Vitamin A supplementation (VAS) programs targeted at children aged 6-59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with ...measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made.
Maternal micronutrient deficiencies may adversely affect fetal and infant health, yet there is insufficient evidence of effects on these outcomes to guide antenatal micronutrient supplementation in ...South Asia.
To assess effects of antenatal multiple micronutrient vs iron-folic acid supplementation on 6-month infant mortality and adverse birth outcomes.
Cluster randomized, double-masked trial in Bangladesh, with pregnancy surveillance starting December 4, 2007, and recruitment on January 11, 2008. Six-month infant follow-up ended August 30, 2012. Surveillance included 127,282 women; 44,567 became pregnant and were included in the analysis and delivered 28,516 live-born infants. Median gestation at enrollment was 9 weeks (interquartile range, 7-12).
Women were provided supplements containing 15 micronutrients or iron-folic acid alone, taken daily from early pregnancy to 12 weeks postpartum.
The primary outcome was all-cause infant mortality through 6 months (180 days). Prespecified secondary outcomes in this analysis included stillbirth, preterm birth (<37 weeks), and low birth weight (<2500 g). To maintain overall significance of α = .05, a Bonferroni-corrected α = .01 was calculated to evaluate statistical significance of primary and 4 secondary risk outcomes (.05/5).
Among the 22,405 pregnancies in the multiple micronutrient group and the 22,162 pregnancies in the iron-folic acid group, there were 14,374 and 14,142 live-born infants, respectively, included in the analysis. At 6 months, multiple micronutrients did not significantly reduce infant mortality; there were 764 deaths (54.0 per 1000 live births) in the iron-folic acid group and 741 deaths (51.6 per 1000 live births) in the multiple micronutrient group (relative risk RR, 0.95; 95% CI, 0.86-1.06). Multiple micronutrient supplementation resulted in a non-statistically significant reduction in stillbirths (43.1 vs 48.2 per 1000 births; RR, 0.89; 95% CI, 0.81-0.99; P = .02) and significant reductions in preterm births (18.6 vs 21.8 per 100 live births; RR, 0.85; 95% CI, 0.80-0.91; P < .001) and low birth weight (40.2 vs 45.7 per 100 live births; RR, 0.88; 95% CI, 0.85-0.91; P < .001).
In Bangladesh, antenatal multiple micronutrient compared with iron-folic acid supplementation did not reduce all-cause infant mortality to age 6 months but resulted in a non-statistically significant reduction in stillbirths and significant reductions in preterm births and low birth weight.
clinicaltrials.gov Identifier: NCT00860470.
Growth failure in sub-Saharan Africa leads to a high prevalence of child stunting starting in infancy, and is attributed to dietary inadequacy, poor hygiene, and morbidity.
To evaluate the impact of ...a program in Malawi providing a lipid-based nutrient supplement to infants from 6–23 months of age, accompanied by a social and behavior change communication intervention to optimize caregiver feeding and handwashing practices.
This impact evaluation was a quasi-experimental, longitudinal study with 1 program and 1 comparison district. Infants were enrolled at 6–7 months of age. Anthropometry, child morbidity, and caregiver feeding and handwashing practices were assessed at enrollment and at 6, 12, and 18 month follow-ups (ages 6, 12, 18, and 24 months, respectively). Changes in the length-for-age z-score (LAZ), weight-for-length z-score (WLZ), and midupper arm circumference (MUAC) were compared using mixed-effects models. Program impacts on child stunting (LAZ < −2), wasting (WLZ < −2), morbidity, and feeding and handwashing practices were estimated using difference-in-differences.
We enrolled 367 infants across the program (n = 176) and comparison (n = 191) districts. The combined prevalences of stunting and wasting at enrollment were 42.1% and 1.4%, respectively, and did not differ by district. At enrollment, the prevalence of severe stunting (LAZ < −3) was higher in the program (15.5%) versus comparison (7.6%) district (P = 0.02), with corresponding lower LAZ scores (−1.9 vs. −1.7, respectively; P = 0.12). Growth velocities favored program children, such that LAZ, WLZ, and MUAC measurements increased by +0.12/y (P = 0.06), +0.12/y (P = 0.04), and +0.24 cm/y (P < 0.001), respectively, leading to comparable LAZ distributions across districts by 24 months of age. Program exposure was associated with 19.8 percentage point (pp) and 13.8 pp reductions in the prevalences of malaria (P = 0.001) and fever (P = 0.02), respectively, at the 18-month follow-up. Improvements of 20 pp (P < 0.01) in minimum dietary diversity and minimum acceptable diet were seen in the program versus comparison district at 18 months of follow-up.
The program improved child growth patterns, with benefits to health and diet apparent after 18 months of exposure. This trial was registered at clinicaltrials.gov as NCT02985359.
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Birth weight, length and circumferences of the head, chest and arm are key measures of newborn size and health in developing countries. We assessed maternal socio-demographic factors associated with ...multiple measures of newborn size in a large rural population in Bangladesh using partial least squares (PLS) regression method. PLS regression, combining features from principal component analysis and multiple linear regression, is a multivariate technique with an ability to handle multicollinearity while simultaneously handling multiple dependent variables. We analyzed maternal and infant data from singletons (n = 14,506) born during a double-masked, cluster-randomized, placebo-controlled maternal vitamin A or β-carotene supplementation trial in rural northwest Bangladesh. PLS regression results identified numerous maternal factors (parity, age, early pregnancy MUAC, living standard index, years of education, number of antenatal care visits, preterm delivery and infant sex) significantly (p<0.001) associated with newborn size. Among them, preterm delivery had the largest negative influence on newborn size (Standardized β = -0.29 - -0.19; p<0.001). Scatter plots of the scores of first two PLS components also revealed an interaction between newborn sex and preterm delivery on birth size. PLS regression was found to be more parsimonious than both ordinary least squares regression and principal component regression. It also provided more stable estimates than the ordinary least squares regression and provided the effect measure of the covariates with greater accuracy as it accounts for the correlation among the covariates and outcomes. Therefore, PLS regression is recommended when either there are multiple outcome measurements in the same study, or the covariates are correlated, or both situations exist in a dataset.
Maternal vitamin A deficiency is a public health concern in the developing world. Its prevention may improve maternal and infant survival.
To assess efficacy of maternal vitamin A or beta carotene ...supplementation in reducing pregnancy-related and infant mortality.
Cluster randomized, double-masked, placebo-controlled trial among pregnant women 13 to 45 years of age and their live-born infants to 12 weeks (84 days) postpartum in rural northern Bangladesh between 2001 and 2007. Interventions Five hundred ninety-six community clusters (study sectors) were randomized for pregnant women to receive weekly, from the first trimester through 12 weeks postpartum, 7000 μg of retinol equivalents as retinyl palmitate, 42 mg of all-trans beta carotene, or placebo. Married women (n = 125,257) underwent 5-week surveillance for pregnancy, ascertained by a history of amenorrhea and confirmed by urine test. Blood samples were obtained from participants in 32 sectors (5%) for biochemical studies.
All-cause mortality of women related to pregnancy, stillbirth, and infant mortality to 12 weeks (84 days) following pregnancy outcome.
Groups were comparable across risk factors. For the mortality outcomes, neither of the supplement group outcomes was significantly different from the placebo group outcomes. The numbers of deaths and all-cause, pregnancy-related mortality rates (per 100,000 pregnancies) were 41 and 206 (95% confidence interval CI, 140-273) in the placebo group, 47 and 237 (95% CI, 166-309) in the vitamin A group, and 50 and 250 (95% CI, 177-323) in the beta carotene group. Relative risks for mortality in the vitamin A and beta carotene groups were 1.15 (95% CI, 0.75-1.76) and 1.21 (95% CI, 0.81-1.81), respectively. In the placebo, vitamin A, and beta carotene groups the rates of stillbirth and infant mortality were 47.9 (95% CI, 44.3-51.5), 45.6 (95% CI, 42.1-49.2), and 51.8 (95% CI, 48.0-55.6) per 1000 births and 68.1 (95% CI, 63.7-72.5), 65.0 (95% CI, 60.7-69.4), and 69.8 (95% CI, 65.4-72.3) per 1000 live births, respectively. Vitamin A compared with either placebo or beta carotene supplementation increased plasma retinol concentrations by end of study (1.46 95% CI, 1.42-1.50 μmol/L vs 1.13 95% CI, 1.09-1.17 μmol/L and 1.18 95% CI, 1.14-1.22 μmol/L, respectively; P < .001) and reduced, but did not eliminate, gestational night blindness (7.1% for vitamin A vs 9.2% for placebo and 8.9% for beta carotene P < .001 for both).
Use of weekly vitamin A or beta carotene in pregnant women in Bangladesh, compared with placebo, did not reduce all-cause maternal, fetal, or infant mortality.
clinicaltrials.gov Identifier: NCT00198822.
The 2015 earthquake in Nepal caused massive damages and triggered relief activities to minimize human suffering. The post-earthquake nutrition and food security situation in the hardest hit areas ...remains uncertain.
Two national cross-sectional surveys were conducted in 2014 and 2016 among households (HH) with pre-school aged children or newly married women. Of the 21 village development committees (VDCs) included in this sample, 7 fell within "earthquake-affected" areas. This paper presents data from 982 HH, 1015 women, and 883 children from 2014 and 1056 HH, 1083 women, and 998 children from 2016 living in these areas, with longitudinal overlap of about 55%. Prevalence estimates and 95% confidence intervals were calculated, and logistic regression was used to calculate p-values, both using robust estimates of standard errors to account for clustering.
From 2014 to 2016, child wasting (weight-for-height z score <-2) fell from 4.5% (95% CI 3.3%- 6.1%) to 2.1% (1.4%- 3.1%) and food insecurity (assessed using the household food insecurity access scale) dropped from 17.6% (11.7%- 25.6%) to 12.4% (6.9%- 21.2%). Child stunting prevalence remained similar at both time-points. Improvements were also evident in dietary diversity and breastfeeding indicators.
Nutrition and food security conditions remained comparable or improved one year after the earthquake despite evidence of structural and other damage. Livelihood resilience to shocks and/or effective nutrition, food or health interventions may have helped buffer the impact on nutrition, although this hypothesis requires further exploration.
Vitamin A supplementation (VAS) for children aged 6-59 months occurs regularly in most sub-Saharan African countries. The present study aimed to explore child, household and delivery platform factors ...associated with VAS coverage and identify barriers to compliance in thirteen African countries.
We pooled data (n ~60 000) from forty-four household coverage surveys and used bivariate and multivariable regression analyses to assess the effects of supplementation strategy, rural v. urban residence, child sex, child age, caregiver education and campaign awareness on child VAS status. Setting/Subjects Primary caregivers of children aged 6-59 months in thirteen countries.
Door-to-door distribution resulted in higher VAS coverage than fixed-site plus outreach approaches (91 v. 63 %) and was a significant predictor of supplementation in the adjusted model (OR=19·0; 95 % CI 17·2, 21·1; P<0·001). Having been informed about the campaign was the main predictor of VAS in the door-to-door (OR=6·8; 95 % CI 5·8, 7·9; P<0·001) and fixed-site plus outreach (OR=72·5; 95 % CI 66·6, 78·8; P<0·001) groups.
Door-to-door provision of VAS may achieve higher coverage than fixed-site models in the African context. However, the phase-out of door-to-door polio immunization campaigns in most sub-Saharan African countries threatens the main distribution vehicle for VAS. Our findings suggest well-informed communities are key to attaining higher coverage using fixed-site delivery alternatives.
We assessed the effect of supplementing newborns with 50000 IU of vitamin A on all-cause infant mortality through 24 weeks of age.
This was a community-based, double-masked, cluster-randomized, ...placebo-controlled trial conducted in 19 unions in rural northwest Bangladesh. The study was nested into and balanced across treatment arms of an ongoing placebo-controlled, weekly maternal vitamin A or beta-carotene supplementation trial. Study-defined sectors (N = 596) were evenly randomized for newborns of participating mothers to receive a single, oral supplement of vitamin A (50000 IU) or placebo as droplets of oil squeezed from a gelatinous capsule. Mothers provided informed consent for newborn participation at approximately 28 weeks' gestation. After birth, typically at home (where >90% of births occurred), infants were supplemented and their vital status was followed through 24 weeks of age. The main outcome measure was mortality through 24 weeks of age.
We obtained maternal consent to dose 17116 live-born infants (99.8% of all eligible) among whom 15937 (93.1%) were visited to be supplemented <30 days after birth and for whom vital status at 24 weeks of age was known. Dosed infants (n = 15902 99.8%) received their study supplement at a median age of 7 hours. Relative to control subjects, the risk of death in vitamin A-supplemented infants was 0.85, reflecting a 15% reduction in all-cause mortality. Protective relative risks were indistinguishable by infant gender, gestational age, birth weight, age at dosing, maternal age, parity, or across the 3 treatment arms of the maternal supplementation trial.
Newborn vitamin A dosing improved infant survival through the first 6 months of life in Bangladesh. These results corroborate previous findings from studies in Indonesia and India and provide additional evidence that vitamin A supplementation shortly after birth can reduce infant mortality in South Asia.
Household food insecurity (HFI) can lead to a poor diet and malnutrition. Yet, little is known about the extent to which maternal diet covaries with food insecurity during pregnancy and lactation.
...Longitudinal associations between HFI and maternal dietary diversity from early pregnancy to 3 mo postpartum were examined in rural Bangladesh.
We repeatedly assessed dietary intake by using a 7-d food-frequency questionnaire in the first and third trimesters of pregnancy and at 3 mo postpartum among 14,600 women enrolled into an antenatal micronutrient supplementation trial. Maternal dietary diversity score (DDS) was constructed as the sum of 10 food groups reportedly consumed at each assessment. Households were classified at 6 mo postpartum as being food secure or having mild, moderate, or severe HFI on the basis of a 9-item standard scale. Generalized estimating equations were used to estimate the longitudinal relation between HFI status and DDS and the likelihood of individual food-group consumption, adjusting for confounders at the maternal and household levels.
The DDS decreased with progressively worse HFI, an association best explained by a derived household wealth index. Compared with women from food-secure households, women of mild, moderate, and severe HFI were less likely, in a dose-response fashion, to have consumed dairy products adjusted ORs (95% CIs): 0.73 (0.69, 0.78), 0.62 (0.58, 0.66), and 0.52 (0.48, 0.55), respectively, eggs 0.81 (0.76, 0.85), 0.73 (0.68, 0.77), and 0.61 (0.57, 0.65), meat 0.83 (0.79, 0.88), 0.73 (0.69, 0.78), and 0.60 (0.56, 0.64), fish 0.87 (0.80, 0.94), 0.76 (0.70, 0.83), and 0.59 (0.54, 0.65), legumes and nuts 0.88 (0.83, 0.93), 0.81 (0.76, 0.87), and 0.79 (0.74, 0.85), and yellow and orange fruit and vegetables 0.85 (0.80, 0.91), 0.78 (0.73, 0.84), and 0.72 (0.67, 0.78). Neither intakes of dark-green leafy vegetables nor of vegetable oil were associated with HFI status.
Antenatal and postnatal maternal dietary diversity, especially intakes of animal-source foods, fruit, and vegetables, declined with worsening food insecurity in rural Bangladesh.
To evaluate the impact of a peer facilitator (PF) approach for improving mothers' knowledge and practices relating to maternal and child nutrition.
A quasi-experimental design nested within a ...large-scale integrated nutrition programme, Suaahara, in Nepal. Suaahara interventions were implemented in all study sites, but peer facilitators were used in only half of the study sites.
Rural, disadvantaged villages in three districts of Nepal: Bhojpur, Bajhang and Rupandehi.
Mothers of children aged 6-23·9 months (n 1890).
Differences over time between comparison (C) and intervention (I) groups show that the PF approach had a significant positive impact on several indicators of mothers' knowledge and practices relating to maternal and child nutrition: (i) knowing that fruits and vegetables are good for children 6-23·9 months (C: -0·7, I: 10·6; P=0·03); (ii) child dietary diversity (C: 0·02, I: 0·04; P=0·02); (iii) child minimum dietary diversity (≥4 of 7 food groups; (C: 6·9, I: 16·0; P=0·02); (iv) maternal dietary diversity (C: 0·1, I: 0·4; P=0·01); and (v) maternal minimum dietary diversity (≥4 food groups; C: 3·6, I: 14·0; P=0·03). Additionally, exposure to a PF three or more times in the past 6 months was positively associated with a small improvement in maternal (β=0·06, P=0·04) and child (β=0·06, P=0·02) dietary diversity scores. Improvements were not observed in maternal health-seeking behaviours such as number of antenatal care visits.
Peer mobilization is a potential approach for improving health- and nutrition-related knowledge and behaviours among women in hard-to-reach communities of Nepal.
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