Affordability of nutritious foods for complementary feeding in Eastern and Southern Africa.

Low intake of diverse complementary foods causes critical nutrient gaps in the diets of young children. Inadequate nutrient intake in the first 2 years of life can lead to poor health, educational, and economic outcomes. In this study, the extent to which food affordability is a barrier to consumption of several nutrients critical for child growth and development was examined in Ethiopia, Mozambique, South Africa, Tanzania, Uganda, and Zambia. Drawing upon data from nutrient gap assessments, household surveys, and food composition tables, current consumption levels were assessed, the cost of purchasing key nutritious foods that could fill likely nutrient gaps was calculated, and these costs were compared with current household food expenditure. Vitamin A is affordable for most households (via dark leafy greens, orange-fleshed vegetables, and liver) but only a few foods (fish, legumes, dairy, dark leafy greens, liver) are affordable sources of iron, animal-source protein, or calcium, and only in some countries. Zinc is ubiquitously unaffordable. For unaffordable nutrients, approaches to reduce prices, enhance household production, or increase household resources for nutritious foods are needed.

Affordability of nutritious foods for complementary feeding in South Asia.

The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6-23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children's diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.

Designing and implementing at-scale programs to improve complementary feeding.

Advancing knowledge about how to improve complementary feeding at large scale is a high priority. This article identifies strategies for designing and implementing programs to improve complementary feeding at large scale, drawing on lessons learned from three initiatives: Alive & Thrive, which implemented large-scale programs in 3 countries; a low-burden intervention in Mexico that used scripted messages; and Estrategia Integral de Atención a la Nutrición, which is introducing large-scale programs tied to Mexico's conditional cash transfer program. These initiatives illustrate different ways of designing and implementing large-scale programs, with lessons about the importance of having partnerships and alliances; well-grounded understanding from research; a public health strategy; scalable program modes and elements; using existing systems where possible; monitoring, learning, and evaluating; and adopting a model aimed at successfully implementing programs at scale. Improving complementary feeding globally is challenging because of the complex behaviors involved, and the development of specific programs geared to complementary feeding is necessary. Designing and implementing such specific programs at large scale is achievable with the intention, commitment, appropriate strategies, and financial support to do so from the outset.

Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial.

BACKGROUND: In 2014, the World Food Programme added to an ongoing health and nutrition program named "Santé Nutritionnelle à Assise Communautaire dans la région de Kayes" (SNACK), the distribution of cash to mothers and/or lipid-based nutrient supplement (LNS) to children aged 6-23 mo, conditional upon attendance at community health centers (CHCs) during the first 1000 d of life. OBJECTIVE: We evaluated the additional impact of the distribution of cash and/or LNS on mean height-for-age z scores (HAZ; primary outcome), stunting (HAZ < -2), and on intermediate outcomes along the program impact pathways. METHODS: In a cluster-randomized controlled trial using a 2 × 2 factorial design, 76 CHCs were randomly assigned to deliver either SNACK, SNACK + Cash, SNACK + LNS, or SNACK + Cash + LNS. Cross-sectional surveys among 12- to 42-mo-old children and their mothers were conducted at baseline (2013, n = 5046) and at endline (2016, n = 5098). RESULTS: Factorial analysis showed no interaction between cash and LNS treatments for HAZ, but found an antagonistic interaction for stunting (OR: 1.55; 95% CI: 1.05, 2.31; P = 0.03). There were no impacts of the cash, LNS, or cash + LNS treatments, compared with the SNACK alone, on either HAZ or stunting (treatment × time interaction). There were significant impacts of the LNS and cash + LNS treatments on attendance at ≥1 growth monitoring (GM) session (OR: 3.95; 95% CI: 1.69, 9.24; OR: 3.90; 95% CI: 1.73, 8.81, respectively) and half the expected sessions (OR: 4.72; 95% CI: 1.47, 15.17; OR: 5.25; 95% CI: 1.82, 15.11, respectively), mothers' knowledge on importance of GM (OR: 1.98; 95% CI: 1.16, 3.39; OR: 3.12; 95% CI: 1.60, 6.09, respectively), and, only for the LNS group, appropriate timing for complementary feeding (OR: 1.62; 95% CI: 1.09, 2.41). CONCLUSIONS: Implementation constraints and suboptimal participation in program activities may explain the lack of impact on child linear growth in this rural region of Mali.This trial was registered at www.isrctn.com as ISRCTN08435964.

Reducing micronutrient deficiencies in Pakistani children: are subsidies on fortified complementary foods cost-effective?

OBJECTIVE: To estimate the cost-effectiveness of price subsidies on fortified packaged complementary foods (FPCF) in reducing iodine deficiency, iron-deficiency anaemia and vitamin A deficiency in Pakistani children. DESIGN: The study proceeded in three steps: (i) we determined the current lifetime costs of the three micronutrient deficiencies with a health economic model; (ii) we assessed the price sensitivity of demand for FPCF with a market survey in two Pakistani districts; (iii) we combined the findings of the first two steps with the results of a systematic review on the effectiveness of FPCF in reducing micronutrient deficiencies. The cost-effectiveness was estimated by comparing the net social cost of price subsidies with the disability-adjusted life years (DALY) averted. SETTING: Districts of Faisalabad and Hyderabad in Pakistan. SUBJECTS: Households with 6-23-month-old children stratified by socio-economic strata. RESULTS: The lifetime social costs of iodine deficiency, iron-deficiency anaemia and vitamin A deficiency in 6-23-month-old children amounted to production losses of $US 209 million and 175 000 DALY. Poor households incurred the highest costs, yet even wealthier households suffered substantial losses. Wealthier households were more likely to buy FPCF. The net cost per DALY of the interventions ranged from a return per DALY averted of $US 783 to $US 65. Interventions targeted at poorer households were most cost-effective. CONCLUSIONS: Price subsidies on FPCF might be a cost-effective way to reduce the societal costs of micronutrient deficiencies in 6-23-month-old children in Pakistan. Interventions targeting poorer households are especially cost-effective.

Findings from a cluster randomised trial of unconditional cash transfers in Niger.

Unconditional cash transfers (UCTs) are used as a humanitarian intervention to prevent acute malnutrition, despite a lack of evidence about their effectiveness. In Niger, UCT and supplementary feeding are given during the June-September "lean season," although admissions of malnourished children to feeding programmes may rise from March/April. We hypothesised that earlier initiation of the UCT would reduce the prevalence of global acute malnutrition (GAM) in children 6-59 months old in beneficiary households and at population level. We conducted a 2-armed cluster-randomised controlled trial in which the poorest households received either the standard UCT (4 transfers between June and September) or a modified UCT (6 transfers from April); both providing 130,000 FCFA/£144 in total. Eligible individuals (pregnant and lactating women and children 6-<24 months old) in beneficiary households in both arms also received supplementary food between June and September. We collected data in March/April and October/November 2015. The modified UCT plus 4 months supplementary feeding did not reduce the prevalence of GAM compared with the standard UCT plus 4 months supplementary feeding (adjusted odds ratios 1.09 (95% CI [0.77, 1.55], p = 0.630) and 0.93 (95% CI [0.58, 1.49], p = 0.759) among beneficiaries and the population, respectively). More beneficiaries receiving the modified UCT plus supplementary feeding reported adequate food access in April and May (p < 0.001) but there was no difference in endline food security between arms. In both arms and samples, the baseline prevalence of GAM remained elevated at endline (p > 0.05), despite improved food security (p < 0.05), possibly driven by increased fever/malaria in children (p < 0.001). Nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs plus supplementary feeding to prevent malnutrition in this context. Caution is required in applying the findings of this study to periods of severe food insecurity.

Cost-effectiveness of prenatal food and micronutrient interventions on under-five mortality and stunting: Analysis of data from the MINIMat randomized trial, Bangladesh.

INTRODUCTION: Nutrition interventions may have favourable as well as unfavourable effects. The Maternal and Infant Nutrition Interventions in Matlab (MINIMat), with early prenatal food and micronutrient supplementation, reduced infant mortality and were reported to be very cost-effective. However, the multiple micronutrients (MMS) supplement was associated with an increased risk of stunted growth in infancy and early childhood. This unfavourable outcome was not included in the previous cost-effectiveness analysis. The aim of this study is to evaluate whether the MINIMat interventions remain cost-effective in view of both favourable (decreased under-five-years mortality) and unfavourable (increased stunting) outcomes. METHOD: Pregnant women in rural Bangladesh, where food insecurity still is prevalent, were randomized to early (E) or usual (U) invitation to be given food supplementation and daily doses of 30 mg, or 60 mg iron with 400 µg of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 µg of folic acid. E reduced stunting at 4.5 years compared with U, MMS increased stunting at 4.5 years compared with Fe60, while the combination EMMS reduced infant mortality compared with UFe60. The outcome measure used was disability adjusted life years (DALYs), a measure of overall disease burden that combines years of life lost due to premature mortality (under five-year mortality) and years lived with disability (stunting). Incremental cost effectiveness ratios were calculated using cost data from already published studies. RESULTS: By incrementing UFe60 (standard practice) to EMMS, one DALY could be averted at a cost of US$24. CONCLUSION: When both favourable and unfavourable outcomes were included in the analysis, early prenatal food and multiple micronutrient interventions remained highly cost effective and seem to be meaningful from a public health perspective.

Association between household food security and infant feeding practices in urban informal settlements in Nairobi, Kenya.

Studies in urban informal settlements show widespread inappropriate infant and young child feeding (IYCF) practices and high rates of food insecurity. This study assessed the association between household food security and IYCF practices in two urban informal settlements in Nairobi, Kenya. The study adopted a longitudinal design that involved a census sample of 1110 children less than 12 months of age and their mothers aged between 12 and 49 years. A questionnaire was used to collect information on: IYCF practices and household food security. Logistic regression was used to determine the association between food insecurity and IYFC practices. The findings showed high household food insecurity; only 19.5% of the households were food secure based on Household Insecurity Access Score. Infant feeding practices were inappropriate: 76% attained minimum meal frequency; 41% of the children attained a minimum dietary diversity; and 27% attained minimum acceptable diet. With the exception of the minimum meal frequency, infants living in food secure households were significantly more likely to achieve appropriate infant feeding practices than those in food insecure households: minimum meal frequency (adjusted odds ratio (AOR)=1.26, P=0.530); minimum dietary diversity (AOR=1.84, P=0.046) and minimum acceptable diet (AOR=2.35, P=0.008). The study adds to the existing body of knowledge by demonstrating an association between household food security and infant feeding practices in low-income settings. The findings imply that interventions aimed at improving infant feeding practices and ultimately nutritional status need to also focus on improving household food security.

Sensitive Timing for Risk of Overweight Among Infants of Low-Income Hispanic Immigrants.

INTRODUCTION: This study examined the association between early weight gain (0-6 months) and risk for overweight, as defined by the Institute of Medicine, at 1 year among infants of low-income Hispanic immigrant mothers. METHOD: Weight-for-age data were extracted from electronic medical records of 335 infants with gestations of 37 weeks or longer and birthweights appropriate for gestational age and without medical problems likely to interfere with growth or feeding. Logistic regression models were constructed to examine the impact of early weight changes on weight status at 1 year. RESULTS: By 12 months, 36.7% of infants had crossed weight-for-age of 84.1% or greater on World Health Organization growth charts. In adjusted models, infants had 20.8 (95% confidence interval = [19.8, 44.0]) times the odds of reaching this benchmark at 1 year for each z score increase at 0 to 6 months. DISCUSSION: The study highlights a time-sensitive opportunity for interventions to reduce risk for overweight for this vulnerable population.

Cost and Use of Pasteurized Donor Human Milk at a Children's Hospital.

OBJECTIVE: To determine the cost and use of pasteurized donor human milk (PDHM) at a children's hospital with a strong human milk culture. DESIGN: A retrospective descriptive cohort study. SETTING: A children's hospital in the northeastern region of the United States. PARTICIPANTS: Infants (N = 281) younger than 1 year of age at the time of hospitalization who received PDHM between January 2011 and November 2014. Infants older than 1 year of age at the time of hospitalization were excluded from the study sample. METHODS: For each eligible infant, the following descriptive characteristics were abstracted from the electronic health record: gestational age, birth weight, primary diagnosis, unit/floor, total volume of PDHM fed to infant, total number of days the infant received PDHM, diet order on day of discharge, and total length of stay in days. Descriptive statistics were used to analyze all data. RESULTS: Of the sample, 70% (n = 197/281) were cared for in the NICU and 30% (n = 84/281) were cared for outside of the NICU. The mean number of days an infant received PDHM was 23 days (range = 1-134 days) and the mean volume consumed daily was 195 ml (range = 6-1,335 ml). Using a purchase cost of U.S. $4.50 per ounce, the average purchase cost of PDHM per day was U.S. $29.19 (range = U.S. $0.90 to U.S. $200.23). CONCLUSION: PDHM is a low-cost intervention compared with many other interventions for the care of hospitalized infants.

Scaling-up interventions to improve infant and young child feeding in India: What will it take?

We assessed India's readiness to deliver infant and young child feeding (IYCF) interventions by examining elements related to policy, implementation, financing, and evidence. We based our analysis on review of (a) nutrition policy guidance and program platforms, (b) published literature on interventions to improve IYCF in India, and (c) IYCF program models implemented between 2007 and 2012. We find that Indian policies are well aligned with global technical guidance on counselling interventions. However, guidelines for complementary food supplements (CFS) need to be reexamined. Two national programs with the operational infrastructure to deliver IYCF interventions offer great potential for scale, but more operational guidance, capacity, and monitoring are needed to actively support delivery of IYCF counselling at scale by available frontline workers. Many IYCF implementation efforts to date have experimented with approaches to improve breastfeeding and initiation of complementary feeding but not with improving diet diversity or the quality of food supplements. Financing is currently inadequate to deliver CFS at scale, and governance issues affect the quality and reach of CFS. Available evidence from Indian studies supports the use of counselling strategies to improve breastfeeding practices and initiation of complementary feeding, but limited evidence exists on improving full spectrum of IYCF practices and the impact and operational aspects of CFS in India. We conclude that India is well positioned to support the full spectrum of IYCF using existing policies and delivery platforms, but capacity, financing, and evidence gaps on critical areas of programming can limit impact at scale.

High Awareness but Low Coverage of a Locally Produced Fortified Complementary Food in Abidjan, Côte d'Ivoire: Findings from a Cross-Sectional Survey.

Poor complementary feeding practices among infants and young children in Côte d'Ivoire are major contributing factors to the country's high burden of malnutrition. As part of a broad effort to address this issue, an affordable, nutritious, and locally produced fortified complementary food product was launched in the Côte d'Ivoire in 2011. The objective of the current research was to assess various levels of coverage of the program and to identify coverage barriers. A cross-sectional household survey was conducted among caregivers of children less than 2-years of age living in Abidjan, Côte d'Ivoire. Four measures of coverage were assessed: "message coverage" (i.e., has the caregiver ever heard of the product?), "contact coverage" (i.e., has the caregiver ever fed the child the product?), "partial coverage" (i.e., has the caregiver fed the child the product in the previous month?), and "effective coverage" (i.e., has the caregiver fed the child the product in the previous 7 days?). A total of 1,113 caregivers with children between 0 and 23 months of age were interviewed. Results showed high message coverage (85.0%), moderate contact coverage (37.8%), and poor partial and effective coverages (8.8% and 4.6%, respectively). Product awareness was lower among caregivers from poorer households, but partial and effective coverages were comparable in both poor and non-poor groups. Infant and young child feeding (IYCF) practices were generally poor and did not appear to have improved since previous assessments. In conclusion, the results from the present study indicate that availability on the market and high awareness among the target population is not sufficient to achieve high and effective coverage. With market-based delivery models, significant efforts are needed to improve demand. Moreover, given the high prevalence of malnutrition and poor IYCF practices, additional modes of delivering IYCF interventions and improving IYCF practices should be considered.

Fundamentos sobre alimentación del lactante sano / Healthy infant feeding

La lactancia materna exclusiva durante los primeros seis meses de vida aporta muchos bene cios tanto al niño como a la madre. El inicio temprano de la lactancia materna prote- ge al recién nacido de las infecciones y reduce la mortalidad neonatal. Alrededor de los seis meses, las necesidades de energía y nutrientes del lactante empiezan a ser superiores a lo que puede aportar la leche materna, por lo que se hace necesaria la introducción de alimentos complementarios. Si no se introducen alimen- tos complementarios alrededor de los seis meses o si son administrados de forma inade- cuada, el crecimiento del niño puede verse afectado. Por lo que el objetivo de este artículo es revisar los fundamentos sobre la alimenta- ción del lactante...(AU)

Association between women's empowerment and infant and child feeding practices in sub-Saharan Africa: an analysis of Demographic and Health Surveys.

OBJECTIVE: To explore the relationship between women's empowerment and WHO recommended infant and young child feeding (IYCF) practices in sub-Saharan Africa. DESIGN: Analysis was conducted using data from ten Demographic and Health Surveys between 2010 and 2013. Women's empowerment was assessed by nine standard items covering three dimensions: economic, socio-familial and legal empowerment. Three core IYCF practices examined were minimum dietary diversity, minimum meal frequency and minimum acceptable diet. Separate multivariable logistic regression models were applied for the IYCF practices on dimensional and overall empowerment in each country. SETTING: Benin, Burkina Faso, Ethiopia, Mali, Niger, Nigeria, Rwanda, Sierra Leone, Uganda and Zimbabwe. SUBJECTS: Youngest singleton children aged 6-23 months and their mothers (n 15 153). RESULTS: Less than 35 %, 60 % and 18 % of children 6-23 months of age met the criterion of minimum dietary diversity, minimum meal frequency and minimum acceptable diet, respectively. In general, likelihood of meeting the recommended IYCF criteria was positively associated with the economic dimension of women's empowerment. Socio-familial empowerment was negatively associated with the three feeding criteria, except in Zimbabwe. The legal dimension of empowerment did not show any clear pattern in the associations. Greater overall empowerment of women was consistently and positively associated with multiple IYCF practices in Mali, Rwanda and Sierra Leone. However, consistent negative relationships were found in Benin and Niger. Null or mixed results were observed in the remaining countries. CONCLUSIONS: The importance of women's empowerment for IYCF practices needs to be discussed by context and by dimension of empowerment.

The economic consequences of selected maternal and early childhood nutrition interventions in low- and middle-income countries: a review of the literature, 2000-2013.

BACKGROUND: Globally, 25% of children aged 0 to 4 years and more than 10% of women aged 15 to 49 years suffer from malnutrition. A range of interventions, promising for improving maternal and child nutrition, may also improve physical and intellectual capacity, and, thereby, future productivity and earnings. METHODS: We conducted a systematic literature review and summarized economic impacts of 23 reproductive, maternal, newborn and child health (RMNCH) interventions, published in 29 empirical studies between 2000 and 2013, using data from 13 low- and middle-income countries. RESULTS: We find that, in low- and middle-income countries, RMNCH interventions were rarely evaluated using rigorous evaluation methods for economic consequences. Nonetheless, based on limited studies, maternal and childhood participation in nutrition interventions was shown to increase individuals' income as adults by up to 46%, depending on the intervention, demography and country. This effect is sizeable considering that poverty reduction interventions, including microfinance and conditional cash transfer programs, have helped increase income by up to 18%, depending on the context. We also found, compared to females, males appeared to have higher economic returns from childhood participation in RMNCH interventions. CONCLUSIONS: Countries with pervasive malnutrition should prioritize investments in RMNCH interventions for their public health benefits. The existing literature is currently too limited, and restricted to a few selected countries, to warrant any major reforms in RMNCH policies based on expected future income impacts. Longitudinal and intergenerational databases remain needed for countries to be better positioned to evaluate maternal and early childhood nutrition intervention programs for future economic consequences.

Women's empowerment in agriculture and child nutritional status in rural Nepal.

OBJECTIVE: To examine the association between women's empowerment in agriculture and nutritional status among children under 2 years of age in rural Nepal. DESIGN: Cross-sectional survey of 4080 households conducted in 2012. Data collected included: child and maternal anthropometric measurements; child age and sex; maternal age, education, occupation and empowerment in agriculture; and household size, number of children, religion, caste and agro-ecological zone. Associations between the Women's Empowerment in Agriculture Index (WEAI)'s Five Domains of Empowerment (5DE) sub-index and its ten component indicators and child length-for-age Z-scores (LAZ) and weight-for-length Z-scores (WLZ) were estimated, using ordinary least-squares regression models, with and without adjustments for key child, maternal and household level covariates. SETTING: Two hundred and forty rural communities across sixteen districts of Nepal. SUBJECTS: Children under 24 months of age and their mothers (n 1787). RESULTS: The overall WEAI 5DE was positively associated with LAZ (ß=0·20, P=0·04). Three component indicators were also positively associated with LAZ: satisfaction with leisure time (ß=0·27, P<0·01), access to and decisions regarding credit (ß=0·20, P=0·02) and autonomy in production (ß=0·10, P=0·04). No indicator of women's empowerment in agriculture was associated with WLZ. CONCLUSIONS: Women's empowerment in agriculture, as measured by the WEAI 5DE and three of its ten component indicators, was significantly associated with LAZ, highlighting the potential role of women's empowerment in improving child nutrition in Nepal. Additional studies are needed to determine whether interventions to improve women's empowerment will improve child nutrition.

Sociodemographic differences and infant dietary patterns.

OBJECTIVES: To identify dietary patterns in US infants at age 6 and 12 months, sociodemographic differences in these patterns, and their associations with infant growth from age 6 to 12 months. METHODS: We analyzed a subsample (760 boys and 795 girls) of the Infant Feeding Practices Study II (2005-2007). Mothers reported their infants' intakes of 18 types of foods in the past 7 days, which were used to derive dietary patterns at ages 6 and 12 months by principal component analysis. RESULTS: Similar dietary patterns were identified at ages 6 and 12 months. At 12 months, infants of mothers who had low education or non-Hispanic African American mothers (vs non-Hispanic white) had a higher score on "High sugar/fat/protein" dietary pattern. Both "High sugar/fat/protein" and "High dairy/regular cereal" patterns at 6 months were associated with a smaller increase in length-for-age z score (adjusted ß per 1 unit dietary pattern score, -1.36 [95% confidence interval (CI), -2.35 to -0.37] and -0.30 [-0.54 to -0.06], respectively), while with greater increase in BMI z score (1.00 [0.11 to 1.89] and 0.32 [0.10 to 0.53], respectively) from age 6 to 12 months. The "Formula" pattern was associated with greater increase in BMI z score (0.25 [0.09 to 0.40]). The "Infant guideline solids" pattern (vegetables, fruits, baby cereal, and meat) was not associated with change in length-for-age or BMI z score. CONCLUSIONS: Distinct dietary patterns exist among US infants, vary by maternal race/ethnicity and education, and have differential influences on infant growth. Use of "Infant guideline solids" with prolonged breastfeeding is a promising healthy diet for infants after age 6 months.

Cost of childhood diarrhoea in rural South Africa: exploring cost-effectiveness of universal zinc supplementation.

OBJECTIVE: To describe the cost of diarrhoeal illness in children aged 6-24 months in a rural South African community and to determine the threshold prevalence of stunting at which universal Zn plus vitamin A supplementation (VAZ) would be more cost-effective than vitamin A alone (VA) in preventing diarrhoea. DESIGN: We conducted a cost analysis using primary and secondary data sources. Using simulations we examined incremental costs of VAZ relative to VA while varying stunting prevalence. SETTING: Data on efficacy and societal costs were largely from a South African trial. Secondary data were from local and international published sources. SUBJECTS: The trial included children aged 6-24 months. The secondary data sources were a South African health economics survey and the WHO-CHOICE (CHOosing Interventions that are Cost Effective) database. RESULTS: In the trial, stunted children supplemented with VAZ had 2·04 episodes (95 % CI 1·37, 3·05) of diarrhoea per child-year compared with 3·92 episodes (95 % CI 3·02, 5·09) in the VA arm. Average cost of illness was $Int 7·80 per episode (10th, 90th centile: $Int 0·28, $Int 15·63), assuming a minimum standard of care (oral rehydration and 14 d of therapeutic Zn). In simulation scenarios universal VAZ had low incremental costs or became cost-saving relative to VA when the prevalence of stunting was close to 20 %. Incremental cost-effectiveness ratios were sensitive to the cost of intervention and coverage levels. CONCLUSIONS: This simulation suggests that universal VAZ would be cost-effective at current levels of stunting in parts of South Africa. This requires further validation under actual programmatic conditions.