Efficacy of novel small-quantity lipid-based nutrient supplements in improving long-chain polyunsaturated fatty acid status of South African infants: a randomised controlled trial.

BACKGROUND/OBJECTIVES: The objective of this study was to investigate the efficacy of small-quantity lipid-based nutrient supplements (SQ-LNS) containing essential fatty acids (EFAs) with or without long-chain polyunsaturated fatty acids (LCPUFAs) in improving LCPUFA status in South African infants fed complementary food. SUBJECTS/METHODS: Six-month-old infants (n = 750) were randomised to receive SQ-LNS, SQ-LNS-plus, or no supplement. Both SQ-LNSs contained micronutrients and EFAs. SQ-LNS-plus additionally contained the LCPUFAs arachidonic acid (AA) and docosahexaenoic acid (DHA), lysine, phytase and other nutrients. Plasma total phospholipid FA composition (% of total FAs) was measured at baseline (n = 353) and at 12 months (n = 293). RESULTS: At baseline, geometric mean (95% CI) plasma DHA and AA were 4.1 (4.0-4.3) and 11.5 (11.2-11.8)% respectively, with significantly higher plasma DHA and AA in breastfed than non-breastfed infants. Infants receiving the SQ-LNS-plus had significantly higher plasma DHA (4.52 (4.3-4.9)) at 12 months than the controls (3.8 (3.6-4.0)), with a higher effect size in infants who no longer received breast milk (ß = 1.148 (95% CI = 0.597, 1.699)) than in infants who were still breastfeeding (ß = 0.544 (95% CI = 0.179, 0.909)). There was no effect of either of the two SQ-LNSs on plasma AA. Consequently, infants receiving the SQ-LNS-plus had a significantly lower plasma n-6 to n-3 PUFA ratio at 12 months than control infants did. CONCLUSIONS: Our study suggests that the provision of SQ-LNS-plus is efficacious in improving plasma DHA status. Particularly, infants who are no longer breastfed may benefit most from LCPUFA-enriched SQ-LNS.

Dietary patterns of 6-24-month-old children are associated with nutrient content and quality of the diet.

We determined the associations of dietary patterns with energy/nutrient intakes and diet quality. Previously collected single 24-hr dietary recalls for children aged 6-11 months (n = 1,585), 12-17 months (n = 1,131), and 18-24 months (n = 620) from four independent studies in low socio-economic populations in South Africa were pooled. A maximum-likelihood factor model, with the principal-factor method, was used to derive dietary (food) patterns. Associations between dietary pattern scores and nutrient intakes were determined using Kendall's Rank Correlations, with Bonferroni-adjusted significance levels. For both 6-11 months and 12-17 months, the formula milk/reverse breast milk pattern was positively associated with energy and protein intake and mean adequacy ratio (MAR). The family foods pattern (6-11 months) and rice and legume pattern (12-17 months) were positively associated with plant protein, fibre, and PU fat; both for total intake and nutrient density of the complementary diet. These two patterns were also associated with the dietary diversity score (DDS; r = 0.2636 and r = 0.2024, respectively). The rice pattern (18-24 months) showed inverse associations for nutrient intakes and nutrient densities, probably because of its inverse association with fortified maize meal. The more westernized pattern (18-24 months) was positively associated with unfavourable nutrients, for example, saturated fat and cholesterol. These results highlight that underlying dietary patterns varied in terms of energy/nutrient composition, nutrient adequacy, nutrient densities of the complementary diet, and dietary diversity.

Effect of small-quantity lipid-based nutrient supplements on growth, psychomotor development, iron status, and morbidity among 6- to 12-mo-old infants in South Africa: a randomized controlled trial.

Background: Evidence on the effect of small-quantity lipid-based nutrient supplements (SQ-LNSs) on early child growth and development is mixed. Objective: This study assessed the effect of daily consumption of 2 different SQ-LNS formulations on linear growth (primary outcome), psychomotor development, iron status (secondary outcomes), and morbidity in infants from age 6 to 12 mo within the context of a maize-based complementary diet. Methods: Infants (n = 750) were randomly assigned to receive SQ-LNS, SQ-LNS-plus, or no supplement. Both SQ-LNS products contained micronutrients and essential fatty acids. SQ-LNS-plus contained, in addition, docosahexaenoic acid, arachidonic acid (important for brain and eye development), lysine (limiting amino acid in maize), phytase (enhances iron absorption), and other nutrients. Infants' weight and length were measured bimonthly. At age 6 and 12 mo, psychomotor development using the Kilifi Developmental Inventory and South African Parent Rating Scale and hemoglobin, plasma ferritin, C-reactive protein, and α1-acid glycoprotein were assessed. WHO Motor Milestone outcomes, adherence, and morbidity were monitored weekly through home visits. Primary analysis was by intention-to-treat, comparing each SQ-LNS group with the control. Results: SQ-LNS-plus had a positive effect on length-for-age zscore at age 8 mo (mean difference: 0.11; 95% CI: 0.01, 0.22; P = 0.032) and 10 mo (0.16; 95% CI: 0.04, 0.27; P = 0.008) but not at 12 mo (0.09; 95% CI: -0.02, 0.21; P = 0.115), locomotor development score (2.05; 95% CI: 0.72, 3.38; P = 0.003), and Parent Rating Score (1.10; 95% CI: 0.14, 2.07; P = 0.025), but no effect for weight-for-age zscore. Both SQ-LNS (P = 0.027) and SQ-LNS-plus (P = 0.005) improved hemoglobin concentration and reduced the risk of anemia, iron deficiency, and iron-deficiency anemia. Both SQ-LNS products reduced longitudinal prevalence of fever, coughing, and wheezing but increased incidence and longitudinal prevalence of diarrhea, vomiting, and rash/sores. Conclusions: Point-of-use fortification with SQ-LNS-plus showed an early transient effect on linear growth and improved locomotor development. Both SQ-LNS products had positive impacts on anemia and iron status. This trial was registered at clinicaltrials.gov as NCT01845610.

Associations of plasma total phospholipid fatty acid patterns with feeding practices, growth, and psychomotor development in 6-month-old South African infants.

The objective of this study was to assess plasma fatty acid (FA) patterns of 6-month-old South African infants and to determine their association with feeding practices, growth, and psychomotor development. Plasma total phospholipid FA composition (% of total FAs) of 6-month-old infants (n = 353) from a peri-urban township was analysed, and principal component and factor analysis were performed to identify plasma FA patterns. Feeding practices, anthropometric measurements, and psychomotor development scores were determined. Four major plasma phospholipid FA patterns were identified: A plant-based C18 FA, a high n-6 long-chain polyunsaturated fatty acids (LCPUFA), a C16:1 and long-chain saturated fatty acid (SFA), and a high n-3 and low n-6 LCPUFA pattern. Formula feeding was associated with higher, whereas breastfeeding was associated with lower scores for the plant-based C18 FA and C16:1 and long-chain SFA patterns. On the other hand, breastfeeding, the consumption of cow's milk, and the consumption of semisolid foods were associated with higher scores, whereas formula feeding was associated with lower scores for the high n-6 LCPUFA pattern. Breastfeeding and the consumption of semisolids were also associated with higher high n-3 and low n-6 LCPUFA pattern scores. The C16:1 and long-chain SFA and high n-3 and low n-6 LCPUFA patterns were positively associated with psychomotor development scores. In 6-month-old South African infants, we identified distinct plasma FA patterns that presumably represent the FA quality of their diet and that are associated with psychomotor development. Our results suggest that breast milk is an important source of n-6 LCPUFAs and formula-fed infants may be at risk of inadequate LCPUFA intake.

Contribution of commercial infant products and fortified staple foods to nutrient intake at ages 6, 12, and 18 months in a cohort of children from a low socio-economic community in South Africa.

Fortification of two staple foods, maize meal and wheat flour (bread), is mandatory, and commercial infant products are widely available in South Africa. Using a 24-hr recall, we determined the contribution of these foods towards nutrient intakes at ages 6 (n = 715), 12 (n = 446), and 18 (n = 213) months in a cohort of children in a peri-urban community, North West province. On the day of recall, commercial infant products were consumed by 83% of children at 6 months, 46% at 12 months, and 15% at 18 months; fortified staples were consumed by 23%, 81%, and 96%, respectively. For consumers thereof, commercial infant products contributed 33% energy and 94% iron intakes at 6 months and 27% energy and 56% iron intakes at 12 months; nutrient densities of the complementary diet was higher than for nonconsumers for most micronutrients. For consumers of fortified staples, energy contribution thereof was 11% at 6 months versus 29% at 18 months; at 18 months, fortified staples contributed >30% of iron, zinc, vitamin A, thiamine, niacin, vitamin B6, and folate; at 12 months, nutrient densities of the complementary diet were higher for zinc, folate, and vitamin B6 but lower for calcium, iron, vitamin A, niacin, and vitamin C than nonconsumers. At ages 12 and 18 months, ~75% of children had low calcium intakes. At 12 months, 51.4% of consumers versus 25.0% (P = 0.005) of nonconsumers of fortified staples had adequate intakes (>EAR) for all eight fortificant nutrients. However, despite fortification, nutrient gaps remain.

Infant Development at the Age of 6 Months in Relation to Feeding Practices, Iron Status, and Growth in a Peri-Urban Community of South Africa.

BACKGROUND: Evidence on the association between feeding practices, iron deficiency, anaemia, stunting, and impaired psychomotor development during infancy is limited. This study assessed the association between psychomotor development with early feeding practices, growth, iron status, and anaemia. METHODS: This was cross-sectional baseline data of a randomised controlled trial which included 6-month-old infants and their mothers or primary caregivers (n = 750) in a peri-urban community in the North West province of South Africa. The Kilifi Developmental Inventory and a parent rating scale were used to assess psychomotor development. Feeding practices and anthropometric measurements were based on the World Health Organisation (WHO) guidelines. Anaemia and iron status were determined by blood sample analysis. RESULTS: Prevalence of anaemia and stunting for the infants were 36.4% and 28.5%, respectively. Multiple regression analysis showed that birth weight was related to combined psychomotor scores (ß = -3.427 (-4.603, 1.891), p < 0.001), as well as parent rating scores (ß = -0.843 (-1.507, -0.180), p = 0.013). Length-for-age z-scores were associated with combined psychomotor scores (ß = -1.419 (-2.466, 0.373), p = 0.008), as well as parent rating scores (ß = -0.747 (-1.483, -0.010), p = 0.047). CONCLUSIONS: In this setting, with high prevalence of anaemia and stunting, important associations between lower psychomotor development scores and birthweight as well as length-for-age z-scores in 6-month-old infants were found. These findings warrant further investigation to develop a greater understanding of factors influencing the association between child growth and psychomotor development within the first 1000 days of life.

The prevalence and factors associated with stunting among infants aged 6 months in a peri-urban South African community.

OBJECTIVE: To determine the prevalence and factors associated with stunting in 6-month-old South African infants. DESIGN: This cross-sectional study was part of the baseline of a randomized controlled trial. Weight-for-length, length-for-age and weight-for-age Z-scores were based on the WHO classification. Blood samples were analysed for Hb, plasma ferritin and soluble transferrin receptor (sTfR). Socio-economic, breast-feeding and complementary feeding practices were assessed by questionnaire. Setting/Subjects Infants aged 6 months (n 750) from a peri-urban area of Matlosana Municipality, North West Province of South Africa. RESULTS: Stunting, underweight, wasting and overweight affected 28·5, 11·1, 1·7 and 10·1 % of infants, respectively. Exclusive breast-feeding to 6 months of age was reported in 5·9 % of the infants. Multivariable binary logistic regression showed that birth weight (OR=0·12; 95 % CI 0·07, 0·21, P8·3 mg/l) concentrations. CONCLUSIONS: The association between stunting and lower birth weight, shorter maternal height and male sex reflects possibly the intergenerational origins of stunting. Therefore, interventions that focus on improving preconceptual and maternal nutritional status, combined with strategies to promote appropriate infant feeding practices, may be an important strategy to prevent stunting in vulnerable settings.

Iodine status and associations with feeding practices and psychomotor milestone development in six-month-old South African infants.

Iodine is important for normal growth and psychomotor development. While infants below 6 months of age receive iodine from breast milk or fortified infant formula, the introduction of complementary foods poses a serious risk for deteriorating iodine status. This cross-sectional analysis assessed the iodine status of six-month-old South African infants and explored its associations with feeding practices and psychomotor milestone development. Iodine concentrations were measured in infant (n = 386) and maternal (n = 371) urine (urinary iodine concentration [UIC]), and in breast milk (n = 257 [breast milk iodine concentrations]). Feeding practices and psychomotor milestone development were assessed in all infants. The median (25th-75th percentile) UIC in infants was 345 (213-596) µg/L and was significantly lower in stunted (302 [195-504] µg/L) than non-stunted (366 [225-641] µg/L) infants. Only 6.7% of infants were deficient. Maternal UIC (128 [81-216] µg/L; rs  = 0.218, p < 0.001) and breast milk iodine concentrations (170 [110-270] µg/kg; rs  = 0.447, p < 0.0001) were associated with infant UIC. Most infants (72%) were breastfed and tended to have higher UIC than non-breastfed infants (p = 0.074). Almost all infants (95%) consumed semi-solid or solid foods, with commercial infant cereals (60%) and jarred infant foods (20%) being the most common solid foods first introduced. Infants who reported to consume commercial infant cereals ≥4 days weekly had significantly higher UIC (372 [225-637] µg/L) than those reported to consume commercial infant cereals seldom or never (308 [200-517] µg/L; p = 0.023). No associations between infant UIC and psychomotor developmental scores were observed. Our results suggest that iodine intake in the studied six-month-old infants was adequate. Iodine in breast milk and commercial infant cereals potentially contributed to this adequate intake.

Acceptability of Novel Small-Quantity Lipid-Based Nutrient Supplements for Complementary Feeding in a Peri-Urban South African Community.

BACKGROUND: Small-quantity lipid-based nutritional supplements (SQ-LNS) may potentially be used for home fortification in poor settings, where low nutrient-dense complementary foods are commonly used for infant feeding. However, they need to be acceptable to succeed. OBJECTIVE: This study assessed the acceptability of 2 novel, SQ-LNS (A and B) for supplementing complementary foods among infants aged 6 to 12 months in a peri-urban South African community. METHODS: Both supplements were soy-based pastes and contained micronutrients and essential fatty acids. In addition, supplement B contained docosahexaenoic acid, arachidonic acid, phytase and l-lysine. Mother-infant pairs were enrolled in a 2-part trial. Part 1 (n = 16) was a test-feeding trial with a crossover randomized design, and a 5-point hedonic scale was used for sensory evaluation (disagree = 1, agree = 5). Part 2 (n = 38) was a 2-week, home-use trial followed by focus group discussions. RESULTS: In part 1, more than 70% of mothers reported a score ≥4 on sensory attributes for both SQ-LNSs indicating that both supplements were well perceived. In part 2, the mean reported consumption over the 2-week period was 65.3% ± 34.2% and 62.0% ± 31.3% of the 20 g daily portion for supplements A and B, respectively. Focus group discussions confirmed a positive attitude toward the supplements in the study population. CONCLUSION: This study showed acceptance of both SQ-LNSs in terms of sensory characteristics as well as in terms of practicality for home use.