Barriers to and Facilitators of the Implementation of a Micronutrient Powder Program for Children: A Systematic Review Based on the Consolidated Framework for Implementation Research.

BACKGROUND: As one of the most cost-effective investments for improving child nutrition, micronutrient powder (MNP) has been widely used in many countries to underpin the Sustainable Development Goals, yet challenges remain regarding its implementation on a large scale. However, few studies have explored the factors that facilitate or impede the implementation process using implementation science theories and frameworks. To address this gap, we adopted the Consolidated Framework of Implementation Research (CFIR) and conducted a systematic review of studies on the implementation barriers to and facilitators of MNP interventions. METHOD: Five publication databases, including EMBASE, Medline, PubMed, Web of Science, and Scopus, were searched for studies on the influencing factors of MNP interventions. Based on the CFIR framework, the facilitators and barriers for the MNP program implementation reported in the included studies were extracted and synthesized by five domains: intervention characteristics, outer setting, inner setting, individual characteristics, and process. RESULTS: A total of 50 articles were eligible for synthesis. The majority of the studies were conducted in lower-middle-income countries (52%) through the free delivery model (78%). The inner setting construct was the most prominently reported factor influencing implementation, specifically including available resources (e.g., irregular or insufficient MNP supply), structural characteristics (e.g., public-driven community-based approach), and access to information and knowledge (e.g., lack of training for primary-level workers). The facilitators of the engagement of private sectors, external guidelines, and regular program monitoring were also highlighted. On the contrary, monotonous tastes and occasional side effects impede intervention implementation. Additionally, we found that the inner setting had an interrelation with other contributing factors in the MNP program implementation. CONCLUSION: Our results suggest that MNP program implementation was prominently influenced by the available resources, organizational structure, and knowledge of both providers and users. Mobilizing local MNP suppliers, engaging public-driven free models in conjunction with market-based channels, and strengthening the training for primary-level health workers could facilitate MNP interventions.

[Association between Yingyangbao cognition and feeding behavior of caregivers in rural areas of Sichuan Province:the mediating effect of self-efficacy].

OBJECTIVE: To describe the current situation of Yingyangbao feeding in rural areas of Sichuan, and to explore the mechanism among micronutrient powder cognition, self-efficacy and feeding behavior. METHODS: The multi-stage cluster sampling method was adopted. In October 2019, in 2 Han counties, 2 Tibetan counties, and 2 Yi counties in Sichuan Province, a total of 108 villages in 36 townships in 6 sample counties were included in the cluster. Caregivers of infants and young children aged 6-24 months were selected as the research subjects, and a face-to-face interview survey was conducted using a self-designed structured questionnaire. RESULTS: A total of 765 caregivers of infants and young children aged 6-24 months were included in this study. The effective feeding rate of the Yingyangbao was 54.43%. The average scores of caregivers Yingyangbao cognition, self-efficacy and feeding behavior were 3.80±1.16, 7.96±1.53 and 0.83±0.38, and there was a significant positive correlation between them. Self-efficacy played a partial mediating effect between caregivers' Yingyangbao cognition and feeding behavior, and the mediating effect accounted for 23.37% of the total effect. CONCLUSION: Yingyangbao cognition directly affects feeding behavior and indirectly affects feeding behavior through self-efficacy.

Insulin-like Growth Factor 1 (IGF1), IGF Binding Protein-3 (IGFBP3) and Growth Response to Daily Zinc Supplementation: A Randomized Trial in Rural Laotian Children.

OBJECTIVES: To assess (a) the impact of daily preventive zinc tablets (7 mg; PZ), zinc-containing multiple micronutrient powder (10 mg zinc, and 13 other micronutrients; MNP) or placebo, delivered for 9 months, on Insulin-like Growth Factor 1 (IGF1) and IGF Binding Protein 3 (IGFBP3) among Laotian children 6-23 months, and (b) whether the effects of PZ and MNP on length-for-age z-scores (LAZ) and weight-for-age z-scores (WAZ) are modified by baseline IGF1 and IGFBP3. DESIGN: A double-blind, placebo-controlled trial (N = 419). METHODS: Plasma IGF1 and IGFBP3 concentrations at baseline and 36 weeks were analyzed by automated chemiluminescent assay. Anthropometry was assessed at baseline, at 18 and 36 weeks. Intervention effects were estimated using ANCOVA. RESULTS: At 36 weeks, geometric mean IGF1 (~39.0-39.2 ng/mL; p = 0.99) and IGFBP3 (2038-2076 ng/mL; p = 0.83) did not differ by group. At 18 weeks (but not at 36 weeks), LAZ in the PZ group (-1.45) was higher than the MNP (-1.70) and control (-1.55) groups (p = 0.01) among children in the highest baseline IGF1 tertile (p for interaction = 0.006). At 36 weeks (but not at 18 weeks), WAZ in the PZ group (-1.55) was significantly higher than the MNP (-1.75) and control (-1.65) groups (p = 0.03), among children in the lowest baseline IGFBP3 tertile (p for interactions = 0.06). CONCLUSIONS: Although IGF1 and IGFBP3 did not respond to PZ and MNP, baseline IGF1 and IGFBP3 significantly modified the impact of PZ on linear and ponderal growth, suggesting that IGF1 bioavailability may drive catch-up growth in zinc-supplemented children.

Impact of market-based home fortification with micronutrient powder on childhood anemia in Bangladesh: a modified stepped wedge design.

Background: Anemia poses a significant public health problem, affecting 1.6 billion people and contributing to the loss of 68.4 million disability-adjusted life years. We assessed the impact of a market-based home fortification program with micronutrient powder (MNP) called Pushtikona-5 implemented by Bangladesh Rural Advancement Committee (BRAC) on the prevalence of anemia among children aged 6-59 months in Bangladesh. Methods: We used a modified stepped wedged design and conducted three baseline, two midline, and three endline surveys to evaluate the Pushtikona-5 program implemented through three BRAC program platforms. We interviewed children's caregivers, and collected finger-prick blood samples from children to measure hemoglobin concentration. We also collected data on coverage of Pushtikona-5 and infant and young child feeding (IYCF) practices. We performed bivariate and multivariable analysis and calculated adjusted risk ratios (ARRs) to assess the effect of program outcomes. Results: A total of 16,936 households were surveyed. The prevalence of anemia was 46.6% at baseline, dropping to 32.1% at midline and 31.2% at endline. These represented adjusted relative reductions of 34% at midline (RR 0.66, 95%CI 0.62 to 0.71, value of p <0.001) and 32% at endline (RR 0.68, 95%CI 0.64 to 0.71, value of p <0.001) relative to baseline. Regarding MNP coverage, at baseline, 43.5% of caregivers surveyed had heard about MNP; 24.3% of children had ever consumed food with MNP, and only 1.8% had consumed three or more sachets in the 7 days preceding the survey. These increased to 63.0, 36.9, and 4.6%, respectively, at midline and 90.6, 68.9, and 11.5%, respectively, at endline. Conclusion: These results show evidence of a reduction in the prevalence of anemia and an improvement in coverage. This study provides important evidence of the feasibility and potential for impact of linking market-based MNP distribution with IYCF promotion through community level health workers.

Adherence to micronutrient powder for home fortification of foods among infants and toddlers in rural China: a structural equation modeling approach.

BACKGROUND: The WHO recommends daily use of micronutrient powder for infants and toddlers at risk of micronutrient deficiencies in low-and-middle-income countries. China has established a micronutrient powder distribution program in many rural townships and villages, yet adherence to micronutrient powder remains suboptimal; a little is known about the behavioral inputs that may influence adherence. This study examines direct and indirect behavioral inputs in micronutrient powder adherence among caregivers in rural western China following the Integrated Behavioral Model (IBM) framework. METHODS: Cross-sectional data were collected from April to May 2019 among 958 caregivers of children aged 6 to 24 months in six counties. Data were collected on micronutrient powder adherence behavior, direct behavioral inputs (knowledge and skills, intention, salience, environmental constraints, and habits), and indirect behavioral inputs (attitudes, perceived social norms, and personal agency). Structural equation modeling (SEM) adjusted for sociodemographic covariates was used to evaluate the IBM framework. RESULTS: Mean micronutrient powder adherence in the previous seven days was 53.02%, and only 22.86% of caregivers consistently fed micronutrient powder from the start of micronutrient powder distribution at six months of age. The SEM model revealed small- to medium-sized effects of salience (ß = 0.440, P < 0.001), intention (ß = 0.374, P < 0.001), knowledge and skills (ß = 0.214, P < 0.001), personal agency (st. effect = 0.172, P < 0.001), environmental constraints (ß=-0.142, P < 0.001), and caregiver generation (ß = 0.119, P < 0.05) on micronutrient powder adherence. Overall, 54.7% of the variance in micronutrient powder adherence was explained by the IBM framework. Salience had the largest impact on micronutrient powder adherence (Cohen's f 2 = 0.227). Compared to parent caregivers, grandparents had a higher degree of micronutrient powder adherence on average (P < 0.001), and behavioral inputs were consistent among both parent and grandparent caregivers. CONCLUSION: There is a need to improve micronutrient powder adherence among rural caregivers. The IBM framework showed a high degree of explanatory power in predicting micronutrient powder adherence behavior. The findings suggest that increased reminders from doctors regarding micronutrient powder and coaching to improve personal agency in micronutrient powder feeding may increase adherence.

Daily supplementation of a multiple micronutrient powder improves folate but not thiamine, riboflavin, or vitamin B12 status among young Laotian children: a randomized controlled trial.

PURPOSE: To assess the effects of intervention with a daily multiple micronutrient powder (MNP) on thiamine, riboflavin, folate, and B12 status among young Laotian children. METHODS: Children (n = 1704) aged 6-23 mo, participating in a double-blind placebo-controlled randomized trial were individually randomized to receive daily either MNP (containing 0.5 mg of thiamine, 0.5 mg riboflavin, 150 µg folic acid, and 0.9 µg vitamin B12 along with 11 other micronutrients) or placebo and followed for ~ 36 weeks. In a randomly selected sub-sample of 260 children, erythrocyte thiamine diphosphate (eThDP), plasma folate and B12 concentrations, and erythrocyte glutathione reductase activation coefficient (EGRac; riboflavin biomarker) were assessed at baseline and endline. RESULTS: There was no treatment effect on endline eThDP concentrations (110.6 ± 8.9 nmol/L in MNP vs. 109.4 ± 8.9 nmol/L in placebo group; p = 0.924), EGRac (1.46 ± 0.3 vs. 1.49 ± 0.3; p = 0.184) and B12 concentrations (523.3 ± 24.6 pmol/L vs. 515.9 ± 24.8 pmol/L; p = 0.678). Likewise, the prevalence of thiamine, riboflavin, and B12 deficiencies did not differ significantly between the two groups. However, endline folate concentration was significantly higher in the MNP compared to the placebo group (28.2 ± 0.8 nmol/L vs 19.9 ± 0.8 nmol/L, respectively; p < 0.001), and correspondingly, the prevalence of folate deficiency was significantly lower in the MNP group (1.6% vs 17.4%; p = 0.015). CONCLUSIONS: Compared to a placebo, daily MNP for 9 months increased only folate but not thiamine, riboflavin, or B12 status in young Laotian children. TRIAL REGISTRATION: The trial was registered at www. CLINICALTRIALS: gov (NCT02428647) on April 29 2015.

Role of home visits by volunteer community health workers: to improve the coverage of micronutrient powders in rural Bangladesh.

OBJECTIVE: We assessed the role of home visits by Shasthya Shebika (SS) - female volunteer community health workers (CHWs) - in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver-provider interaction on coverage variables. DESIGN: We used data from three cross-sectional surveys undertaken at baseline (n 1927), midline (n 1924) and endline (n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver's household in the 12 months preceding the survey considering three outcome variables - message (ever heard), contact (ever used) and effective coverage (regular used) of MNP. We performed multiple logistic regressions to explore the determinants of coverage, employed an 'interaction term' and calculated an odds ratio (OR) to assess the modifying effect of SS's home visits on coverage. SETTINGS: Sixty-eight sub-districts from ten districts of Bangladesh. PARTICIPANTS: Children aged 6-59 months and their caregivers. RESULTS: A home visit from an SS positively impacts message coverage at both midline (ratio of OR 1·70; 95 % CI 1·25, 2·32; P < 0·01) and endline (ratio of OR 3·58; 95 % CI 2·22, 5·78; P < 0·001), and contact coverage both at midline (ratio of OR 1·48; 95 % CI 1·06, 2·07; P = 0·021) and endline (ratio of OR 1·74; 95 % CI 1·23, 2·47; P = 0·002). There was no significant effect of a SS's home visit on effective coverage. CONCLUSIONS: The households visited by BRAC's volunteer CHWs have better message and contact coverage among the children aged 6-59 months.

Determinants of adherence to micronutrient powder use among young children in Ethiopia.

In Ethiopia, home fortification of complementary foods with micronutrient powders (MNPs) was introduced in 2015 as a new approach to improve micronutrient intakes. The objective of this study was to assess factors associated with intake adherence and drivers for correct MNP use over time to inform scale-up of MNP interventions. Mixed methods including questionnaires, interviews and focus group discussions were used. Participants, 1,185 children (6-11 months), received bimonthly 30 MNP sachets for 8 months, with instruction to consume 15 sachets/month, that is, a sachet every other day and maximum of one sachet per day. Adherence to distribution (if child receives ≥14 sachets/month) and adherence to instruction (if child receives exactly 15[±1] sachets/month) were assessed monthly by counting used sachets. Factors associated with adherence were examined using generalized estimating equations. Adherence fluctuated over time, an average of 58% adherence to distribution and 28% for adherence to instruction. Average MNP consumption was 79% out of the total sachets provided. Factors positively associated with adherence included ease of use (instruction), child liking MNP and support from community (distribution and instruction) and mother's age >25 years (distribution). Distance to health post, knowledge of correct use (OR = 0.74, 95% CI = 0.66-0.81), perceived negative effects (OR = 0.73, 95% CI = 0.54-0.99) and living in Southern Nations, Nationalities and People Region (OR = 0.59, 95% CI = 0.52-0.67) were inversely associated with adherence to distribution. Free MNP provision, trust in the government and field staff played a role in successful implementation. MNP is promising to be scaled-up, by taking into account factors that positively and negatively determine adherence.

Unintended consequences of programmatic changes to infant and young child feeding practices in Bangladesh.

BRAC, an international development organization, implemented a home-fortification programme from 2014 to 2018 in Bangladesh. This study aimed to understand the unintended consequences of programmatic changes that occurred during the implementation of the programme on the prevalence of good infant and young child feeding (IYCF) practices and other associated factors. We used pooled data from eight cross-sectional surveys and data from a series of qualitative investigations carried out as part of a mixed-methods evaluation approach. A total of 6,479 caregivers of children aged 6 to 23 months participated in the surveys. The prevalence of good IYCF practices increased from baseline (42.1%) to midline (45.3%), but it decreased at the endline survey (31.9%). Qualitative investigations identified several reasons for low IYCF practices at the programme level, such as the withdrawal of community health worker (CHW) incentives for promoting IYCF, providing incentives for the home-fortification of micronutrient powder (MNP) and changing the focus from IYCF promotion to MNP promotion. A multivariable generalized estimating equation model for pooled data revealed that caregivers were 28% (adjusted risk ratio [ARR]: 0.72, 95% CI [0.67, 0.78]) less likely to maintain good IYCF practices during the period when CHWs were not incentivized to promote IYCF compared to the period when CHWs were incentivized to promote it. The prevalence of good IYCF practices decreased from both baseline and midline to the endline survey due to the unintended consequences of the programmatic changes. An integrated intervention strategy to promote the home-fortification of MNP and IYCF could be helpful to avoid unintended negative consequences of programmatic changes.

Lessons learned from implementing the pilot Micronutrient Powder Initiative in four districts in Ghana.

BACKGROUND: Micronutrient deficiencies affect many children in low-income settings due primarily to over-reliance on complementary foods low in nutrients. Home-fortification (HF) could improve children's diet quality in these settings. The Ghana Health Service, supported by UNICEF, integrated the pilot Micronutrient Powder Initiative (MPI) into Child Welfare Clinic (CWC) services in four districts (Tain, Tolon, Talensi, and Ho West), whereby micronutrient powder (MNP) is supplied for HF for children aged 6-23 months attending CWCs. This study's main aim was to identify the facilitators, barriers and "lessons learned" after 2 years of program implementation. METHODS: This was a qualitative cross-sectional study. MNP distributed and children enrolled were obtained from program records. Primary data were collected from November to December 2019 and included, by district: interviews with senior program staff; key informant interviews and focus group discussion with caregivers in each of 6 sub-districts; and discussions workshop with frontline staff from at least 10 health facilities. Besides field notes, all interactions were audio-recorded and transcribed verbatim. Qualitative data were analyzed using NVivo10. RESULTS: The MPI remains on-going, with about 2.5 million MNP sachets distributed to nearly 30,000 children within 90 district-months. Caregivers generally accept the MNP; reported positive responses in children include: "increased appetite", "less frequent illnesses, "increased energy/strength", "increased weight", and "walking independently relatively early". Main facilitators are: generally regular MNP availability; increased patronage of CWC services; various contact points for supplying MNPs; fairly strong social mobilization strategy; good integration of MPI with CWC services; "one-on-one" counselling for caregivers reporting side effects; and tracing caregivers to address concerns and monitor adherence. Main barriers are: lack of counselling materials; caregivers' suspicions towards the program; absence of refresher training for frontline workers; and perceived MNP side-effects. Key lessons learned are: incorporating MNPs into CWC services is feasible, acceptable, and could reduce child micronutrient deficiencies in program districts; and MPI's success requires stronger community sensitization, equipping frontline workers to advise caregivers and manage side-effects, and consciously identifying and managing logistical challenges. CONCLUSION: Further research is needed to evaluate the effectiveness of the MPI in reducing micronutrient deficiencies among 6-23-months-olds in Ghana.

The Impact of Local Agrobiodiversity and Food Interventions on Cost, Nutritional Adequacy, and Affordability of Women and Children's Diet in Northern Kenya: A Modeling Exercise.

Wild plant species are often excellent sources of micronutrients and have the potential to promote healthy living, yet they are under-exploited. Distribution of micronutrient powders as diet supplements can play an effective role in reducing micronutrient deficiencies among infants and young children. However, assessing their effects in ensuring a nutritious diet at low cost have been limited. This study assessed the impact of including wild plant species and micronutrient powders in modeled optimized lowest-cost diets for women and children in rural Kenya. Market surveys, focus group discussions in six villages and a 24-h dietary intake recall were used to collect data that were subsequently entered in the cost of diet linear programming tool to model lowest-cost nutritious diets for women and children in Turkana County, Kenya. Three wild vegetables, three wild fruits, and micronutrient powder were added to the models to assess their impact on the cost and the nutrient adequacy of the diets. A locally adapted cost optimized nutritious diet without any intervention costs between 50 and 119 Kenyan shillings (KES) daily ($0.5 to $1.2) for children between 6 and 23 months and 173 to 305 KES ($1.8 to $2.9) for women. Addition of the three wild vegetables resulted in cost reductions between 30 and 71% as well as making up for iron and zinc gaps. The micronutrient powder had an insignificant effect on diet cost and filling nutrient gaps. Edible wild plant species, specifically wild vegetables, can reduce diet costs in considerable proportions while filling nutrient gaps year-round. However, affordability of a nutritious diet remains a major challenge in Turkana County, irrespective of the wealth group.

Micronutrient powder use in Arequipa, Peru: Barriers and enablers across multiple levels.

In Peru, nearly half of children aged 6-36 months were diagnosed with anaemia in 2017. To address this disease, the Peruvian Ministry of Health implemented a national programme in 2014, distributing free micronutrient powders (MNPs) to all children of this age. However, rates of childhood anaemia remain high. The aim of this study was to explore factors at all levels of the Social-Ecological Model that affect MNP use and adherence in Arequipa, an Andean city with childhood anaemia rates higher than the national average. We conducted in-depth interviews with 20 health personnel and 24 caregivers and 12 focus group discussions with 105 caregivers. We identified numerous barriers, including negative side effects (constipation, vomiting, and diarrhoea), poor taste of MNP, lack of familial and peer support for its use, insufficient informational resources provided by the health system, and limited human resources that constricted health personnel abilities to implement MNP programming successfully. Facilitators identified included concern about the long-term effects of anaemia, support from organizations external to the health system, well-coordinated care within the health system, and provision of resources by the Ministry of Health. We found that community or organizational and societal factors were key to limited MNP use and adherence, specifically the limited time health personnel have to address caregivers' doubts during appointments and the lack of informational resources outside of these appointments. Potential policy implications could be to increase informational resources available outside of individualized counselling by strengthening existing collaborations with community organizations, increasing media coverage, and providing group counselling.

Effect of Micronutrient Powder (MNP) with a Low-Dose of Iron on Hemoglobin and Iron Biomarkers, and Its Effect on Morbidities in Rural Bangladeshi Children Drinking Groundwater with a High-Level of Iron: A Randomized Controlled Trial.

Micronutrient Powder (MNP) is beneficial to control anemia, but some iron-related side-effects are common. A high level of iron in the groundwater used for drinking may exacerbate the side-effects among MNP users. We conducted a randomized controlled trial examining the effect of a low-dose iron MNP compared with the standard MNP in children aged 2-5 years residing in a high-groundwater-iron area in rural Bangladesh. We randomized 327 children, who were drinking from the "high-iron" wells (≥2 mg/L), to receive either standard (12.5 mg iron) or low-dose iron (5.0 mg iron) MNP, one sachet per day for two months. Iron parameters were measured both at baseline and end-point. The children were monitored weekly for morbidities. A generalized linear model was used to determine the treatment effect of the low-dose iron MNP. Poisson regressions were used to determine the incidence rate ratios of the morbidities. The trial was registered at ISRCTN60058115. Changes in the prevalence of anemia (defined as a hemoglobin level < 11.0 g/dL) were 5.4% (baseline) to 1.0% (end-point) in the standard MNP; and 5.8% (baseline) to 2.5% (end-point) in the low-dose iron MNP groups. The low-dose iron MNP was non-inferior to the standard MNP on hemoglobin outcome (ß = -0.14, 95% CI: -0.30, 0.013; p = 0.07). It resulted in a lower incidence of diarrhea (IRR = 0.29, p = 0.01, 95% CI: 0.11-0.77), nausea (IRR = 0.24, p = 0.002, 95% CI: 0.09-0.59) and fever (IRR = 0.26, p < 0.001, 95% CI: 0.15-0.43) compared to the standard MNP. Low-dose iron MNP was non-inferior to the standard MNP in preventing anemia yet demonstrated an added advantage of lowering the key side-effects.

Maternal Human Milk Oligosaccharide Profile Modulates the Impact of an Intervention with Iron and Galacto-Oligosaccharides in Kenyan Infants.

There is little data on human milk oligosaccharide (HMO) composition in Sub-Saharan Africa. Iron fortificants adversely affect the infant gut microbiota, while co-provision of prebiotic galacto-oligosaccharides (GOS) mitigates most of the adverse effects. Whether variations in maternal HMO profile can influence the infant response to iron and/or GOS fortificants is unknown. The aim of this study was to determine HMO profiles and the secretor/non-secretor phenotype of lactating Kenyan mothers and investigate their effects on the maternal and infant gut microbiota, and on the infant response to a fortification intervention with 5 mg iron (2.5 mg as sodium iron ethylenediaminetetraacetate and 2.5 mg as ferrous fumarate) and 7.5 g GOS. We studied mother-infant pairs (n = 80) participating in a 4-month intervention trial in which the infants (aged 6.5-9.5 months) received daily a micronutrient powder without iron, with iron or with iron and GOS. We assessed: (1) maternal secretor status and HMO composition; (2) effects of secretor status on the maternal and infant gut microbiota in a cross-sectional analysis at baseline of the intervention trial; and (3) interactions between secretor status and intervention groups during the intervention trial on the infant gut microbiota, gut inflammation, iron status, growth and infectious morbidity. Secretor prevalence was 72% and HMOs differed between secretors and non-secretors and over time of lactation. Secretor status did not predict the baseline composition of the maternal and infant gut microbiota. There was a secretor-status-by-intervention-group interaction on Bifidobacterium (p = 0.021), Z-scores for length-for-age (p = 0.022) and weight-for-age (p = 0.018), and soluble transferrin receptor (p = 0.041). In the no iron group, longitudinal prevalence of diarrhea was higher among infants of non-secretors (23.8%) than of secretors (10.4%) (p = 0.001). In conclusion, HMO profile may modulate the infant gut microbiota response to fortificant iron; compared to infants of secretor mothers, infants of non-secretor mothers may be more vulnerable to the adverse effect of iron but also benefit more from the co-provision of GOS.

Ethiopian mothers' experiences with micronutrient powders: Perspectives from continuing and noncontinuing users.

As part of a formative evaluation of a micronutrient powder (MNP) trial in Ethiopia that was organized according to a programme impact pathway model, we conducted in-depth focused ethnographic interviews with caregivers of children between 6 and 23 months who had accepted to try "Desta," a locally branded MNP. After stratification into two subgroups by child age, respondents were randomly selected from lists of caregivers who had received MNP from government health workers between 1 and 3 months prior to the interview date. Thirty women who were either currently giving Desta to their child ("continuing users," n = 14) or had stopped feeding Desta ("noncontinuing users," n = 16) were purposefully recruited from both urban and rural areas in the two different regions where the trial was conducted. Interviews were recorded, transcribed and translated, and coded for both emerging and prespecified themes. On the basis of identifiable components in the caregiver adherence process, this paper focuses exclusively on factors that facilitated and inhibited "appropriate use" and "continued use." For "appropriate use," defined as the caregiver preparing and child consuming MNP as directed, we identified four common themes in caregiver narratives. With respect to "continued use," the caregiver providing and child consuming the minimum number of MNP sachets over a recommended time period, our interviews spontaneously elicited five themes. We also examined caregivers' perceptions related to problems in obtaining refills. Attention to caregivers' perspectives reflected in their narratives offers opportunities to improve MNP utilization in Ethiopia, with potential application in other social and cultural settings.

A macro- and micronutrient-fortified complementary food supplement reduced acute infection, improved haemoglobin and showed a dose-response effect in improving linear growth: a 12-month cluster randomised trial.

Inadequate protein quality may be a risk factor for poor growth. To examine the effect of a macronutrient-micronutrient supplement KOKO Plus (KP), provided to infants from 6 to 18 months of age, on linear growth, a single-blind cluster-randomised study was implemented in Ghana. A total of thirty-eight communities were randomly allocated to receive KP (fourteen communities, n 322), a micronutrient powder (MN, thirteen communities, n 329) and nutrition education (NE, eleven communities, n 319). A comparison group was followed cross-sectionally (n 303). Supplement delivery and morbidity were measured weekly and anthropometry monthly. NE education was provided monthly. Baseline, midline and endline measurements at 6, 12 and 18 months included venous blood draws, diet, anthropometry, morbidity, food security and socio-economics. Length-for-age Z-score (LAZ) was the primary outcome. Analyses were intent-to-treat using mixed-effects regressions adjusted for clustering, sex, age and baseline. No differences existed in mean LAZ scores at endline (-1·219 (sd 0·06) KP, -1·211 (sd 0·03) MN, -1·266 (sd 0·03) NE). Acute infection prevalence was lower in the KP than NE group (P = 0·043). Mean serum Hb was higher in KP infants free from acute infection (114·02 (sd 1·87) g/l) than MN (107·8 (sd 2·5) g/l; P = 0·047) and NE (108·8 (sd 0·99) g/l; P = 0·051). Compliance was 84·9 % (KP) and 87·2 % (MN) but delivery 60 %. Adjusting for delivery and compliance, LAZ score at endline was significantly higher in the KP v. MN group (+0·2 LAZ; P = 0·026). A macro- and micronutrient-fortified supplement KP reduced acute infection, improved Hb and demonstrated a dose-response effect on LAZ adjusting consumption for delivery.

Iron status and inherited haemoglobin disorders modify the effects of micronutrient powders on linear growth and morbidity among young Lao children in a double-blind randomised trial.

Some studies found that providing micronutrient powder (MNP) causes adverse health outcomes, but modifying factors are unknown. We aimed to investigate whether Fe status and inherited Hb disorders (IHbD) modify the impact of MNP on growth and diarrhoea among young Lao children. In a double-blind controlled trial, 1704 children of age 6-23 months were randomised to daily MNP (with 6 mg Fe plus fourteen micronutrients) or placebo for about 36 weeks. IHbD, and baseline and final Hb, Fe status and anthropometrics were assessed. Caregivers provided weekly morbidity reports. At enrolment, 55·6 % were anaemic; only 39·3 % had no sign of clinically significant IHbD. MNP had no overall impact on growth and longitudinal diarrhoea prevalence. Baseline Hb modified the effect of MNP on length-for-age (LAZ) (P for interaction = 0·082). Among children who were initially non-anaemic, the final mean LAZ in the MNP group was slightly lower (-1·93 (95 % CI -1·88, -1·97)) v. placebo (-1·88 (95 % CI -1·83, -1·92)), and the opposite occurred among initially anaemic children (final mean LAZ -1·90 (95 % CI -1·86, -1·94) in MNP v. -1·92 (95 % CI -1·88, -1·96) in placebo). IHbD modified the effect on diarrhoea prevalence (P = 0·095). Among children with IHbD, the MNP group had higher diarrhoea prevalence (1·37 (95 % CI 1·17, 1·59) v. 1·21 (95 % CI 1·04, 1·41)), while it was lower among children without IHbD who received MNP (1·15 (95 % CI 0·95, 1·39) v. 1·37 (95 % CI 1·13, 1·64)). In conclusion, there was a small adverse effect of MNP on growth among non-anaemic children and on diarrhoea prevalence among children with IHbD.

Provision of Pre- and Postnatal Nutritional Supplements Generally Did Not Increase or Decrease Common Childhood Illnesses in Bangladesh: A Cluster-Randomized Effectiveness Trial.

BACKGROUND: Nutritional interventions may affect child morbidity. OBJECTIVE: The aim of this study was to examine whether providing lipid-based nutrient supplements (LNSs) to pregnant and lactating women or LNS or micronutrient powder (MNP) to their infants influences child morbidity. METHODS: In a 4-arm cluster-randomized effectiveness trial, participants enrolled at ≤20 weeks of gestation (n = 4011) received: 1) maternal LNSs until 6 mo postpartum and child LNSs from 6-24 mo of age (LNS-LNS); 2) iron and folic acid (IFA) until 3 mo postpartum and child LNSs at 6-24 mo (IFA-LNS); 3) IFA (as above) and child MNP at 6-24 mo (IFA-MNP); or 4) IFA and no child supplement (IFA-Control). At 6, 12, 18, and 24 mo of age, we collected information on acute lower and upper respiratory infection (ALRI/AURI), diarrhea, and fever in the previous 14 d, and on episodes of illness in the previous 6 mo. RESULTS: At 6 mo, prevalence of ALRI, fever, or diarrhea in the previous 14 d (17.6%, 18.9% and 6.8%, respectively) did not differ between infants of women who received LNS and infants of women who received IFA, but prevalence of AURI was lower in the LNS-LNS group than in all other groups combined (27.7% compared with 31.7%; OR: 0.83; 95% CI: 0.70, 0.99). At 12, 18, and 24 mo, the 4 arms did not differ in prevalence of fever (∼18.3%) or ALRI (≤15%) in the previous 14 d, but prevalence of AURI at 12 mo was lower in IFA-LNS than in IFA-Control infants (27.6% compared with 33.9%, OR: 0.74; 95% CI: 0.56, 0.99). The mean ± SD number of diarrhea episodes in the previous 6 mo was significantly higher among IFA-LNS than among IFA-Control infants at 6-12 (0.46 ± 0.04 compared with 0.33 ± 0.03) and 12-18 (0.45 ± 0.03 compared with 0.33 ± 0.02) mo. No other pairwise group differences were significant. CONCLUSION: Providing LNSs to women or LNSs or MNP to children generally did not increase or decrease childhood illnesses. This trial was registered at clinicaltrials.gov as NCT01715038.

Acceptance and Compliance With Micronutrient Powder and Complementary Food Blend Use by Filipino Mothers and Their Promotion by Community Workers.

BACKGROUND: Despite the nationwide micronutrient powder (MNP) supplementation, the Philippines only saw limited success in reducing the prevalence of anemia-a condition that has remained a public health concern among young children. OBJECTIVE: To assess and explore the acceptability and compliance to MNP and Bigas-Mongo (BigMo) complementary food blend among mothers/caregivers of children aged 6 to 23 months and the promotion of these products by community health workers (CHWs). METHODS: This study was part of the randomized controlled trial involving 3 methods of data collection: (1) bimonthly visits to mothers and caregivers for 6 months to determine the level of acceptability and compliance of the 4 intervention groups; (2) initial and final interviews with mothers/caregivers (initial = 141; final = 130) to gather their experiences and difficulties in MNP and BigMo preparation and feeding; and (3) focus group discussion (n = 4) among CHWs (n = 13) to understand their perceptions and difficulties in promoting MNP and BigMo. RESULTS: The overall compliance to MNP consumption was 74.7%, with some difference between the groups. Analysis of the information received from mothers/caregivers showed that maternal adaptive strategies in preparing and feeding MNP to their children could affect MNP use, while nonreceptiveness of mothers to integrating MNP into the child's feeding routine, perceived side effects, and perceived unfavorable taste and smell were key factors considered to limit MNP use. CONCLUSION: This study provides insights into MNP and BigMo acceptability and compliance by mothers and their promotion by CHWs, which may be useful in improving MNP program and complementary feeding projects and programs in similar settings.

Guts, Germs, and Iron: A Systematic Review on Iron Supplementation, Iron Fortification, and Diarrhea in Children Aged 4-59 Months.

BACKGROUND: The impact of iron supplements and iron fortification on diarrhea in children is controversial, with some studies reporting an increase and others reporting no effect. OBJECTIVE: The aim of the study was systematically assess the published literature on oral iron supplementation and fortification to evaluate its impact on diarrhea incidence among children aged 4-59 mo. METHODS: Randomized controlled trials of oral iron supplementation or iron fortification that reported diarrheal outcomes in children aged 4-59 mo were identified from a systematic search of 5 databases. RESULTS: Of the 906 records identified, 19 studies were found to fit the inclusion criteria for this systematic review. However, variable case definitions for diarrhea made meta-analysis impossible. Of the 19 studies, 7 (37%) studies showed a significant increase, either in overall diarrhea incidence or within a specific subgroup of the population, between iron-supplemented and control groups. Subgroups included children who were iron-replete and children undergoing their first month of iron intervention. Two studies reported an increase in bloody diarrhea. The remaining 12 (63%) studies showed no difference between iron-supplemented and control groups. CONCLUSIONS: Studies on iron supplementation and fortification use divergent case definitions for diarrhea. A number of studies (37%) showed an increase in overall diarrhea incidence or within a specific subgroup of the population, between iron-supplemented and control groups, but the majority (63%) did not. In addition, there was no clear relation between diarrhea and type of intervention or amount of iron administered observed. In future studies, we recommend that diarrhea be clearly defined and consistently recorded as a secondary outcome. Antibiotic status of participants receiving iron should also be collected to help assess possible drug interactions resulting in a "red stool effect." Finally, further microbiome research is required to better understand the effects of oral iron on specific bacterial species in the colon.