Association between Child Nutritional Anthropometric Indices and Iron Deficiencies among Children Aged 6-59 Months in Nepal.

Developmental impairment remains an important public health problem among children in many developing countries, including Nepal. Iron deficiency in children may affect development and lead to anaemia. This study on 1702 children aged 6-59 months aimed to assess the association between nutritional anthropometric indices and iron deficiencies. Data for this study were extracted from the 2016 Nepal National Micronutrient Status Survey. Three nutritional anthropometric indices (stunting, wasting and underweight) and their association with anaemia and iron deficiencies (ferritin and sTfR biomarkers) were assessed by conducting multivariate statistical analyses. The prevalence of stunting, wasting and underweight among children aged 6-59 months was 35.6%, 11.7% and 29.0%, respectively. Most of the children were not stunted (64.4%), not wasted (71.0%) and not underweight (88.3%). Belonging to castes other than the Janajati, Dalit and Brahmin castes increased the odds of anaemia and iron deficiency (ferritin biomarker). Children in the age group 6-23 months were significantly at higher odds of having anaemia and iron deficiency (ferritin and sTfR biomarkers). Stunting significantly increased the odds of anaemia [adjusted odds ratio (OR): 1.55; 95% confidence interval (CI): (1.11, 2.17)], iron deficiency (ferritin biomarker [OR: 1.56; 95% CI: (1.16, 2.08)] and sTfR biomarker [OR: 1.60; 95% CI: (1.18, 2.15)]). Further, underweight significantly increased the odds of anaemia [OR: 1.69; 95% CI: (1.12, 2.54)] and iron deficiency (sTfR biomarker [OR: 1.48; 95% CI: (1.14, 1.93)]). Interventions to minimise the occurrence of anaemia and iron deficiencies among children in Nepal should focus on providing appropriate healthcare services that would reduce the burden of stunting and underweight.

The Prevalence of Anemia in Children Aged 6-23 Months and its Correlates Differ by District in Kapilvastu and Achham Districts in Nepal.

Background: Analyses of predictors of anemia or malnutrition often pool national or regional data, which may hide variability at subnational levels. Objectives: We sought to identify the risk factors for anemia in young Nepali children aged 6-23 mo in 2 districts: Kapilvastu and Achham. Methods: This is an analysis of two cross-sectional surveys that were conducted as part of a program evaluation of an infant and young child feeding and micronutrient powder intervention that included anemia as a primary outcome. Baseline and endline surveys in each district (in 2013 and 2016) included hemoglobin assessments in n = 4709 children who were representative of children 6-23 mo in each district. Log-binomial regression models accounting for the survey design were used to estimate univariable and multivariable prevalence ratios for risk factors at multiple levels-underlying, direct, and biological causes. Average attributable fractions (AFs) for the population were calculated for significant predictor biomarkers of anemia in multivariable models. Results: In Accham, the prevalence of anemia was 31.4%; significant predictors included child's age, household asset ownership, length-for-age z-score, inflammation (CRP concentration > 0.5 mg/L; α-1 acid glycoprotein concentration > 1 mg/mL), and iron deficiency (serum ferritin concentration < 12 µg/L with BRINDA-inflammation adjustment). In Kapilvastu, the prevalence of anemia was 48.1%; significant predictors included child's sex and ethnicity, wasting and weight-for-length z-score, any morbidity in the previous 2 wk, consumption of fortified foods, receipt of multiple micronutrient powder distributions, iron deficiency, zinc deficiency (nonfasting serum zinc concentration of <65 µg/dL in the morning and that of <57 µg/dL in the afternoon), and inflammation. In Achham, average AFs were 28.2% and 19.8% for iron deficiency and inflammation, respectively. Average AFs for anemia in Kapilvastu were 32.1%, 4.2%, and 4.9% for iron deficiency, zinc deficiency, and inflammation, respectively. Conclusions: The prevalence of anemia and its risk factors varied between districts, with inflammation contributing to a greater share of anemia in Achham than in Kapilvastu. The estimated AF for iron deficiency was around 30% in both districts; iron-delivering interventions and multisectoral approaches to anemia are warranted.

The effect of interventions distributing home fortification products on infant and young child feeding (IYCF) practices: A systematic narrative review.

Interventions distributing micronutrient powders (MNPs) and small-quantity lipid-based nutrient supplements (SQ-LNS), or home fortification products (HFPs), have the potential to improve infant and young child feeding (IYCF) practices and children's nutrition. We systematically searched for studies on the effect of interventions distributing HFP on IYCF practices. We identified 12 (8 MNP, 4 SQ-LNS) studies: seven programmes with IYCF behaviour change communications (BCC) and MNP (IYCF-MNP) and one provided MNP without IYCF BCC (MNP only). Three SQ-LNS studies came from randomised trials without an IYCF component (SQ-LNS only) and one from a programme with both IYCF BCC and SfQ-LNS (IYCF-SQ-LNS). Five IYCF-MNP programmes reported positive associations with some IYCF practices-four with minimum dietary diversity, two with minimum meal frequency, four with minimum acceptable diet, and three with the initiation of complementary foods at 6 months. Two reported no association between MNP and IYCF indicators, and one reported a decline in IYCF practices during the intervention, although it also reported significant changes to the IYCF programme during the evaluation period. Two studies from interventions that distributed SQ-LNS (one from a related set of randomised controlled trials and the sole IYCF-SQ-LNS programme) reported a positive association with IYCF practices; one trial reported no change in breast milk intake with the provision of SQ-LNS and one found no association with IYCF practices. SQ-LNS and MNP can address nutrient gaps for young children in low-resource settings; our findings indicate that programmes that combine HFP with IYCF interventions may also contribute to improved IYCF practices in some settings.

To see, hear, and live: 25 years of the vitamin A programme in Nepal.

Nepal has a rich history of vitamin A research and a national, biannual preschool vitamin A supplementation (VAS) programme that has sustained high coverage for 25 years despite many challenges, including conflict. Key elements of programme success have included (a) evidence of a 26-30% reduction in child mortality from two, in-country randomized trials; (b) strong political and donor support; (c) positioning local female community health volunteers as key operatives; (d) nationwide community mobilization and demand creation for the programme; and (e) gradual expansion of the programme over a period of several years, conducting and integrating delivery research, and monitoring to allow new approaches to be tested and adapted to available resources. The VAS network has served as a platform for delivering other services, including anthelmintic treatment and screening for acute malnutrition. We estimate that VAS has saved over 45,000 young lives over the past 15 years of attained national coverage. Consumption of vitamin A- and carotenoid-rich foods by children and women nationally remains low, indicating that supplementation is still needed. Current challenges and opportunities to improving vitamin A status include lower VAS coverage among younger children (infants 6-11 months of age), finding ways to increase availability and access to dietary vitamin A sources, and ensuring local programme investments given the recent decentralization of the government.

Individual, household and national factors associated with iron, vitamin A and zinc deficiencies among children aged 6-59 months in Nepal.

Iron, vitamin A and zinc deficiencies are the top three micronutrients contributing to disability-adjusted life years globally. The study assessed the factors associated with iron, vitamin A, and Zinc deficiencies among Nepalese children (n = 1709) aged 6-59 months using data from the 2016 Nepal National Micronutrient Status Survey. The following cut-off points were applied: iron deficiency [ferritin < 12 µg/L or soluble transferrin receptor (sTfR) > 8.3 mg/L], vitamin A deficiency (retinol-binding protein < 0.69 µmol/L) and zinc deficiency (serum zinc < 65 µg/dl for morning sample and <57 µg/dl for afternoon sample). We used multiple logistic regression adjusted for sampling weights and clustering to examine the predictors of micronutrient deficiencies. The prevalence of iron depletion (ferritin), tissue iron (sTfR), vitamin A and zinc deficiencies were 36.7%, 27.6%, 8.5% and 20.4%, respectively. Children were more likely to be iron deficient (ferritin) if aged 6-23 months, stunted, and in a middle-wealth quintile household. Vitamin A deficiency was associated with development region and was higher among children living in severe food-insecure households and those who did not consume fruits. Zinc deficiency was higher among children in rural areas and the poorest wealth quintile. The Government of Nepal should focus on addressing micronutrient deficiencies in the early years, with emphasis on improving food systems, promote healthy diets, among younger and stunted children and provide social cash transfer targeting high-risk development regions, poorest and food insecure households.

The evolution, progress, and future direction of Nepal's universal salt iodization program.

Nepal is located in what was once known as the Himalayan Goitre Belt and once had one of the highest prevalence's of iodine deficiency disorders in the world. However, through a well-executed universal salt iodization program implemented over the past 25 years, it has achieved optimal iodine intake for its population, effectively eliminating the adverse consequences of iodine deficiency disorders. A comprehensive review of policy and legislation, surveys, and program reports was undertaken to examine the key elements contributing to the success of this program. The paper reviews the origins and maturation of salt iodization in Nepal, as well as trends in the coverage of iodized salt, the iodine content in salt, and population iodine status over the past two decades. The paper describes critical components of the program including advocacy efforts, trade issues with India, the role of the Salt Trading Corporation, monitoring, and periodic program reviews. The paper discusses the recent findings from the 2016 national micronutrient survey demonstrating the success of the salt iodization program and describes emerging challenges facing the program in the future.

Factors associated with anaemia in a nationally representative sample of nonpregnant women of reproductive age in Nepal.

We used cross-sectional data from the 2016 Nepal National Micronutrient Status Survey to evaluate factors associated with anaemia among a nationally representative sample of nonpregnant women 15- 49 years (n = 1, 918). Haemoglobin, biomarkers of iron status and other micronutrients, infection, inflammation, and blood disorders were assessed from venous blood. Soil-transmitted helminth and Helicobacter pylori infections were assessed from stool. Sociodemographic, household, and health characteristics and diet were ascertained by interview. We conducted bivariate analyses between candidate predictors and anaemia (haemoglobin <12.0 g/ dL, altitude- and smoking-adjusted). Candidate predictors that were significant in bivariate models (P < 0.05) were included in the multivariable logistic regression model, accounting for complex sampling design. Anaemia prevalence was 20.2% (95% confidence interval [CI] [17.6, 22.8]). Associated with reduced anaemia odds were living in the Mountain and Hill ecological zones relative to the Terai (adjusted odds ratio [AOR] 0.35, 95% CI [0.21, 0.60] and AOR 0.41, 95% CI [0.29, 0.59], respectively), recent cough (AOR 0.56, 95% CI [0.38, 0.82]), hormonal contraceptive use (AOR 0.58; 95% CI [0.38, 0.88]), ln ferritin (micrograms per litre; AOR 0.43, 95% CI [0.35, 0.54]), and ln retinol binding protein (micrograms per litre; AOR 0.20, 95% CI [0.11, 0.37]). Residing in a house with an earth floor (AOR 1.74, 95% CI [1.18, 2.56]), glucose-6- phosphate dehydrogenase deficiency (AOR 2.44, 95% CI [1.66, 3.60]), and haemoglobinopathies (AOR 6.15, 95% CI [3.09, 12.26]) were associated with increased anaemia odds. Interventions that improve micronutrient status, ensure access to hormonal birth control, and replace dirt floors to reduce infection risk might help reduce anaemia in this population.

Factors associated with anaemia among adolescent boys and girls 10-19 years old in Nepal.

We used data from the 2016 Nepal National Micronutrient Status Survey to evaluate factors associated with anaemia (World Health Organization cut-points using altitude- and smoking-adjusted haemoglobin [Hb]) among nationally representative samples of adolescents 10-19 years. Hb, biomarkers of micronutrients, infection and inflammation were assessed from venous blood. Sociodemographic and household characteristics, dietary diversity, pica and recent morbidity were ascertained by interview. We explored bivariate relationships between candidate predictors and anaemia among boys (N = 967) and girls (N = 1,680). Candidate predictors with P < 0.05 in bivariate analyses were included in sex-specific multivariable logistic regression models. Anaemia prevalence was 20.6% (95% confidence interval [CI] [17.1, 24.1]) among girls and 10.9% (95% CI [8.2, 13.6]) among boys. Among girls, living in the Mountain and Hill ecological zones relative to the Terai (adjusted odds ratio [AOR] 0.28, 95% CI [0.15, 0.52] and AOR 0.42, 95% CI [0.25, 0.73], respectively), ln ferritin (µg/L) (AOR 0.53, 95% CI [0.42, 0.68]) and ln retinol binding protein (RBP) (µmol/L) (AOR 0.08, 95% CI [0.04, 0.16]) were associated with reduced anaemia odds. Older age (age in years AOR 1.19, 95% CI [1.12, 1.27]) and Janajati ethnicity relative to the Muslim ethnicity (AOR 3.04, 95% CI [1.10, 8.36]) were associated with higher anaemia odds. Among boys, ln RBP [µmol/L] (AOR 0.25, 95% CI [0.10, 0.65]) and having consumed flesh foods (AOR 0.57, 95% CI [0.33, 0.99]) were associated with lower anaemia odds. Open defecation (AOR 2.36, 95% CI [1.15, 4.84]) and ln transferrin receptor [mg/L] (AOR 3.21, 95% CI [1.25, 8.23]) were associated with increased anaemia odds. Anaemia among adolescents might be addressed through effective public health policy and programs targeting micronutrient status, diet and sanitation.

A review of the maternal iron and folic acid supplementation programme in Nepal: Achievements and challenges.

In the late 1990s, an estimated 75% of pregnant women in Nepal were anaemic. Although iron and folic acid (IFA) supplements were available free of charge, coverage among pregnant women was very low. In response, the Government of Nepal launched the Iron Intensification Programme (IIP) in 2003 to improve the coverage of IFA supplementation and anthelminthic treatment during pregnancy, as well as promote the utilization of antenatal care. This review examined how the IIP programme contributed to Nepal's success in increasing the consumption of IFA supplements during pregnancy. Nepal's cadre of Female Community Health Volunteers were engaged in the IIP to support the community-based distribution of IFA supplements to pregnant women and complement IFA distribution through health facilities and outreach services. As a result, the country achieved a fourfold increase in the proportion of women who took IFA supplements during pregnancy between 2001 and 2016 (from 23% to 91%) and a 12-fold increase in the proportion who took IFA supplements for at least 90 days during pregnancy (from 6% to 71%). The increase in coverage of IFA supplements accompanied an increase in the coverage of antenatal care during the same period. By 2016, the prevalence of anaemia in pregnant women decreased to 46%, highlighting the need to tackle other causes of anaemia and improve haemoglobin concentration before pregnancy, while maintaining the successful efforts to reach pregnant women with IFA supplements at the community level.

The VitMin Lab Sandwich-ELISA Assays for Iron and Inflammation Markers Compared Well with Clinical Analyzer Reference-Type Assays in Subsamples of the Nepal National Micronutrient Status Survey.

BACKGROUND: The low cost and small specimen volume of the VitMin Lab ELISA assays for serum ferritin (Fer), soluble transferrin receptor (sTfR), C-reactive protein (CRP), and α-1-acid glycoprotein (AGP) have allowed their application to micronutrient surveys conducted in low-resource countries for ∼2 decades. OBJECTIVES: We conducted a comparison between the ELISA and reference-type assays used in the US NHANES. METHODS: Using the Roche clinical analyzer as a reference, we measured random subsets of the 2016 Nepal National Micronutrient Status Survey (200 serum samples from children aged 6-59 mo; 100 serum samples from nonpregnant women) for Fer, sTfR, CRP, and AGP. We compared the combined data sets with the ELISA survey results using descriptive analyses. RESULTS: The Lin's concordance coefficients between the 2 assays were ≥0.89 except for sTfR (Lin's ρ = 0.58). The median relative difference to the reference was as follows: Fer, -8.5%; sTfR, 71.2%; CRP, -19.5%; and AGP, -8.2%. The percentage of VitMin samples agreeing within ±30% of the reference was as follows: Fer, 88.5%; sTfR, 1.70%; CRP, 74.9%; and AGP, 92.9%. The prevalence of abnormal results was comparable between the 2 assays for Fer, CRP, and AGP, and for sTfR after adjusting to the Roche assay. Continued biannual performance (2007-2019) of the VitMin assays in CDC's external quality assessment program (6 samples/y) demonstrated generally acceptable performance. CONCLUSIONS: Using samples from the Nepal survey, the VitMin ELISA assays produced mostly comparable results to the Roche reference-type assays for Fer, CRP, and AGP. The lack of sTfR assay standardization to a common reference material explains the large systematic difference observed for sTfR, which could be corrected by an adjustment equation pending further validation. This snapshot comparison together with the long-term external quality assessment links the survey data generated by the VitMin Lab to the Roche assays used in NHANES.

Age, Ethnicity, Glucose-6-Phosphate Dehydrogenase Deficiency, Micronutrient Powder Intake, and Biomarkers of Micronutrient Status, Infection, and Inflammation Are Associated with Anemia Among Children 6-59 Months in Nepal.

BACKGROUND: Anemia is a major concern for children in Nepal; however, little is known about context-specific causes of anemia. OBJECTIVE: We used cross-sectional data from the 2016 Nepal National Micronutrient Status Survey to evaluate factors associated with anemia in a nationally representative, population-based sample of children 6-59 mo (n = 1367). METHODS: Hemoglobin, biomarkers of iron status and other micronutrients, infection, inflammation, and blood disorders were assessed from venous blood samples. Soil-transmitted helminth (STH) and Helicobacter pylori infections were assessed from stool. Anthropometry was measured with standard procedures. Sociodemographic and household characteristics, diet, micronutrient powder (MNP) intake, pica, and morbidity recall were ascertained by caregiver interview. Multivariable logistic regression that accounted for complex sampling design, determined predictors of anemia (hemoglobin <11.0 g/dL, altitude adjusted); candidate predictors were variables with P < 0.05 in bivariate models. RESULTS: Anemia prevalence was 18.6% (95% CI: 15.8, 21.4). MNP intake [adjusted OR (AOR): 0.25, 95% CI: 0.07, 0.86], log (ln) ferritin (µg/L) (AOR: 0.49, 95% CI: 0.38, 0.64), and ln RBP (µmol/L) (AOR: 0.42, 95% CI: 0.18, 0.95) were associated with reduced odds of anemia. Younger age (6-23 mo compared with 24-59 mo; AOR: 2.29, 95% CI: 1.52, 3.46), other Terai ethnicities (AOR: 2.59, 95% CI: 1.25, 5.35) and Muslim ethnicities (AOR: 3.15, 95% CI: 1.30, 7.65) relative to Brahmin/Chhetri ethnicities, recent fever (AOR: 1.68, 95% CI: 1.08, 2.59), ln C-reactive protein (mg/L) (AOR: 1.23, 95% CI: 1.03, 1.45), and glucose-6-phosphate dehydrogenase deficiency (AOR: 2.84, 95% CI: 1.88, 4.30) were associated with increased odds of anemia. CONCLUSION: Both nonmodifiable and potentially modifiable factors were associated with anemia. Thus some but not all anemia might be addressed through effective public health policy, programs, and delivery of nutrition and infection prevention and control.

Predictors of micronutrient powder (MNP) knowledge, coverage, and consumption during the scale-up of an integrated infant and young child feeding (IYCF-MNP) programme in Nepal.

Large-scale programmes using micronutrient powders (MNPs) may not achieve maximum impact due to limited/inappropriate MNP coverage, consumption, and use. We identify predictors of MNP coverage, maternal knowledge of appropriate use, and child MNP consumption in Nepal. A cross-sectional survey was conducted in 2,578 mother-child pairs representative of children 6-23 months in two districts that were part of the post-pilot, scale-up of an integrated infant and young child feeding-MNP (IYCF-MNP) programme. Children aged 6-23 months were expected to receive 60 MNP sachets every 6 months from a female community health volunteer (FCHV) or health centre. Outcomes of interest were MNP coverage (ever received), maternal knowledge of appropriate use (correct response to seven questions), repeat coverage (receipt ≥ twice; among children 12-23 months who had received MNP at least once, n = 1342), and high intake (child consumed ≥75% of last distribution, excluding those with recent receipt/insufficient time to use 75% at recommended one-sachet-per-day dose, n = 1422). Multivariable log-binomial regression models were used to identify predictors of the four outcomes. Coverage, knowledge of appropriate use, and repeat coverage were 61.3%, 33.5%, and 45.9%, respectively. Among MNP receivers, 97.9% consumed MNP at least once and 38.9% of eligible children consumed ≥75% of last distribution. FCHV IYCF-MNP counselling was positively associated with knowledge, coverage, repeat coverage, and high intake; health worker counselling with knowledge and coverage indicators; and radio messages with coverage indicators only. FCHV counselling had the strongest association with knowledge, coverage, and high intake. Community-based counselling may play a vital role in improving coverage and intake in MNP programmes.

Changes in growth, anaemia, and iron deficiency among children aged 6-23 months in two districts in Nepal that were part of the post-pilot scale-up of an integrated infant and young child feeding and micronutrient powder intervention.

There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross-sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6-23 months in two districts in Nepal that were part of a post-pilot scale-up of a IYCF-MNP programme. Multivariable log-binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length-for-age z-score <-2), wasting (weight-for-length z-score <-2), underweight (weight-for-age z-score <-2), anaemia (altitude-adjusted haemoglobin <110 µg/L), moderate or severe anaemia (altitude-adjusted haemoglobin <100 g/L), iron deficiency (inflammation-adjusted ferritin <12 µg/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers' interactions with female community health volunteers (FCHVs; >1× per month or monthly vs. <1× per month) and MNP coverage (1 or ≥2 distributions vs. none among children 12-23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable-adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal-FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF-MNP programmes to improve children's nutritional status.

Infant and Young Child Feeding (IYCF) Practices Improved in 2 Districts in Nepal during the Scale-Up of an Integrated IYCF and Micronutrient Powder Program.

BACKGROUND: Three-quarters of the ≥50 programs that use micronutrient powders (MNPs) integrate MNPs into infant and young child feeding (IYCF) programs, with limited research on impacts on IYCF practices. OBJECTIVE: This study assessed changes in IYCF practices in 2 districts in Nepal that were part of a post-pilot scale-up of an integrated IYCF-MNP program. METHODS: This analysis used cross-sectional surveys (n = 2543 and 2578 for baseline and endline) representative of children aged 6-23 mo and their mothers in 2 districts where an IYCF program added MNP distributions through female community health volunteers (FCHVs) and health workers (HWs). Multivariable log-binomial models estimated prevalence ratios comparing reported IYCF at endline with baseline and at endline on the basis of exposure to different sources of IYCF information. Mothers who received FCHV-IYCF counseling with infrequent (≤1 time/mo) and frequent (>1 time/mo) interactions were compared with mothers who never received FCHV-IYCF counseling. The receipt of HW-IYCF counseling and receipt of MNPs from an FCHV (both yes or no) were also compared. RESULTS: The prevalence of minimum dietary diversity (MDD) and minimum acceptable diet (MAD) was significantly higher at endline than at baseline. In analyses from endline, compared with mothers who never received FCHV counseling, only mothers in the frequent FCHV-IYCF counseling group were more likely to report feeding the minimum meal frequency (MMF) and MAD, with no difference for the infrequent FCHV-IYCF counseling group in these indicators. HW-IYCF counseling was not associated with these indicators. Mothers who received MNPs from their FCHV were more likely to report initiating solid foods at 6 mo and feeding the child the MDD, MMF, and MAD compared with mothers who did not, adjusting for HW- and FCHV-IYCF counseling and demographic covariates. CONCLUSIONS: Incorporating MNPs into the Nepal IYCF program did not harm IYCF and may have contributed to improvements in select practices. Research that uses experimental designs should verify whether integrated IYCF-MNP programs can improve IYCF practices.

Antenatal Iron-Folic Acid Supplementation Reduces Neonatal and Under-5 Mortality in Nepal.

BACKGROUND: Antenatal iron-folic acid (IFA) supplementation improves maternal anemia and poor pregnancy outcomes. Antenatal use of IFA supplements also has an effect on child survival. OBJECTIVE: The current study investigated the effect of antenatal IFA supplements on the risk of childhood mortality in Nepal over a 15-y period from 1996 to 2011. METHODS: Survival information of 12,891 singleton most recent live-born infants from pooled 2001, 2006, and 2011 Nepal Demographic and Health Surveys was used. Primary outcomes were mortality indicators in children <5 y of age and the main exposure variable was use of IFA supplements. Data were analyzed by using STATA 13.1 (StataCorp) and were adjusted for the cluster sampling design. Analyses used multivariate Cox proportional hazards regression adjusted for potential confounders. RESULTS: Antenatal use of IFA supplements significantly reduced the risk of early neonatal deaths by 45% [adjusted HR (aHR): 0.55; 95% CI: 0.38, 0.79] and total neonatal deaths by 42% (aHR: 0.58; 95% CI: 0.39, 0.85). Similarly, the risk of infant and under-5 mortality was significantly reduced by 32% and 48%, respectively. For mothers who started IFA at 1-4 mo of pregnancy and used 150-240 supplements, neonatal and under-5 mortality were significantly reduced by 55% (aHR: 0.45; 95% CI: 0.24, 0.85) and 57% (aHR: 0.43; 95% CI: 0.23, 0.78), respectively. Population attributable risk estimates found 15% of under-5 deaths were attributed to nonuse of IFA, and 29,000 under-5 deaths could be prevented in the next 5 y with universal IFA coverage. CONCLUSIONS: Antenatal IFA supplementation significantly reduces the risk of neonatal and under-5 deaths in Nepal. The greatest effect on child survival was found in women who started IFA early in pregnancy and took 150-240 supplements. Universal IFA coverage could improve neonatal and child survival.