Assessment of the effectiveness of a small quantity lipid-based nutrient supplement on reducing anaemia and stunting in refugee populations in the Horn of Africa: Secondary data analysis.

Stunting and micronutrient malnutrition are persistent public health problems in refugee populations. UNHCR and its partner organisations implement blanket supplementary feeding programmes using a range of special nutritional products as one approach to address these issues. The evidence base for the efficacy and effectiveness of a small quantity lipid-based nutrient supplement, Nutributter®, in reducing stunting and anaemia is limited. Secondary data analysis was used to assess the effectiveness of Nutributter® distribution on anaemia and stunting in children aged 6-23 months (programme target group) and 6-59 months (the standard age group sampled in routine nutrition surveys). Analysis was conducted using routine pre and post-intervention cross-sectional nutrition survey data collected between 2008-2011 in five refugee camps in Kenya and Djibouti. Changes in total anaemia (Haemoglobin<110g/L), anaemia categories (mild, moderate and severe), and stunting (height-for-age z-score <-2) were explored using available data on the Nutributter® programme and contextual factors. A significant reduction in the prevalence of anaemia in children aged 6-23 months and 6-59 months was seen in four of five, and in all five camps, respectively (p<0.05). Reductions ranged from 12.4 to 23.0, and 18.3 to 29.3 percentage points in each age group. Improvements were largely due to reductions in moderate and severe anaemia and occurred where the prevalence of acute malnutrition was stable or increasing. No change in stunting was observed in four of five camps. The replicability of findings across five sites strongly suggests that Nutributter® distribution was associated with a reduction in anaemia, but not stunting, among refugee children in the Horn of Africa. Benefits were not restricted to the 6-23 month target group targeted by the nutrition programme. However, even following this intervention anaemia remained a serious public health problem and additional work to define and evaluate an effective intervention package is warranted.

Blood pressure and the capacity-load model in 8-year-old children from Nepal: Testing the contributions of kidney size and intergenerational effects.

OBJECTIVES: Growth patterns in early life are increasingly linked with subsequent cardio-metabolic risk, but the underlying mechanisms require elucidation. We have developed a theoretical model of blood pressure, treating it as a function of homeostatic metabolic capacity, and antagonistic metabolic load. We sought to differentiate prenatal and postnatal components of metabolic capacity, and to identify intergenerational contributions to offspring capacity and load. METHODS: We followed up at 8 years a cohort of children originally recruited into a randomized trial of maternal micronutrient supplementation in pregnancy. Maternal anthropometry was measured at recruitment. Offspring anthropometry was measured at birth, 2 years and 8 years. Offspring blood pressure, kidney size, and body composition were measured at 8 years. Regression analysis was used to investigate potential associations of maternal phenotype, birth phenotype, and current body composition with kidney size and blood pressure. RESULTS: Blood pressure was positively associated with body fat, but negatively associated with birth weight and relative leg length. Kidney size was positively associated with birth weight but not with relative leg length. Adjusting for adiposity, blood pressure was independently negatively associated with birth weight, relative leg length, and kidney length. Maternal height and BMI predicted offspring size at birth and at 8 years, but not blood pressure. CONCLUSIONS: Our data provide support for the capacity-load model of blood pressure in Nepalese children. Fetal and postnatal growth and kidney dimensions all contribute to metabolic capacity. Maternal phenotype contributed to offspring capacity and load, but these associations did not propagate to blood pressure. Am. J. Hum. Biol. 28:555-565, 2016. © 2016 The Authors American Journal of Human Biology Published by Wiley Periodicals, Inc.

The REFANI-N study protocol: a cluster-randomised controlled trial of the effectiveness and cost-effectiveness of early initiation and longer duration of emergency/seasonal unconditional cash transfers for the prevention of acute malnutrition among children, 6-59 months, in Tahoua, Niger.

BACKGROUND: The global burden of acute malnutrition among children remains high, and prevalence rates are highest in humanitarian contexts such as Niger. Unconditional cash transfers are increasingly used to prevent acute malnutrition in emergencies but lack a strong evidence base. In Niger, non-governmental organisations give unconditional cash transfers to the poorest households from June to September; the 'hunger gap'. However, rising admissions to feeding programmes from March/April suggest the intervention may be late. METHODS/DESIGN: This cluster-randomised controlled trial will compare two types of unconditional cash transfer for 'very poor' households in 'vulnerable' villages defined and identified by the implementing organisation. 3,500 children (6-59 months) and 2,500 women (15-49 years) will be recruited exhaustively from households targeted for cash and from a random sample of non-recipient households in 40 villages in Tahoua district. Clusters of villages with a common cash distribution point will be assigned to either a control group which will receive the standard intervention (n = 10), or a modified intervention group (n = 10). The standard intervention is 32,500 FCFA/month for 4 months, June to September, given cash-in-hand to female representatives of 'very poor' households. The modified intervention is 21,500 FCFA/month for 5 months, April, May, July, August, September, and 22,500 FCFA in June, providing the same total amount. In both arms the recipient women attend an education session, women and children are screened and referred for acute malnutrition treatment, and the households receive nutrition supplements for children 6-23 months and pregnant and lactating women. The trial will evaluate whether the modified unconditional cash transfer leads to a reduction in acute malnutrition among children 6-59 months old compared to the standard intervention. The sample size provides power to detect a 5 percentage point difference in prevalence of acute malnutrition between trial arms. Quantitative and qualitative process evaluation data will be prospectively collected and programme costs will be collected and cost-effectiveness ratios calculated. DISCUSSION: This randomised study design with a concurrent process evaluation will provide evidence on the effectiveness and cost-effectiveness of earlier initiation of seasonal unconditional cash transfer for the prevention of acute malnutrition, which will be generalisable to similar humanitarian situations. TRIAL REGISTRATION: ISRCTN25360839, registered March 19, 2015.

Operational guidance on the use of special nutritional products in refugee populations.

BACKGROUND: Stunting, acute malnutrition, and micronutrient malnutrition are persistent public health problems in refugee populations worldwide. In recent years there has been an increase in the availability and use of special nutritional products in emergency and development contexts to help address inadequate nutrient intakes from low-diversity diets. The availability of new special nutritional products, and the decision by the United Nations High Commissioner for Refugees (UNHCR) to use blanket supplementary feeding programs to prevent stunting and anemia, raised new challenges for designing, monitoring, and evaluating nutritional programs. OBJECTIVE: To develop an Operational Guidance on the use of special nutritional products for the prevention of micronutrient malnutrition, stunting, and acute malnutrition in refugee populations. Methods. A literature review and a series of consultations with technical experts, operational organizations, and field staff were performed over a period of 2 years. The Operational Guidance was finalized and released in December 2011. RESULTS: The Operational Guidance describes six stages for defining nutritionalproblems and identifying possible solutions; assessing and managing risks; testing acceptability and adherence, program design and implementation; and monitoring and evaluation. Key performance indicators are defined and a working nomenclature for new special nutritional products is described. CONCLUSIONS: The UNHCR Operational Guidance has filled an important gap in helping field staff deal with the opportunities and challenges of preventing undernutrition through the use of new products in blanket supplementary feeding programs. The need for further integration of guidance on selective feeding programs is discussed.