the optimal mix, targeting, and exposure to VA interventions to maximize public health benefit while minimizing any potential risk.

Why is multiple micronutrient powder ineffective at reducing anaemia among 12–24 month olds in Colombia? Evidence from a randomised controlled trial

In Colombia’s bottom socio-economic strata, 46.6% of children under two are anaemic. A prevalence of above 20% falls within the WHO guidelines for daily supplementation with multiple micronutrient powder (MNP). To evaluate the effect of daily MNP supplementation on anaemia amongst Colombian children aged 12–24 months we ran a cluster RCT (n=1440). In previous work, we found the intervention had no impact on haemoglobin or anaemia in this population. In this current paper, we investigate this null result and find it cannot be explained by an underpowered study design, inaccurate measurements, low adoption of and compliance with the intervention, or crowding out through dietary substitution. We conclude that our intervention was ineffective at reducing rates of childhood anaemia because MNP itself was inefficacious in our population, rather than poor implementation of or adherence to the planned intervention. Further analysis of our data and secondary data suggests that the evolution with age of childhood anaemia in Colombia, and its causes, appear different from those in settings where MNP has been effective. Firstly, rates of anaemia peak at much earlier ages and then fall rapidly. Secondly, anaemia that remains after the first year of life is relatively, and increasingly as children get older, unrelated to iron deficiency. We suggest that factors during gestation, birth, breastfeeding and early weaning may be important in explaining very high rates of anaemia in early infancy. However, the adverse effects of these factors appear to be largely mitigated by the introduction of solid foods that often include meat. This renders population wide MNP supplementation, provided after a diet of solid foods has become established, an ineffective instrument with which to target Colombia’s childhood anaemia problem.

Integration to Implementation and the Micronutrient Forum: A Coordinated Approach for Global Nutrition. Case Study Application: Safety and Effectiveness of Iron Interventions.

Paramount among the challenges to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance. The Integration to Effective Implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the food and nutrition enterprise. The 2014 Micronutrient Forum (MNF) Global Conference held in Addis Ababa, Ethiopia, in June 2014 offered the opportunity to apply the I-to-I approach with the use of current concerns about the safety and effectiveness of interventions to prevent and treat iron deficiency (ID) as a case study. ID is associated with a range of adverse outcomes, especially in pregnant and nonpregnant women, infants, and primary school-age children. Strategies to combat ID include iron supplementation, multiple micronutrient powders, and food-based interventions to enhance dietary iron intake. Recent reports indicate potential increased adverse risks when iron is provided in areas with high infection burdens (e.g., malaria). This paradox has weakened iron intervention programs. Furthermore, the selection and interpretation of available biomarkers for assessing iron nutrition have been found to be compromised by the inflammatory process. These issues highlight the need for a comprehensive approach that considers basic biology, assessment, interventions, and how these can be translated into appropriate programs and policies. The application of the I-to-I with the use of the MNF offered an opportunity to explore how that might be achieved.

The role of folate in malaria - implications for home fortification programmes among children aged 6-59 months.

Folic acid and iron supplementation has historically been recommended as the preferred anaemia control strategy among preschoolers in sub-Saharan Africa and other resource-poor settings, but home fortification of complementary foods with multiple micronutrient powders (MNPs) can now be considered the preferred approach. The World Health Organization endorses home fortification with MNPs containing at least iron, vitamin A and zinc to control childhood anaemia, and calls for concomitant malaria control strategies in malaria endemic regions. Among other micronutrients, current MNP formulations generally include 88 μg folic acid (corresponding to 100% of the Recommended Nutrient Intake). The risks and benefits of providing supplemental folic acid at these levels are unclear. The limited data available indicate that folate deficiency may not be a major public health problem among children living in sub-Saharan Africa and supplemental folic acid may therefore not have any benefits. Furthermore, supraphysiological, and possibly even physiological, folic acid dosages may favour Plasmodium falciparum growth, inhibit parasite clearance of sulphadoxine-pyrimethamine (SP)-treated malaria and increase subsequent recrudescence. Even though programmatic options to limit prophylactic SP use or to promote the use of insecticide treated bed nets may render the use of folic acid safer, programmatic barriers to these approaches are likely to persist. Research is needed to characterise the prevalence of folate deficiency among young children worldwide and to design safe MNP and other types of fortification approaches in sub-Sahara Africa. In parallel, updated global guidance is needed for MNP programmes in these regions.

Adding multiple micronutrient powders to a homestead food production programme yields marginally significant benefit on anaemia reduction among young children in Nepal.

Anaemia affects 46% of preschool-aged children in Nepal. A cluster-randomised study was conducted in rural Nepal to test whether providing micronutrient powders (MNP) in addition to enhanced homestead food production (EHFP) programme, consisting of home gardens, poultry and nutrition education, could lead to a higher reduction in anaemia compared with providing only EHFP. This sub-study enrolled 335 children aged 6-9 months into one of three groups: (1) EHFP + MNP; (2) EHFP; or (3) control. The EHFP + MNP group received 60 sachets of MNP for flexible consumption at the start and 6 months later for a total supplementation period of 11 months. The MNP contained 15 micronutrients including iron (10 mg encapsulated ferrous fumarate). Haemoglobin and anthropometry were measured at baseline and post-MNP supplementation. Mean ± SE haemoglobin concentration increased significantly in all groups, with a slightly higher but non-significant increase in the EHFP + MNP and EHFP compared with control (difference-in-differences: 4.1 g L(-1) for EHFP + MNP vs. control; 3.6 g L(-1) for EHFP vs. control; 0.5 g L(-1) for EHFP + MNP vs. EHFP). Anaemia decreased at a slightly higher magnitude in the EHFP + MNP [51.5 percentage points (PP)] than the EHFP (48.6 PP) and control (39.6 PP), with adjusted odds ratios (95% CI) at post-supplementation of 0.52 (0.25-1.12) for EHFP + MNP and 0.69 (0.35-1.36) for EHFP, compared with control. There was no impact on child growth. Combining EHFP and MNP programmes yielded a marginally significant reduction in anaemia among children.

Multiple micronutrient powders for home (point-of-use) fortification of foods in pregnant women.

It is estimated that 32 million pregnant women suffer from anaemia worldwide. Due to increased metabolic demands, pregnant women are particularly vulnerable to anaemia and vitamin and mineral deficiencies, leading to adverse health effects in both the mother and her baby. Despite the demonstrated benefits of prenatal supplementation with iron and folic acid or multiple micronutrients, poor adherence to routine supplementation has limited the effectiveness of this intervention in many settings. Micronutrient powders for point-of-use fortification are packed, single-dose sachets containing vitamins and minerals that can be added onto prepared food to improve its nutrient profile. The use of multiple micronutrient powders for point-of-use fortification of foods in pregnant women could be an alternative intervention to prenatal micronutrient supplementation. To assess the effects of prenatal home (point-of-use) fortification of foods with multiple micronutrient powders on maternal and newborn health. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and the International Clinical Trials Registry Platform (ICTRP) (31 January 2015). We also contacted relevant agencies to identify ongoing and unpublished studies. Randomised controlled trials (both individual and cluster randomisation) and quasi-randomised trials, irrespective of language or publication status.The intervention was micronutrient powders for point-of-use fortification of foods, containing at least three micronutrients with one of them being iron, provided to pregnant women of any gestational age and parity. Five comparison groups were considered: no intervention/placebo, iron and folic acid supplements, iron-only supplements, folic-acid only supplements, and multiple micronutrients in supplements. Two review authors independently assessed the eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. Our search identified 12 reports (relating to six studies). We included two cluster-randomised controlled trials (involving 1172 women) - these trials were considered to be at a moderate to high risk of bias due to methodological limitations. One trial is ongoing, and three studies were excluded. Micronutrient powders for point-of-use fortification of foods versus iron and folic acid supplementsOne trial (involving 478 pregnant women attending 42 antenatal care centres) compared micronutrient powders containing iron, folic acid, vitamin C and zinc with iron and folic acid tablets provided daily from 14 to 22 weeks to 32 weeks' gestation. The trial did not report on any of this review's primary outcomes: maternal anaemia at or near term, maternal iron deficiency, maternal mortality, adverse effects, low birthweight, preterm births. Nor did the trial report on the majority of this review's secondary outcomes, with the exception of maternal adherence. Adherence to micronutrient powders was lower than adherence to iron and folic acid supplements (risk ratio (RR) 0.76, 95% confidence interval (CI) 0.66 to 0.87, one study, n = 405). Micronutrient powders for point-of-use fortification of foods versus same multiple micronutrients in supplementsOne study (involving 694 pregnant women from 18 communities), compared micronutrient powders containing iron, folic acid, vitamin C, zinc, iodine, vitamin E and vitamin B12 with tablets containing the same seven micronutrients. There was no difference in maternal anaemia at 37 weeks of gestation (RR 0.92, 95% CI 0.53 to 1.59, one study, n = 470, very low quality evidence). The trial did not report on any of this review's other primary outcomes in relation to maternal iron deficiency, maternal mortality, adverse effects, low birthweight, or preterm birth. In terms of this review's secondary outcomes, the included trial did not report on the majority of this review's prespecified secondary outcomes with one exception - there was no clear difference in maternal haemoglobin Hb or near term (mean difference (MD) 1.0 g/L, 95% CI -1.77 to 3.77, one study, n = 470). Limited evidence suggests that micronutrient powders for point-of-use fortification of foods have no clear difference as multiple micronutrient supplements on maternal anaemia (very low quality evidence) and Hb at or near term. There is limited evidence to suggest that women were more likely to adhere to taking tablets than using micronutrient powders.The overall quality of evidence was judged very low (due to methodological limitations), and no evidence was available for the majority of primary and secondary outcomes. Therefore, more evidence is needed to assess the potential benefits or harms of the use of micronutrient powders in pregnant women on maternal and infant health outcomes. Future trials should also assess adherence to micronutrient powders and be adequately powered to evaluate the effects on birth outcomes and morbidity.

Adherence to multiple micronutrient powder among young children in rural Bangladesh: a cross-sectional study

BackgroundMultiple micronutrient powder (MMNP) can be sprinkled onto any semisolid food and can be given to young children to address iron deficiency anemia. The female community health volunteers of BRAC (an NGO) known as Shasthya Shebikas (SS) sell MMNP sachets during their regular household visits. Currently there are no data on adherence or real uptake of MMNP by children. The objective of the study was to assess adherence to MMNP and associated factors among children aged 6–59 months in rural Bangladesh.MethodsA cross sectional study was conducted in Saturia Sub-district among 78 children aged 6–59 months who were fed MMNP supplied by BRAC SS in the past 60 days. A one stage cluster sampling technique was used to select mothers with eligible children. Semi-structured questionnaire was used for interviews. A logistic regression model was developed to obtain adjusted odds ratios (AOR) with 95% CI.ResultsSample mean adherence was calculated to be 70%. In multivariate analysis, age of mother in years (AOR = 0.74, 95% CI: 0.61-0.88), households belonging to poorer (AOR = 0.01, 95% CI: 0.00-0.68), middle (AOR = 0.04, 95% CI: 0.00-0.35) and richer (AOR = 0.11, 95% CI: 0.01-0.84) wealth quintiles and mothers who prefer to feed flexibly (AOR = 0.03, 95% CI: 0.00-0.26) were significantly associated with high adherence. Further, for every one unit increase in visit by BRAC SS in the past 60 days, the odds of having high adherence significantly increased by 55% (AOR = 1.55, 95% CI: 1.09-2.20).ConclusionsSS are the key to improving adherence through regular visits to households of MMNP users. However, expanding coverage beyond the vicinity of the SS’s household is a challenge. Perception of families whose children have low adherence should be studied.

Multiple Micronutrients And Early Learning Interventions Promote Infant Micronutrient Status And Development

BackgroundMalnutrition and lack of early learning (EL) opportunities are major causes for children not reaching their developmental potential. &#x0D;ObjectiveTo evaluate the impact of multiple micronutrient powder (MNP) and EL intervention on infants' micronutrient status and development.&#x0D;Methods497 infants (6‐12 mos) were enrolled from 26 villages in rural India and randomized using a 2X2 design to receive MNP (iron, zinc, vitamins A,B2,B12, C and folic acid ) vs. placebo (B2) and EL vs. control. The EL intervention was based on the UNICEF‐developed Care for Child Development and delivered through biweekly home visits. Baseline, post‐intervention (6 mos) and follow‐up (12 mos) evaluations included 2ml venous blood and Mullens Scales of Early Learning. Data were analyzed using 2‐way ANOVA, adjusting for baseline, with MNP X EL interactions to assess intervention synergy. &#x0D;ResultsNo baseline differences (66% anemic (Hb&lt;11 g/dL), 31% inadequate iron stores (ferritin&gt;12 µg/L), 20% stunted (HAZ&lt;‐2), 19% underweight (WAZ&lt;‐2). At follow‐up, the prevalence of micronutrient (MN) deficiencies was significantly lower in the MNP group. Significant interactions in motor and language performance showed that children who received either or both interventions had better scores than children who received neither. Table 1. Percent MN Deficiencies at Follow‐Up * p &amp;lt; .05 MNP Placebo Infant % % Hemoglobin (&amp;lt; 11g/dL) * 50.2 74.2 Ferritin (&amp;lt;12 ug/L) * 32.6 81.6 Transferrin receptor (&amp;gt; 2mg/L) * 44.1 81.7 Vitamin B12 (&amp;lt;200p/mL) * 2.6 9.1 Zinc (&amp;lt;65 ug/dL) 2.1 1.8 Table 2. MNP x EL Interaction at Post Intervention: Mean (SE) * p&amp;lt;.05 MNP Placebo EL Control EL Control Gross Motor 50.2 (1.0) 51.8 (1.0) 51.7 (1.0) 48.7 (1.0) * Language 38.9 (0.6) 39.3 (0.6) 40.3 (0.6) 48.1 (0.6) * ConclusionHome MNP and EL can improve infant MN status and development.

A 22-Element Micronutrient Powder Benefits Language but Not Cognition in Bangladeshi Full-Term Low-Birth-Weight Children

Background:Low-birth-weight children are known to be at risk of both anemia and cognitive/language deficits in their early years. Objective:The aim of the current study was to examine the effects of a 22-element multiple micronutrient powder (MNP) on the cognitive and language development of full-term low-birth-weight (LBW-T) children in Bangladesh. Methods:The current study was a follow-up of children who were enrolled in a randomized cluster trial at 7–12 mo of age. Children in 12 intervention clusters (communities) were administered a daily 22-element MNP sachet with their food for 5 mo, and both intervention and control groups (also 12 clusters) received nutrition, health, and hygiene education. The current study involved the assessment of children at 16–22 mo of age (22-element MNP group: n = 96; control group: n = 82) on 3 subtests of the Bayley Scales of Infant and Toddler Development III test to measure cognitive, receptive language, and expressive language development. Results:There was a significant effect of the 22-element MNP on children’s expressive language scores (d = 0.39), and stunting moderated the effect on receptive language scores; there was no effect on cognitive development (d = 0.08). Conclusion:An MNP may thus offer one feasible solution to improve language development of LBW-T children in low-resource community settings. This trial was registered at clinicaltrials.gov as NCT01455636.

Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial

Stimulation and nutrition delivered through health programmes at a large scale could potentially benefit more than 200 million young children worldwide who are not meeting their developmental potential. We investigated the feasibility and effectiveness of the integration of interventions to enhance child development and growth outcomes in the Lady Health Worker (LHW) programme in Sindh, Pakistan. We implemented a community-based cluster-randomised effectiveness trial through the LHW programme in rural Sindh, Pakistan, with a 2 × 2 factorial design. We randomly allocated 80 clusters (LHW catchments) of children to receive routine health and nutrition services (controls; n=368), nutrition education and multiple micronutrient powders (enhanced nutrition; n=364), responsive stimulation (responsive stimulation; n=383), or a combination of both enriched interventions (n=374). The allocation ratio was 1:20 (ie, 20 clusters per intervention group). The data collection team were masked to the allocated intervention. All children born in the study area between April, 2009, and March, 2010, were eligible for enrolment if they were up to 2·5 months old without signs of severe impairments. Interventions were delivered by LHWs to families with children up to 24 months of age in routine monthly group sessions and home visits. The primary endpoints were child development at 12 and 24 months of age (assessed with the Bayley Scales of Infant and Toddler Development, Third Edition) and growth at 24 months of age. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT007159636. 1489 mother-infant dyads were enrolled into the study, of whom 1411 (93%) were followed up until the children were 24 months old. Children who received responsive stimulation had significantly higher development scores on the cognitive, language, and motor scales at 12 and 24 months of age, and on the social-emotional scale at 12 months of age, than did those who did not receive the intervention. Children who received enhanced nutrition had significantly higher development scores on the cognitive, language, and social-emotional scales at 12 months of age than those who did not receive this intervention, but at 24 months of age only the language scores remained significantly higher. We did not record any additive benefits when responsive stimulation was combined with nutrition interventions. Responsive stimulation effect sizes (Cohen's d) were 0·6 for cognition, 0·7 for language, and 0·5 for motor development at 24 months of age; these effect sizes were slightly smaller for the combined intervention group and were low to moderate for the enhanced nutrition intervention alone. Children exposed to enhanced nutrition had significantly better height-for-age Z scores at 6 months (p<0·0001) and 18 months (p=0·02) than did children not exposed to enhanced nutrition. Longitudinal analysis showed a small benefit to linear growth from enrolment to 24 months (p=0·026) in the children who received the enhanced nutrition intervention. The responsive stimulation intervention can be delivered effectively by LHWs and positively affects development outcomes. The absence of a major effect of the enhanced nutrition intervention on growth shows the need for further analysis of mediating variables (eg, household food security status) that will help to optimise future nutrition implementation design. UNICEF.

Caregiver perceptions, practices, and preferences relating to multiple micronutrient powders for children 6‐23 mo of age in the northern highlands of Peru (804.28)

Background: To ensure multiple micronutrient powders (MNP) for children have their intended effect, it is important to understand caregivers’ experiences. Objective: We aimed to assess perceptions, practices, and preferences relating to the use of MNP among caregivers of children enrolled in a study to compare different MNP dosing schemes in Cajamarca, Peru. Methods: Infants age 6‐11 mo (n=400) were randomly assigned to 6 mo daily, 6 mo intermittent (every other day), 12 mo daily, or 12 mo intermittent MNP supplementation. MNP were provided monthly and field staff conducted home visits twice monthly. Unused MNP sachets were collected throughout and at endline (12 mo) all caregivers were asked about their experiences using MNP. Results: Most (94%) reported being very satisfied with MNP. One quarter (27%) reported difficulties remembering to give the MNP scheme as recommended. The most frequently reported strategies for remembering were keeping the MNP in the kitchen or bedroom. Most (98%) reported that giving their child MNP eventually became part of their regular routine; about half (59%) said that this took a week or less. Adherence was high; 85% of the MNP sachets were used and almost everyone (98%) reported giving all or most of the MNP to their child. Most (95%) reported noticing benefits after giving MNP to their child; increased appetite and increased hemoglobin (as informed by the study nurse) were most common. Caregivers assigned to the daily scheme were over 3 times more likely to say they would select their own scheme, compared to those in the intermittent group (OR: 3.6, 95%CI: 2.3‐5.7). Conclusions: MNP were acceptable and used with high adherence over the long term in this population; daily supplementation was preferred over intermittent.Grant Funding Source: Supported by the Micronutrient Initiative

Preschool based point‐of‐use fortification with micronutrients for six months reduces anaemia with modest effects on growth in rural India (624.22)

Objective: To examine the impact of preschool based point‐of‐use micronutrient fortification on children’s anemia, micronutrient status and growth.Methods: 320 pre‐schoolers were enrolled from 22 ICDS centres from rural Andhra Pradesh, India into a double masked, randomized 6‐month trial to receive either multiple micronutrient powder (MNP) or placebo powder, mixed into the lunch meal. Baseline and end line measures included hemoglobin (Hb), ferritin, sTfR, CRP, height and weight. Mixed effects models were used for mean comparison of groups and growth analysis adjusted for baseline and clustering effect.Results: Children in MNP showed significant (p&lt;0.001) improvements in mean Hb from 10.9 to 12.1g/dL and ferritin 20.3to 25.1µg/L respectively compared to placebo, 10.9 to 11.21 for Hb and 16.6 to 14.6mg/L for ferritin. Mean sTfR decreased significantly in MNP group (0.98) compared to placebo (0.11). Height increased from 89.6 to 94.4 cm in MNP compared to placebo from 88.5 to 93.5cm.The height increment was significantly higher in MNP ( 5.1 vs 4.7 cm, p&lt;0.05) . Significant difference in height increments (0.6 to 0.9 cm) was observed in MNP children with anemia/ID/IDA compared to placebo.Conclusions: Point‐of‐use fortification with MNP reduced IDA /anemia and showed height improvement amongst preschoolers.ClinicalTrials.gov Identifier: NCT01660958Grant Funding Source: Mathile Institute for the Advancement of Human Nutrition and the Micronutrient Initiative