Table of Contents
Summary
25
1. Introduction
33
1.1 Importance of complementary feeding for child health
33
1.2 Guiding principles for complementary feeding
34
1.3 Scope and organization of this ...report
34
2. Energy and nutrients needed from complementary foods
35
2.1 Energy, protein and lipids
35
2.2 Micronutrients
35
3. Methods
36
3.1 Sources searched and search strategy
36
3.2 Measurement of the treatment effect of interventions
36
3.3 Evaluation of methodological quality and level of evidence
37
3.4 Number of relevant studies identified
38
4. Findings of the systematic review
38
4.1 Types of intervention strategies
38
4.1.1 Educational interventions
38
4.1.2 Provision of food offering extra energy (with or without micronutrient fortification)
43
4.1.3 Micronutrient fortification of complementary foods
43
4.1.4 Increasing energy density of complementary foods through simple technology
46
4.1.5 Categorization of results by intervention strategy
46
4.2 Growth outcomes
46
4.2.1 Interventions using educational approaches
46
4.2.2 Interventions in which provision of complementary food was the only treatment
49
4.2.3 Interventions in which provision of complementary food was combined with another strategy, usually education for mothers
51
4.2.4 Interventions in which complementary foods were fortified with additional micronutrients
53
4.2.5 Interventions to increase energy density of complementary foods
55
4.3 Morbidity outcomes
55
4.3.1 Interventions using educational approaches
55
4.3.2 Interventions in which provision of complementary food was the only treatment
57
4.3.3 Interventions in which provision of complementary food was combined with another strategy, usually education for mothers
57
4.3.4 Interventions in which complementary foods were fortified with additional micronutrients
58
4.3.5 Interventions to increase energy density of complementary foods
59
4.4 Child development
61
4.4.1 Interventions in which provision of complementary food was the only treatment
61
4.4.2 Interventions in which complementary foods were fortified with additional micronutrients
62
4.5 Micronutrient intake
63
4.5.1 Intervention studies using educational approaches
63
4.5.2 Interventions in which provision of complementary food was the only treatment
64
4.5.3 Interventions in which provision of complementary food was combined with another strategy, usually education for mothers
64
4.5.4 Interventions in which complementary foods were fortified with additional micronutrients
65
4.5.5 Interventions to increase energy density of complementary foods
66
4.6 Iron status
66
4.6.1 Intervention studies using educational approaches
66
4.6.2 Interventions in which complementary food was provided, with or without another strategy such as education for mothers
68
4.6.3 Interventions in which commercially processed complementary foods were fortified with iron or multiple micronutrients
68
4.6.4 Interventions in which home fortification of complementary foods was the primary intervention
68
4.7 Zinc status
72
4.7.1 Interventions in which complementary foods were fortified with additional micronutrients, either commercially or with home fortification
72
4.8 Vitamin A status
72
4.8.1 Interventions in which complementary foods were fortified with additional micronutrients, either commercially or with home fortification
72
5. Discussion
75
5.1 Impact of complementary feeding interventions on growth
75
5.2 Impact of complementary feeding interventions on morbidity
77
5.3 Impact of complementary feeding interventions on child development
78
5.4 Impact of complementary feeding interventions on micronutrient intake
78
5.5 Impact of complementary feeding interventions on micronutrient status
78
5.6 Conclusions
79
Acknowledgments
82
References
82
Summary
Introduction
Complementary feeding interventions are usually targeted at the age range of 6–24 months, which is the time of peak incidence of growth faltering, micronutrient deficiencies and infectious illnesses in developing countries. After 2 years of age, it is much more difficult to reverse the effects of malnutrition on stunting, and some of the functional deficits may be permanent. Therefore, interventions that are effective at reducing malnutrition during this vulnerable period should be a high priority. Although several types of interventions can be targeted to this age range (e.g. micronutrient supplementation), a food‐based, comprehensive approach may be more effective and sustainable than programmes targeting individual nutrient deficiencies. For this review, a broad definition of ‘complementary feeding interventions’ is used so as to capture the full range of strategies that can be used.
Scope and methods of the review
The interventions described in this review generally include one or more components related to the Guiding Principles for Complementary Feeding of the Breastfed Child (PAHO/WHO 2003). The 10 guiding principles cover: (1) duration of exclusive breastfeeding and age of introduction of complementary foods; (2) maintenance of breastfeeding; (3) responsive feeding; (4) safe preparation and storage of complementary foods; (5) amount of complementary food needed; (6) food consistency; (7) meal frequency and energy density; (8) nutrient content of complementary foods; (9) use of vitamin‐mineral supplements or fortified products for infant and mother; and (10) feeding during and after illness. This review includes any relevant intervention that targeted children within the age range of 6–24 months. In some cases, the intervention may have included children older than 24 months, but in all studies at least some of the children were between 6 and 24 months. The assumption is that many of the children in these studies were breastfed, although a certain proportion will have terminated breastfeeding before 24 months. Although strategies for optimizing the duration of exclusive breastfeeding or increasing the total duration of breastfeeding may have a direct influence on several of the outcomes of interest, this review will not cover those strategies because another report will review those results.
The primary outcomes of interest for this review include growth, morbidity and child development. Micronutrient intake and micronutrient status were also included as outcomes because of their link to these key functional outcomes. Studies that assessed the impact of complementary feeding interventions on feeding practices only were not included because of time constraints and because it has been demonstrated previously that appropriately designed interventions can have a positive impact on feeding practices (Caulfield et al. 1999). For most intervention strategies and outcomes, the literature search was focused on the period from 1996 to 2006, as the previous review by Caulfield et al. (1999) covered the period from 1970 to 1997. For certain interventions not covered in the previous review (i.e. using amylase to increase energy density and interventions focused on iron status outcomes), studies dating back to 1990 were included. Only studies conducted in developing countries were included. The search was conducted using electronic methods, inspection of websites of key private voluntary organizations and the bibliographies of published papers, and personal contacts. The two authors of this review independently assessed the quality of each of the reviewed studies, and those scored as 2– (non‐randomized studies with a high risk of bias) were not included in the tabulation of results.
In total, 42 papers were included in the review. These papers report results from 29 efficacy trials and 13 effectiveness studies or programme reports from 25 developing countries. Interventions were considered efficacy trials if there was a high degree of assurance of delivery of the ‘treatment’, generally under carefully controlled research conditions (e.g. provision of a fortified complementary food with frequent follow‐up to assess adherence). Evaluations of interventions carried out in a programme setting, generally with less ability to control delivery of and adherence to ‘treatment’, were considered effectiveness studies.
To compare growth (weight and length) results across studies (when these results were reported as means ± SD), we calculated the treatment effect size for each outcome of interest using the formula:
When possible, the effect sizes for each outcome were averaged across interventions to obtain a rough estimate of overall impact. Effect size can be categorized as small (∼0.2), medium (∼0.5) or large (∼0.8).
Interventions were grouped into five categories depending on the main strategy used:
1
education about complementary feeding as the main treatment,
2
complementary food or a food product offering extra energy (with or without added micronutrients) provided as the only treatment,
3
provision of food combined with some other strategy, usually education for mothers,
4
fortification of complementary foods (centrally processed fortified foods or home‐fortification products) with micronutrients (with no difference in energy provided to intervention vs. control groups), and
5
increased energy density and/or nutrient bioavailability of complementary foods through the use of simple technologies.
Some studies had more than one intervention group and may thus be included in more than one of the categories. In these situations, only the results for the intervention groups that are relevant to the comparison in question are included in that section. Some of the interventions targeted only malnourished children, but most were aimed at all children in the target age range.
Results
Growth
Nearly all of the studies assessed growth as an outcome. There were six efficacy trials and five effectiveness studies in which the main intervention strategy was education about complementary feeding. Taking these 11 studies together, educationa
Despite the importance of magnesium to health and most importantly to women of reproductive age who are entering pregnancy, very few surveys have investigated the magnesium status of women of ...reproductive age, particularly in Africa. Additionally, the software and programs used to analyze dietary intake vary across countries in the region.
To assess the dietary magnesium intake of women of reproductive age in Ghana and to compare the estimate of magnesium intake obtained from two commonly used dietary analysis programs.
We collected magnesium intake from 63 Ghanaian women using a semiquantitative 150-item food frequency questionnaire. Dietary data was analyzed using two different dietary analysis programs, Nutrient Data Software for Research (NDSR) and the Elizabeth Stewart Hands and Associates (ESHA) Food Processor Nutrition Analysis software. We used the Wilcoxon signed rank test to compare the mean differences between the two dietary programs.
There were significant differences between the average dietary magnesium intake calculated by the two dietary programs, with ESHA estimating higher magnesium intake than NDSR (M±SE; ESHA: 200 ± 12 mg/day; NDSR: 168 ± 11 mg/day; p<0. 05). The ESHA database included some ethnic foods and was flexible in terms of searching for food items which we found to be more accurate in assessing the magnesium intake of women in Ghana. Using the ESHA software, 84% of the study women had intake below the recommended dietary allowances (RDA) of 320mg/day.
It is possible that the ESHA software provided an accurate estimate of magnesium in this population because it included specific ethnic foods. Concerted efforts such as magnesium supplementation and nutrition education should be considered to improve the magnesium intake of women of reproductive age in Ghana.
Inadequate micronutrient intakes are relatively common in low‐ and middle‐income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an ...increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost‐effectiveness of MMS compared with IFA. Recent meta‐analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual‐participant data meta‐analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost‐effective method to reduce the risk of adverse birth outcomes.
This review presents the conclusions of a task force that set out to provide guidance to countries considering using multiple micronutrient supplements in pregnant women by assessing the available evidence.
Objectives
We analysed mutually comparable surveys on adolescent attitudes and behaviours from nine sites in seven sub‐Saharan African countries, to determine the relationship between school ...enrolment and adolescent health outcomes.
Methods
Data from the Africa Research, Implementation Science, and Education Network cross‐sectional adolescent health surveys were used to examine the associations of current school enrolment, self‐reported general health and four major adolescent health domains: (i) sexual and reproductive health; (ii) nutrition and non‐communicable diseases; (iii) mental health, violence and injury; and (iv) healthcare utilisation. We used multivariable Poisson regression models to calculate relative risk ratios with 95% confidence intervals (CI), controlling for demographic and socio‐economic characteristics. We assessed heterogeneity by gender and study site.
Results
Across 7829 adolescents aged 10–19, 70.5% were in school at the time of interview. In‐school adolescents were 14.3% more likely (95% CI: 6–22) to report that their life is going well; 51.2% less likely (95% CI: 45–67) to report ever having had sexual intercourse; 32.6% more likely (95% CI: 9–61) to report unmet need for health care; and 30.1% less likely (95% CI: 15–43) to report having visited a traditional healer. School enrolment was not significantly associated with malnutrition, low mood, violence or injury. Substantial heterogeneity was identified between genders for sexual and reproductive health, and in‐school adolescents were particularly less likely to report adverse health outcomes in settings with high average school enrolment.
Conclusions
School enrolment is strongly associated with sexual and reproductive health and healthcare utilisation outcomes across nine sites in sub‐Saharan Africa. Keeping adolescents in school may improve key health outcomes, something that can be explored through future longitudinal, mixed‐methods, and (quasi‐)experimental studies.
Objectifs
Nous avons analysé des enquêtes mutuellement comparables sur les attitudes et les comportements d'adolescents dans neuf sites dans sept pays d'Afrique subsaharienne, afin de déterminer la relation entre la scolarisation et les résultats de la santé des adolescents.
Méthodes
Des données provenant d'enquêtes transversales sur la santé des adolescents menées par le Réseau Africain de Recherche, d’Implémentation, de Science et d'Education ont été utilisées pour examiner les associations existant entre la scolarisation, l'état de santé général autodéclaré et les quatre principaux domaines de la santé des adolescents: (i) santé sexuelle et reproductive ; (ii) nutrition et maladies non transmissibles; (iii) santé mentale, violence et blessures et (iv) utilisation des soins de santé. Nous avons utilisé des modèles de régression multivariée de Poisson pour calculer les rapports de risque relatifs avec des intervalles de confiance (IC) à 95%, en tenant compte des caractéristiques démographiques et socioéconomiques. Nous avons évalué l'hétérogénéité par sexe et par site d'étude.
Résultats
Sur 7.829 adolescents âgés de 10 à 19 ans, 70,5% étaient à l'école au moment de l'enquête. Les adolescents scolarisés étaient 14,3% (IC95%: 6–22) plus susceptibles de déclarer que leur vie se passait bien, 51,2% (IC95%: 45–67) moins susceptibles de déclarer avoir déjà eu des rapports sexuels, 32,6% (IC95%: 39–91) plus susceptibles de signaler un besoin de soins de santé non satisfait et 30,1% (IC95%: 15–43) moins susceptibles de déclarer avoir rendu visite à un guérisseur traditionnel. La scolarisation n’était pas associée de manière significative à la malnutrition, à la mauvaise humeur, à la violence ou aux blessures. Une hétérogénéité substantielle a été identifiée entre les sexes pour la santé sexuelle et reproductive, et les adolescents scolarisés étaient particulièrement moins susceptibles de faire état de résultats défavorables pour la santé dans les milieux où la moyenne de scolarisation était élevée.
Conclusions
La scolarisation est fortement associée aux résultats en matière de santé sexuelle et reproductive et d'utilisation des soins de santé dans neuf sites en Afrique subsaharienne. Garder les adolescents à l'école peut améliorer les principaux résultats de santé, ce qui peut être exploré dans le cadre de futures études longitudinales.
Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost‐effective intervention to reduce ...these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low‐ and middle‐income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy‐three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.
The specific aim of this research prioritization exercise was to inform the direction of research and investments needed to support the implementation of multiple micronutrient supplementation (MMS) interventions for pregnant women in low‐ and middle‐income countries (LMIC) using the Child Health and Nutrition Research Initiative methodology. This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.
Little is known about the impact of small‐quantity lipid‐based nutrient supplements (SQ‐LNSs) on maternal morbidity. This secondary outcome analysis aimed to compare morbidity symptoms among women in ...two trials evaluating the efficacy of SQ‐LNSs. From enrolment (≤20‐week gestation) to 6 months postpartum, Ghanaian (n = 1320) and Malawian (n = 1391) women were assigned to consume daily: 60 mg iron and 400 µg folic acid until childbirth and placebo thereafter (iron and folic acid IFA group); or multiple micronutrients (MMN); or 20 g/day SQ‐LNSs. Within country, we used repeated measures logistic regression and analysis of variance models to compare group differences in the period prevalence and percentage of days of monitoring when women had fever, gastrointestinal, reproductive, and respiratory symptoms during the second and third trimesters of pregnancy (n ~ 1243 in Ghana, 1200 in Malawi) and 0–3 and 3–6 months postpartum (n ~ 1212 in Ghana, 730 in Malawi). Most outcomes did not differ significantly among groups, with the following exceptions: in Ghana, overall, the prevalence of vomiting was lower in the LNS (21.5%) than MMN (25.6%) group, with the IFA group (23.2%) in‐between (p = 0.046); mean ± SD percentage of days with nausea was greater in the LNS (3.5 ± 10.3) and MMN (3.3 ± 10.4) groups than the IFA (2.7 ± 8.3) group (p = 0.002). In Malawi, during 3–6 month postpartum, the prevalence of severe diarrhoea was greater in the LNS (8.1%) than the MMN (2.9%) group, with IFA (4.6%) in‐between, p = 0.041). We conclude that the type of nutrient supplement received during pregnancy and lactation generally does not influence morbidity symptoms in these settings. Clinicaltrials.gov identifiers: NCT00970866; NCT01239693.
Key messages
Ghanaian and Malawian women assigned to receive iron and folic acid (pregnancy only) or multiple micronutrients (pregnancy and lactation) or small‐quantity lipid‐based nutrient supplements (SQ‐LNSs) (pregnancy and lactation) generally did not differ in morbidity outcomes during the second and third trimesters of pregnancy and 0–3 and 3–6 months lactation.
The lack of group differences in most of the morbidity outcomes corroborates previous results of no significant group differences in the percentage of women who experienced severe adverse events or mean concentrations of two biomarkers of inflammation (C‐reactive protein and alpha‐1 glycoprotein) or percentage of women with elevated concentrations of the biomarkers.
Overall, there was no consistent evidence that SQ‐LNS or multiple micronutrients increased or decreased maternal morbidity during pregnancy or lactation, compared to iron and folic acid.
Objectives
To investigate several basic psychometric properties, including construct, convergent and discriminant validity, of the tablet‐based Rapid Assessment of Cognitive and Emotional Regulation ...(RACER) among children aged 4–6 years in Ghana.
Methods
We investigated whether RACER tasks administered to children in Ghana could successfully reproduce expected patterns of performance previously found in high‐income countries on similar tasks assessing inhibitory control (e.g., slower responses on inhibition trials), declarative memory (e.g., higher accuracy on previously seen items), and procedural memory (e.g., faster responses on sequence blocks). Next, we assessed the validity of declarative memory and inhibitory control scores by examining associations of these scores with corresponding paper‐based test scores and increasing child age. Lastly, we examined whether RACER was more sensitive than paper‐based tests to environmental risk factors common in low‐ and middle‐income countries (LMICs).
Results
Of the 966 children enrolled, more than 96% completed the declarative memory and inhibitory control tasks; however, around 30% of children were excluded from data analysis on the procedural memory task due to missing more than half of trials. The performance of children in Ghana replicated previously documented patterns of performance. RACER inhibitory control accuracy score was significantly correlated with child age (r (929) = .09, p = .007). However, our findings did not support other hypotheses.
Conclusions
The high task completion rates and replication of expected patterns support that certain RACER sub‐tasks are feasible for measuring child cognitive development in LMIC settings. However, this study did not provide evidence to support that RACER is a valid tool to capture meaningful individual differences among children aged 4–6 years in Ghana.
Anaemia has serious effects on human health and has multifactorial aetiologies. This study aimed to determine putative risk factors for anaemia in children 6–59 months and 15‐ to 49‐year‐old ...non‐pregnant women living in Ghana. Data from a nationally representative cross‐sectional survey were analysed for associations between anaemia and various anaemia risk factors. National and stratum‐specific multivariable regressions were constructed separately for children and women to calculate the adjusted prevalence ratio (aPR) for anaemia of variables found to be statistically significantly associated with anaemia in bivariate analysis. Nationally, the aPR for anaemia was greater in children with iron deficiency (ID; aPR 2.20; 95% confidence interval CI: 1.88, 2.59), malaria parasitaemia (aPR 1.96; 95% CI: 1.65, 2.32), inflammation (aPR 1.26; 95% CI: 1.08, 1.46), vitamin A deficiency (VAD; aPR 1.38; 95% CI: 1.19, 1.60) and stunting (aPR 1.26; 95% CI: 1.09, 1.46). In women, ID (aPR 4.33; 95% CI: 3.42, 5.49), VAD (aPR 1.61; 95% CI: 1.24, 2.09) and inflammation (aPR 1.59; 95% CI: 1.20, 2.11) were associated with anaemia, whereas overweight and obese women had lower prevalence of anaemia (aPR 0.74; 95% CI: 0.56, 0.97). ID was associated with child anaemia in the Northern and Middle belts, but not in the Southern Belt; conversely, inflammation was associated with anaemia in both children and women in the Southern and Middle belts, but not in the Northern Belt. Anaemia control programmes should be region specific and aim at the prevention of ID, malaria and other drivers of inflammation as they are the main predictors of anaemia in Ghanaian children and women.
Micronutrient deficiencies remain common among women and children in Sub‐Saharan Africa (SSA); in pregnant/lactating women, the intakes of essential fatty acids may also be low. Enriching ...home‐prepared foods with small‐quantity lipid‐based nutrient supplements (SQ‐LNSs) is a promising new strategy of delivering additional micronutrients, essential fatty acids and good quality protein to women and children. This narrative review aimed to examine the impact of SQ‐LNSs supplementation among women and infants and young children in SSA, and to discuss the differential impact of SQ‐LNS consumption across different settings.
Papers reporting randomized trials conducted in SSA in which apparently healthy women and/or ≥6‐mo‐old children received SQ‐LNSs were identified through electronic and manual searches.
Prenatal SQ‐LNS consumption reduced the prevalence of low gestational weight gain in Ghana when compared with multiple micronutrients supplementation, and was associated with poorer iron/hemoglobin status when compared with iron‐plus‐folic acid supplementation. SQ‐LNSs received alone or as intervention package improved infant/child growth in two trials in Ghana and one trial each in Burkina Faso, Kenya, Zimbabwe and South Africa, but had no impact on growth in two trials in Malawi. SQ‐LNSs supplementation improved motor development in Ghana, Burkina Faso, Malawi, Kenya, and South Africa, but had no impact on language, socio‐emotional, and executive functions in Ghana and Malawi and on Griffiths’ developmental scores in Malawi.
SQ‐LNSs may contribute to improving child growth in SSA. More research is needed to determine the iron level in SQ‐LNSs effective for improving both maternal hemoglobin/iron status and birth outcomes.
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