A mixed method study exploring adherence to and acceptability of small quantity lipid-based nutrient supplements (SQ-LNS) among pregnant and lactating women in Ghana and Malawi Prenatal Lipid-Based Nutrient Supplements Affect Maternal Anthropometric Indicators Only in Certain Subgroups of Rural Bangladeshi Women. Effect of early neonatal vitamin A supplementation on mortality during infancy in Ghana (Neovita): a randomised, double-blind, placebo-controlled trial Effect of neonatal vitamin A supplementation on mortality in infants in Tanzania (Neovita): a randomised, double-blind, placebo-controlled trial Small-quantity, lipid-based nutrient supplements provided to women during pregnancy and 6 mo postpartum and to their infants from 6 mo of age increase the mean attained length of 18-mo-old children in semi-urban Ghana: a randomized controlled trial12 Lipid-based nutrient supplements for pregnant women reduce newborn stunting in a cluster-randomized controlled effectiveness trial in Bangladesh. Effects of maternal and child lipid-based nutrient supplements on infant development: a randomized trial in Malawi. Efficacy of early neonatal supplementation with vitamin A to reduce mortality in infancy in Haryana, India (Neovita): a randomised, double-blind, placebo-controlled trial Mineral- and vitamin-enhanced micronutrient powder reduces stunting in full-term low-birth-weight infants receiving nutrition, health, and hygiene education: a 2 × 2 factorial, cluster-randomized trial in Bangladesh. Evaluation of the uptake and impact of neonatal vitamin A supplementation delivered through the Lady Health Worker programme on neonatal and infant morbidity and mortality in rural Pakistan: an effectiveness trial Impact of small‐quantity lipid‐based nutrient supplement on hemoglobin, iron status and biomarkers of inflammation in pregnant Ghanaian women Effects of pre- and post-natal lipid-based nutrient supplements on infant development in a randomized trial in Ghana. Daily co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition: a multicentre, double-blind, randomised placebo-controlled trial Gut bacteria that prevent growth impairments transmitted by microbiota from malnourished children Improving dietary diversity of school adolescents through school based nutrition education and home gardening in Jimma Zone: Quasi-experimental design.
Background Supplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements ( SQ-LNS ) has result ed in improvements in birth outcomes in some low-income setting s. In order to be effective , SQ-LNS must be consumed regularly over sustained periods . Methods The objective was to assess and compare acceptability of and adherence to SQ-LNS consumption among pregnant and lactating women in Ghana and Malawi throughout 12 months of supplementation . We enrolled women before 20 gestation weeks into r and omized trials in Ghana ( n = 1320 ) and Malawi ( n = 869 ) . In the SQ-LNS group participants received a 20 g sachet of supplement per day during pregnancy and the first 6 months of lactation . In the control groups participants received multiple micronutrients ( MMN ) during pregnancy and lactation or iron and folic acid ( IFA ) during pregnancy and calcium during lactation . We used question naires to collect data on self-reported adherence to daily use of supplements and conducted in-depth interviews with women in the SQ-LNS group to examine acceptability . Results The mean self-reported adherence during the supplementation period was lower in Ghana ( 79.9 % ) than in Malawi ( 91.7 % ) for all supplements ( difference 11.8 % , P < 0.001 ) . Over time , adherence increased in Malawi but decreased in Ghana . In both countries , adherence in the SQ-LNS group was non-inferior to that in the control groups . Participants typically reported consuming SQ-LNS as instructed but when interviewers queried about experiences , most of the women described incidents of non-adherence . A usual reason for not consuming SQ-LNS was nausea and vomiting during pregnancy . Especially in Malawi , women reported sharing SQ-LNS with families and friends . Sustained use of  SQ-LNS  was attributed to expected health benefits and favorable sensory attributes . Often women compared their pregnancy to previous ones , and were of the view that SQ-LNS made a positive difference . ConclusionS elf-reported sustained adherence to consume  SQ-LNS  daily was high in both sites but lower in Ghana than in Malawi . In Ghana , adherence decreased over time whereas in Malawi adherence increased . Acceptability and adherence appeared interlinked , complex and context -related . Sustained consumption of SQ-LNS may require tailoring interventions by context .Trial registration The Ghana trial was registered at clinical trials.gov as NCT00970866 , and the Malawi trial as NCT01239693 BACKGROUND Maternal undernutrition and low macro- and micronutrient intake and weight gain during pregnancy have been reported in Bangladesh . OBJECTIVE We aim ed to determine the effects of lipid-based nutrient supplements for pregnant and lactating women ( LNS-PL ) on weight gain and midupper arm circumference ( MUAC ) during pregnancy . METHODS The Rang-Din Nutrition Study , a cluster-r and omized effectiveness trial conducted in Bangladesh , enrolled 4011 pregnant women at ≤20 wk gestation who received either 60 mg Fe + 400 μg folic acid/d or 20 g LNS-PL/d ( 118 kcal ) containing essential fatty acids and vitamins and minerals until delivery . At 36 wk gestation , women were interviewed at home and then attended a follow-up examination at local clinics ( n = 2877 ) , where anthropometric measurements were taken . RESULTS No significant differences between intervention groups in maternal weight gain per week , low weight gain per week , or MUAC at 36 wk gestation were observed in the full sample . However , among multiparous women aged ≥25 y , those in the LNS-PL group gained 34 g/wk more than their counterparts in the iron and folic acid ( IFA ) group ( P = 0.001 ) , whereas no differences were seen in the other parity/age subgroups . Women aged ≥25 y in the LNS-PL group had a 0.4-cm greater MUAC than their counterparts in the IFA group ( P = 0.003 ) ; no significant differences were observed in the other age groups . Among women whose height at baseline was in the lowest quartile of the distribution , those in the LNS-PL group had a 0.1 - 0.3-cm greater MUAC at 36 wk gestation than those in the IFA group ( P = 0.004 - 0.014 ) . CONCLUSIONS Lipid-based nutrient supplements provided during pregnancy did not affect maternal anthropometric indicators in the overall sample but increased MUAC among women aged ≥25 y and those with lower stature and weight gain among multiparous women aged ≥25 y. This trial was registered at clinical trials.gov as NCT01715038 BACKGROUND Results of r and omised controlled trials of newborn ( age 1 - 3 days ) vitamin A supplementation  have been inconclusive . The WHO is coordinating three large r and omised trials in Ghana , India , and Tanzania ( Neovita trials ) . We present the findings of the Neovita trial in Ghana . METHODS This study was a population -based , individually r and omised , double-blind , placebo-controlled trial in the Brong Ahafo region of Ghana . The trial participants were infants aged at least 2 h , identified at home or facilities on the day of birth or in the next 2 days , able to feed orally , and likely to stay in the study area for at least 6 months . They were r and omly assigned ( ratio 1:1 ) to receive either one oral dose of vitamin A ( 50,000 IU ) or placebo immediately after recruitment . The research team and parents of the infants were masked to treatment assignment . Follow-up home visits were undertaken every 4 weeks , when data were recorded for deaths , facility use , and care seeking . The primary outcome was post-supplementation mortality to 6 months of age . Analysis was by intention to treat . Potential adverse events were recorded at 1 and 3 days after supplementation . This trial is registered with the Australian New Zeal and Clinical Trials Registry (ANZCTR)CTRN12610000582055 . FINDINGS We assessed 26,414 livebirths for eligibility between Aug 16 , 2010 , and Nov 7 , 2011 . We recruited 22,955 newborn infants , with 11,474 r and omly assigned to receive vitamin A and 11,481 to receive placebo . Loss to follow-up was low with vital status at 6 months of age reported for 22,698 ( 98·9 % ) infants . We recorded 278 post-supplementation deaths to 6 months of age in the vitamin A group ( mortality risk 24·5 in 1000 supplemented infants ) and 248 deaths in the placebo group ( mortality risk 21·8 per 1000 supplemented infants ) , relative risk ( RR ) 1·12 ( 95 % CI 0·95 - 1·33 ; p=0·183 ) and risk difference ( RD ) 2·66 ( 95 % CI -1·25 to 6·57 ; p=0·18 ) . Adverse events within 3 days of supplementation did not differ by trial group . 122 infants died in the first 3 days after supplementation ; 70 ( 0·6 % ) in the vitamin A and 52 ( 0·5 % ) in the placebo group ( risk ratio [ RR ] 1·35 , 95 % CI 0·94 - 1·93 , p=0·102 ) . 53 infants were reported to have a bulging fontanelle ; 32 ( 0·3 % ) in the vitamin A group and 21 ( 0·2 % ) in the placebo group ( RR 1·53 , 0·88 - 2·62 , p=0·130 ) . INTERPRETATION The results of this trial do not support inclusion of newborn vitamin A supplementation as a child survival strategy in Ghana . FUNDING Bill & Melinda Gates Foundation grant to the WHO BACKGROUND Supplementation of vitamin A in children aged 6 - 59 months improves child survival and is implemented as global policy . Studies of the efficacy of supplementation of infants in the neonatal period have inconsistent results . We aim ed to assess the efficacy of oral supplementation with vitamin A given to infants in the first 3 days of life to reduce mortality between supplementation and 180 days ( 6 months ) . METHODS We did an individually r and omised , double-blind , placebo-controlled trial of infants born in the Morogoro and Dar es Salaam regions of Tanzania . Women were identified during antenatal clinic visits or in the labour wards of public health facilities in Dar es Salaam . In Kilombero , Ulanga , and Kilosa districts , women were seen at home as part of the health and demographic surveillance system . Newborn infants were eligible for r and omisation if they were able to feed orally and if the family intended to stay in the study area for at least 6 months . We r and omly assigned infants to receive one dose of 50,000 IU of vitamin A or placebo in the first 3 days after birth . Infants were r and omly assigned in blocks of 20 , and investigators , participants ' families , and data analysis teams were masked to treatment assignment . We assessed infants on day 1 and day 3 after dosing , as well as at 1 , 3 , 6 , and 12 months after birth . The primary endpoint was mortality at 6 months , assessed by field interviews . The primary analysis included only children who were not lost to follow-up . This trial is registered with the Australian New Zeal and Clinical Trials Registry ( ANZCTR ) , number ACTRN12610000636055 . FINDINGS Between Aug 26 , 2010 , and March 3 , 2013 , 31,999 newborn babies were r and omly assigned to receive vitamin A ( n=15,995 ) or placebo ( n=16,004 ; 15,428 and 15,464 included in analysis of mortality at 6 months , respectively ) . We did not find any evidence for a beneficial effect of vitamin A  supplementation on mortality in infants at 6 months ( 26 deaths per 1000 livebirths in vitamin A vs 24 deaths per 1000 livebirths in placebo group ; risk ratio 1·10 , 95 % CI 0·95 - 1·26 ; p=0·193 ) . There was no evidence of a differential effect for vitamin A supplementation on mortality by sex ; risk ratio for mortality at 6 months for boys was 1·08 ( 0·90 - 1·29 ) and for girls was 1·12 ( 0·91 - 1·39 ) . There was also no evidence of adverse effects of supplementation within 3 days of dosing . INTERPRETATION Neonatal vitamin A supplementation did not result in any immediate adverse events , but had no beneficial effect on survival in infants in Tanzania . These results strengthen the evidence against a global policy recommendation for neonatal vitamin A supplementation . FUNDING Bill & Melinda Gates Foundation to WHO Background : Childhood stunting usually begins in utero and continues after birth ; therefore , its reduction must involve actions across different stages of early life . Objective : We evaluated the efficacy of small-quantity , lipid-based nutrient supplements ( SQ-LNSs ) provided during pregnancy , lactation , and infancy on attained size by 18 mo of age . Design : In this partially double-blind , individually r and omized trial , 1320 women at ≤20 wk of gestation received st and ard iron and folic acid ( IFA group ) , multiple micronutrients ( MMN group ) , or SQ-LNS ( LNS group ) daily until delivery , and then placebo , MMNs , or SQ-LNS , respectively , for 6 mo postpartum ; infants in the LNS group received SQ-LNS formulated for infants from 6 to 18 mo of age ( endline ) . The primary outcome was child length by 18 mo of age . Results : At endline , data were available for 85 % of 1228 infants enrolled ; overall mean length and length-for-age z score ( LAZ ) were 79.3 cm and −0.83 , respectively , and 12 % of the children were stunted ( LAZ < −2 ) . In analysis based on the intended treatment , mean ± SD length and LAZ for the LNS group ( 79.7 ± 2.9 cm and −0.69 ± 1.01 , respectively ) were significantly greater than for the IFA ( 79.1 ± 2.9 cm and −0.87 ± 0.99 ) and MMN ( 79.1 ± 2.9 cm and −0.91 ± 1.01 ) groups ( P = 0.006 and P = 0.009 , respectively ) . Differences were also significant for weight and weight-for-age z score but not head or midupper arm circumference , and the prevalence of stunting in the LNS group was 8.9 % , compared with 13.7 % in the IFA group and 12.9 % in the MMN group ( P = 0.12 ) . In analysis based on actual supplement provided at enrollment , stunting prevalences were 8.9 % compared with 15.1 % and 11.5 % , respectively ( P = 0.045 ) . Conclusion : Provision of SQ-LNSs to women from pregnancy to 6 mo postpartum and to their infants from 6 to 18 mo of age may increase the child ’s attained length by age 18 mo in similar setting s. This trial was registered at clinical trials.gov as NCT00970866 BACKGROUND Maternal undernutrition and newborn stunting [ birth length-for-age z score ( LAZ ) < -2 ] are common in Bangladesh . OBJECTIVE The objective was to evaluate the effect of lipid-based nutrient supplements for pregnant and lactating women ( LNS-PLs ) on birth outcomes . DESIGN We conducted a cluster-r and omized effectiveness trial ( the Rang-Din Nutrition Study ) within a community health program in rural Bangladesh . We enrolled 4011 pregnant women at ≤20 gestational weeks ; 48 clusters received iron and folic acid ( IFA ; 60 mg Fe + 400 μg folic acid ) and 16 clusters received LNS-PLs ( 20 g/d , 118 kcal ) containing essential fatty acids and 22 vitamins and minerals . Both of the supplements were intended for daily consumption until delivery . Primary outcomes were birth weight and length . RESULTS Infants in the LNS-PL group had higher birth weights ( 2629 ± 408 compared with 2588 ± 413 g ; P = 0.007 ) , weight-for-age z scores ( -1.48 ± 1.01 compared with -1.59 ± 1.02 ; P = 0.006 ) , head-circumference-for-age z scores ( HCZs ; -1.26 ± 1.08 compared with -1.34 ± 1.12 ; P = 0.028 ) , and body mass index z scores ( -1.57 ± 1.05 compared with -1.66 ± 1.03 ; P = 0.005 ) than those in the IFA group ; in adjusted models , the differences in length ( 47.6 ± 0.07 compared with 47.4 ± 0.04 cm ; P = 0.043 ) and LAZ ( -1.15 ± 0.04 compared with -1.24 ± 0.02 ; P = 0.035 ) were also significant . LNS-PLs  reduced the risk of newborn stunting ( 18.7 % compared with 22.6 % ; RR : 0.83 ; 95 % CI : 0.71 , 0.97 ) and small head size ( HCZ < -2 ) ( 20.7 % compared with 24.9 % ; RR : 0.85 ; 95 % CI : 0.73 , 0.98 ) . The effects  of LNS-PL on newborn stunting were greatest in infants born before a 10-wk interruption in LNS-PL distribution ( n = 1301 ; 15.7 % compared with 23.6 % ; adjusted RR : 0.69 ; 95 % CI : 0.53 , 0.89 ) and in infants born to women ≤24 y of age or with household food insecurity . CONCLUSION Prenatal lipid-based nutrient supplements can improve birth outcomes in Bangladeshi women , especially those at higher risk of fetal growth restriction . This trial was registered at clinical trials.gov as NCT01715038 BACKGROUND Maternal and infant undernutrition is associated with poor infant development ; however , few studies have examined the impact of combined pre- and postnatal dietary supplementation on infant development . OBJECTIVE Our objective was to determine whether provision of small-quantity lipid-based nutrient supplements ( SQ-LNSs ) to mothers during pregnancy and the first 6 mo postpartum , and to children aged 6 - 18 mo , improves infant development in Malawi . DESIGN We r and omly assigned 869 pregnant women to receive one of the following daily : an iron and folic acid ( IFA ) capsule , a multiple micronutrient ( MMN ) capsule containing 18 micronutrients , or a 20-g sachet of SQ-LNSs containing 22 vitamins and minerals , protein , carbohydrates , essential fatty acids , and 118 kcal . Children in the lipid-based nutrient supplement ( LNS ) group only received SQ-LNSs from 6 to 18 mo of age . We monitored the acquisition of 11 developmental milestones monthly by maternal report ; observed the attainment of 7 motor milestones at 6 , 12 , and 18 mo of age ; and conducted a comprehensive assessment of motor , language , and socioemotional development and executive function at 18 mo of age . The primary analysis was by intention-to-treat . RESULTS By maternal report , children in the LNS group achieved walking alone ( B = 0.53 ; 95 % CI : 0.11 , 0.94 ; P = 0.034 ) and waving goodbye ( B = 0.60 ; 95 % CI : 0.12 , 1.08 ; P = 0.040 ) earlier than the IFA group and st and ing with assistance earlier than the MMN group ( B = 0.51 ; 95 % CI : 0.12 , 0.89 ; P = 0.029 ) . By research er observation , there was a trend ( P = 0.052 ) for a greater percentage of children in the LNS group ( 58 % ) to walk alone at age 12 mo than in the IFA ( 49 % ) and MMN ( 49 % ) groups . At age 18 mo , there were no significant differences between groups in any scores . CONCLUSION Although provision of SQ-LNSs to pregnant women and infants in Malawi may affect the age of acquisition of certain developmental milestones , it did not affect our assessment s of motor , language , socioemotional , or executive function skills at 18 mo of age . This trial was registered at clinical trials.gov as NCT01239693 BACKGROUND Vitamin A supplementation in children aged 6 months to 5 years has been shown to reduce mortality . The efficacy of neonatal supplementation with vitamin A to reduce mortality in the first 6 months of life is plausible but not established . We aim ed to assess the efficacy of neonatal oral supplementation with vitamin A to reduce mortality between supplementation and 6 months of age . METHODS We undertook an individually r and omised , double-blind , placebo-controlled trial in Haryana , India . We identified pregnant women through a surveillance programme undertaken every 3 months of all female residents in two districts of Haryana , India , aged 15 - 49 years , and screened every identified livebirth . Eligible participants were neonates whose parents consented to participate , were likely to stay in the study area until at least 6 months of age , and were able to feed orally at the time of enrolment . Participants were r and omly assigned to receive oral capsules containing vitamin A ( retinol palmitate 50,000 IU plus vitamin E 9·5 - 12·6 IU ) or placebo ( vitamin E 9·5 - 12·6 IU ) within 72 h of birth . R and omisation was in blocks of 20 according to a r and omisation list prepared by a statistician not otherwise involved with the trial . Investigators , participants ' families , and the data analysis team were masked to treatment allocation . The primary outcome was mortality between supplementation and 6 months of age . Analysis included all participants assigned to study groups . This trial is registered with Clinical Trials.gov , number NCT01138449 , and the Indian Council of Medical Research Clinical Trial Registry , number CTRI/2010/091/000220 . FINDINGS Between June 24 , 2010 , and July 1 , 2012 we screened 47,777 neonates and r and omly assigned 44,984 to receive vitamin A ( 22,493 ) or placebo ( 22,491 ) . Between supplementation and 6 months of age , 656 infants died in the vitamin A group compared with 726 in the placebo group ( 29·2 per 1000 vs 32·3 per 1000 ; difference -3·1 per 1000 , 95 % CI -6·3 to 0·1 ; risk ratio 0·90 , 95 % CI 0·81 to 1·00 ) . We noted no significant interactions between the intervention effect and sex on mortality at 6 months ( p=0·409 ) . Supplementation with 50,000 IU vitamin A within the first 72 h of life was generally safe and well tolerated , with the exception of a small excess risk of transient bulging fontanelle ( 205 cases in the vitamin A group confirmed by physician vs 80 cases in the placebo group , risk ratio 2·56 [ 95 % CI 1·98 - 3·32 ] ) . INTERPRETATION The findings of this study , done in a population in which vitamin A deficiency is a moderate public health problem , are consistent with a modest reduction in mortality between supplementation and 6 months of age . These findings must be viewed together with similar trials in other population s to enable determination of appropriate public health policy . FUNDING Bill & Melinda Gates Foundation to WHO BACKGROUND The causes of stunting are complex but likely include prenatal effects , inadequate postnatal nutrient intake , and recurrent infections . Low-birth-weight ( LBW ) infants are at high risk of stunting . More than 25 % of live births in low- and middle-income countries are at full term with low birth weight ( FT-LBW ) . Evidence on the efficacy of specific interventions to enhance growth in this vulnerable group remains scant . OBJECTIVE We investigated the independent and combined effects of a directed use of a water-based h and sanitizer ( HS ) and a mineral- and vitamin-enhanced micronutrient powder ( MNP ) ( 22 minerals and vitamins ) to prevent infections and improve nutrient intake to reduce stunting in FT-LBW infants . DESIGN The study was a prospect i ve 2 × 2 factorial , cluster-r and omized trial in 467 FT-LBW infants during 2 periods : from 0 to 5 mo postpartum ( 0 - 180 d postpartum ) and from 6 to 12 mo postpartum ( 181 - 360 d postpartum ) with the use of 48 clusters . All groups received the same general nutrition , health , and hygiene education ( NHHE ) at enrollment and throughout the 12 mo . Group assignments initially included the following 2 groups : no HS ( control ) group or HS from 0 to 5 mo postpartum . These assignments were followed by further divisions into the following 4 groups from 6 to 12 mo postpartum : 1 ) no HS and no MNP ( control ) , 2 ) HS only , 3 ) MNP only , and 4 ) HS and MNP . RESULTS When delivered in combination with NHHE , the use of an HS showed no additional benefit in reducing indicators of infection in the first or second half of infancy or the likelihood of stunting at 12 mo postpartum . FT-LBW infants who received the MNP ( with or without the HS ) were significantly less likely to be stunted at 12 mo than were controls ( OR : 0.35 ; 95 % CI : 0.15 , 0.84 ; P = 0.017 ) . CONCLUSIONS The use of a mineral- and vitamin-enhanced MNP  significantly reduced stunting in FT-LBW infants in this high-risk setting . The use of a water-based HS did not have an additive effect . This trial was registered at clinical trials.gov as NCT01455636 Background Despite evidence for the benefits of vitamin A supplementation ( VAS ) among children 6 to 59 months of age , the feasibility of introduction and potential benefit of VAS in the neonatal period in public health programmes is uncertain . Objective The primary objective was to evaluate the feasibility and effectiveness of early neonatal VAS ( single dose of 50 000 international units within 48–72 hours after birth ) delivered through the public sector Lady Health Worker ( LHW ) programme in rural Pakistan and to document its association with a reduction in mortality at 6 months of age . Methods A community-based , cluster r and omised , placebo-controlled trial was undertaken in two districts of rural Pakistan . LHWs dispensed vitamin A/placebo in identical capsules to newborn infants within 48–72 hours of birth . Follow-up visits were undertaken at 1 week of age and every 4 weeks thereafter until 6 months of age . Results Of a total of 15 433 consecutive pregnancies among eligible women of reproductive age , 13 225 pregnancies were registered , 12 218 live births identified and 11 028 newborn infants reached by LHWs . Of these , 5380 ( 49 % ) received neonatal VAS and 5648 ( 51 % ) placebo . The LHWs successfully delivered the capsules to 79 % of newborns within 72 hours of birth with no significant adverse effects . Although the proportion of days observed with symptoms of fever , diarrhoea or rapid breathing were lower with neonatal VAS , these differences were not statistically significant . Mortality rates in the two groups were comparable at 6 months of age . Conclusions While our study demonstrated that neonatal VAS was safe and could be feasibly delivered by LHWs in Pakistan as part of their early postnatal visits , the overall lack of benefit on neonatal and 6-month morbidity and mortality in our population suggests the need for further evaluation of this intervention in population s at risk . Trial registration number Clinical Trials.gov NCT00674089 Abstract We examined hemoglobin ( Hb , g/L ) , iron status ( zinc protoporphyrin , ZPP , & mgr;mol/mol heme , and transferrin receptor , TfR , mg/L ) and inflammation ( C‐reactive protein , CRP and alpha‐1 glycoprotein , AGP ) in pregnant Ghanaian women who participated in a r and omized controlled trial . Women ( n = 1320 ) received either 60 mg Fe + 400‐&mgr;g folic acid ( IFA ) ; 18 micronutrients including 20‐mg Fe ( MMN ) or small‐quantity lipid‐based nutrient supplements ( SQ‐LNS , 118 kcal/d ) with the same micronutrient levels as in MMN , plus four additional minerals ( LNS ) daily during pregnancy . Intention‐to‐treat analysis included 349 , 354 and 354 women in the IFA , MMN and LNS groups , respectively , with overall baseline mean Hb and anemia ( Hb < 100 ) prevalence of 112 and 13.3 % , respectively . At 36 gestational weeks , overall Hb was 117 , and anemia prevalence was 5.3 % . Compared with the IFA group , the LNS and MMN groups had lower mean Hb ( 120 ± 11 vs. 115 ± 12 and 117 ± 12 , respectively ; P < 0.001 ) , higher mean ZPP ( 42 ± 30 vs. 50 ± 29 and 49 ± 30 ; P = 0.010 ) and TfR ( 4.0 ± 1.3 vs. 4.9 ± 1.8 and 4.6 ± 1.7 ; P < 0.001 ) , and greater prevalence of anemia ( 2.2 % vs. 7.9 % and 5.8 % ; P = 0.019 ) , elevated ZPP ( > 60 ) [ 9.4 % vs. 18.6 % and 19.2 % ; P = 0.003 ] and elevated TfR ( > 6.0 ) [ 9.0 % vs. 19.2 % and 15.1 % ; P = 0.004 ] . CRP and AGP concentrations did not differ among groups . We conclude that among pregnant women in a semi‐urban setting in Ghana , supplementation with SQ‐LNS or MMN containing 20 mg iron result ed in lower Hb and iron status but had no impact on inflammation , when compared with iron ( 60 mg ) plus folic acid ( 400 & mgr;g ) . The amount of iron in such supplements that is most effective for improving both maternal Hb/iron status and birth outcomes requires further evaluation . This trial was registered at Clinical Trials.gov as : NCT00970866 BACKGROUND Maternal and infant undernutrition is negatively associated with infant development . AIMS We tested the hypothesis that provision of small-quantity lipid-based nutrient supplements ( SQ-LNS ) to pregnant women and infants positively affects infant development . STUDY DESIGN In a partially double-blind r and omized controlled trial , we compared the following daily maternal supplements during pregnancy and until 6months post-partum : iron/folic acid capsule ( IFA ) , capsule containing 18 micronutrients ( MMN ) , or 20 g SQ-LNS .  Children in the SQ-LNS group also received SQ-LNS from age 6 to 18months . The study is registered as NCT00970866 . SUBJECTS 1320 pregnant women in Ghana enrolled in the trial ; 1173 of their children participated in developmental assessment . OUTCOME MEASURES We monitored the acquisition of 10 developmental milestones monthly by parental report , observed the attainment of 6 motor milestones at 6 , 12 , and 18months , and conducted detailed assessment of motor , language , socio-emotional , and executive function at 18months . RESULTS By research er observation , a greater percentage of children in the SQ-LNS group ( 53 % ) was able to walk alone at 12months than in the IFA group ( 43 % ; RR=1.23 , 95 % CI=1.02 - 1.49 ; p=0.025 ) . We found no significant differences between groups in milestone acquisition by parent report or in any scores at 18months . The difference in mean z-scores between groups ranged from 0.03 - 0.13 for motor ( p=0.84 ) , 0.01 - 0.08 for language ( p=0.46 ) , 0.01 - 0.02 for socio-emotional ( p=0.75 ) , and 0.00 - 0.02 for executive function ( p=0.95 ) . CONCLUSION While provision of maternal and child SQ-LNS in Ghana may affect walking at 12months , it did not affect infant development at 18months Summary Background Children with complicated severe acute malnutrition ( SAM ) have a greatly increased risk of mortality from infections while in hospital and after discharge . In HIV-infected children , mortality and admission to hospital are prevented by daily co-trimoxazole prophylaxis , despite locally reported bacterial resistance to co-trimoxazole . We aim ed to assess the efficacy of daily co-trimoxazole prophylaxis on survival in children without HIV being treated for complicated SAM . Methods We did a multicentre , double-blind , r and omised , placebo-controlled study in four hospitals in Kenya ( two rural hospitals in Kilifi and Malindi , and two urban hospitals in Mombasa and Nairobi ) with children aged 60 days to 59 months without HIV admitted to hospital and diagnosed with SAM . We r and omly assigned eligible participants ( 1:1 ) to 6 months of either daily oral co-trimoxazole prophylaxis ( given as water-dispersible tablets ; 120 mg per day for age < 6 months , 240 mg per day for age 6 months to 5 years ) or matching placebo . Assignment was done with computer-generated r and omisation in permuted blocks of 20 , stratified by centre and age younger or older than 6 months . Treatment allocation was concealed in opaque , sealed envelopes and patients , their families , and all trial staff were masked to treatment assignment . Children were given recommended medical care and feeding , and followed up for 12 months . The primary endpoint was mortality , assessed each month for the first 6 months , then every 2 months for the second 6 months . Secondary endpoints were nutritional recovery , readmission to hospital , and illness episodes treated as an outpatient . Analysis was by intention to treat . This trial was registered at Clinical Trials.gov , number NCT00934492 . Findings Between Nov 20 , 2009 , and March 14 , 2013 , we recruited and assigned 1778 eligible children to treatment ( 887  to co-trimoxazole prophylaxis and 891 to placebo )  . Median age was 11 months ( IQR 7–16 months ) , 306 ( 17 % ) were younger than 6 months , 300 ( 17 % ) had oedematous malnutrition ( kwashiorkor ) , and 1221 ( 69 % ) were stunted ( length-for-age Z score < –2 ) . During 1527 child-years of observation , 122 ( 14 % ) of 887 children in the co-trimoxazole group died , compared with 135 ( 15 % ) of 891 in the placebo group ( unadjusted hazard ratio [ HR ] 0·90 , 95 % CI 0·71–1·16 , p=0·429 ; 16·0 vs 17·7 events per 100 child-years observed ( CYO ) ; difference −1·7 events per 100 CYO , 95 % CI −5·8 to 2·4 ] ) . In the first 6 months of the study ( while participants received study medication ) , 63 suspected grade 3 or 4 associated adverse events were recorded among 57 ( 3 % ) children ; 31 ( 2 % ) in the co-trimoxazole group and 32 ( 2 % ) in the placebo group ( incidence rate ratio 0·98 , 95 % CI 0·58–1·65 ) . The most common adverse events of these grade s were urticarial rash ( grade 3 , equally common in both groups ) , neutropenia ( grade 4 , more common in the co-trimoxazole group ) , and anaemia ( both grade s equally common in both groups ) . One child in the placebo group had fatal toxic epidermal necrolysis with concurrent Pseudomonas aeruginosa bacteraemia . Interpretation Daily co-trimoxazole prophylaxis did not reduce mortality in children with complicated SAM without HIV . Other strategies need to be tested in clinical trials to reduce deaths in this population . Funding Wellcome Trust , Microbiota and infant development Malnutrition in children is a persistent challenge that is not always remedied by improvements in nutrition . This is because a characteristic community of gut microbes seems to mediate some of the pathology .  Human gut microbes  can be transplanted effectively into germ-free mice to recapitulate their associated phenotypes . Using this model , Blanton et al. found that the microbiota of healthy children relieved the harmful effects on growth caused by the microbiota of malnourished children . In infant mammals , chronic undernutrition results in growth hormone resistance and stunting . In mice , Schwarzer et al. showed that strains of Lactobacillus plantarum in the gut microbiota sustained growth hormone activity via signaling pathways in the liver , thus overcoming growth hormone resistance . Together these studies reveal that specific beneficial microbes could potentially be exploited to resolve undernutrition syndromes . Science , this issue p. 10.1126/science.aad3311 , p. 854 Microbes from healthy children protect mice from the detrimental effects of the microbiota of malnourished infants . INTRODUCTION As we come to appreciate how our microbial communities ( microbiota ) assemble following birth , there is an opportunity to determine how this facet of our developmental biology relates to the healthy or impaired growth of infants and children . Childhood undernutrition is a devastating global health problem whose long-term sequelae , including stunting , neurodevelopmental abnormalities , and immune dysfunction , remain largely refractory to current therapeutic interventions . RATIONALE To test the hypothesis that perturbations in the normal development of the gut microbiota are causally related to undernutrition , we first applied r and om forests ( RF ) , a machine learning method , to bacterial 16S ribosomal RNA data sets generated from fecal sample s that were collected serially from healthy Malawian infants and children during their first 3 postnatal years . Age-discriminatory bacterial taxa were identified with distinctive time-dependent changes in their relative abundances ; they were used to construct a sparse RF-derived model describing a program of normal postnatal gut microbiota development that is shared across biologically unrelated individuals . A metric based on this model ( microbiota-for-age Z-score ) was used to define the state of development ( maturation ) of fecal microbiota from infants and children with varying degrees of undernutrition . Fecal sample s obtained from 6- and 18-month-old children with healthy growth patterns or with varying degrees of undernutrition were transplanted into young germ-free mice that were fed a representative Malawian diet . The recipient animals ’ rate of lean body mass gain was characterized by serial quantitative magnetic resonance , their metabolic phenotypes were determined by targeted mass spectrometry , and their femoral bone morphologic features were delineated by microcomputed tomography . RESULTS Undernourished children in the Malawian birth cohort that we studied have immature gut microbiota . Unlike microbiota from healthy children , immature microbiota transmit impaired growth , altered bone morphology , and metabolic abnormalities in the muscle , liver , and brain to recipient gnotobiotic mice . The representation of several age-discriminatory taxa in the transplanted microbiota harbored by recipient animals correlated with their growth rates . Microbiota from 6-month-old infants produced greater effects on growth than did microbiota from 18-month-old children , although in each age bin , the growth effects produced by a healthy donor ’s community were greater than those produced by an undernourished donor ’s community . Cohousing coprophagic mice shortly after they received microbiota from healthy or severely stunted and underweight 6-month-old infants result ed in the invasion of age- and growth-discriminatory taxa from the former into the latter microbiota in the recipient animals , with associated prevention of growth impairments . Introducing cultured members from this group of invasive species ameliorated growth and metabolic abnormalities in recipients of microbiota from undernourished donors . CONCLUSION These pre clinical findings provide evidence that gut microbiota immaturity is causally related to childhood undernutrition . The age- and growth-discriminatory taxa that we identified should help direct studies of the effects of host and environmental factors on gut microbial community development , and they represent therapeutic targets for repairing or preventing gut microbiota immaturity . Pre clinical evidence that gut microbiota immaturity is causally related to childhood undernutrition . ( A ) A model of normal gut microbial community development in Malawian infants and children , based on the relative abundances of 25 bacterial taxa that provide a microbial signature defining the “ age , ” or state of maturation , of an individual ’s ( fecal ) microbiota . ( Hierarchical clusterings of operational taxonomic units are indicated on the left . ) ( B ) Fecal sample s from healthy ( H ) or stunted and underweight ( Un ) infants and children were transplanted into separate groups of young germ-free mice that were fed a Malawian diet . The immature microbiota of Un donors transmitted impaired growth phenotypes to the mice . ( C ) Evidence that a subset of age-discriminatory taxa are also growth-discriminatory . Cohousing mice shortly after they received microbiota from 6-month-old healthy or undernourished donors result ed in the invasion of taxa from the healthy donor ’s microbiota ( HCH ) into the undernourished donor ’s microbiota ( UnCH ) among recipient animals and prevented growth impairments . Adding cultured invasive growth-discriminatory taxa directly to the Un donor ’s microbiota ( Un+ ) improved growth .  Undernourished children exhibit impaired development of their gut microbiota .  Transplanting microbiota from 6- and 18-month-old healthy or undernourished Malawian donors into young germ-free mice that were fed a Malawian diet revealed that immature microbiota from undernourished infants and children transmit impaired growth phenotypes . The representation of several age-discriminatory taxa in recipient animals correlated with lean body mass gain ; liver , muscle , and brain metabolism ; and bone morphology .  Mice were cohoused shortly after receiving microbiota from healthy or severely stunted and underweight infants ; age- and growth-discriminatory taxa from the microbiota of the former were able to invade that of the latter , which prevented growth impairments in recipient animals . Adding two invasive species , Ruminococcus gnavus and Clostridium symbiosum , to the microbiota from undernourished donors also ameliorated growth and metabolic abnormalities in recipient animals . These results provide evidence that microbiota immaturity is causally related to undernutrition and reveal potential therapeutic targets and agents PURPOSE The purpose of this operational study was to assess the effectiveness school-based health and nutrition intervention supported with backyard gardening on the dietary diversity among school adolescents . METHODS A total of 1000 school adolescents from 10 to 19years were selected r and omly . The intervention involved peer-led behavior change communication and health promotion through school media and health clubs . Data were collected at baseline , midline and end-line using structured question naires . Multivariable logistic regression analyses were used to determine the independent effect of interventions . RESULTS There was a significant increment of proportion of school children consuming diversified diet among the intervention group from 34.8 % at baseline through 65.6 % at midline to 74.7 % at the end-line ( p<0.001 ) . Among control group , there was no change from midline ( 49.4 % ) to endline ( 48.8 % ) , though there was a change from baseline ( 32.1 % ) to midline ( 49.4 % ) . A significant difference of dietary diversity intake was observed between intervention and control groups at midline ( F=5.64 , p=0.042 ) and endline ( F=5.85 , p<0.001 ) survey . Being in the intervention school ( OR=2.55 [ 1.55 , 3.50 ] ) , being a boy ( OR=1.75 [ 1.91 , 2.56 ] ) and having farmer mothers ( OR=2.58 [ 1.01 , 6.87 ] ) were independent positive predictors of a diversified diet intake . However , having a mother who attended secondary schools were inversely associated ( OR=0.25 [ 0.06 , 0.97 ] ) with consuming a diversified diet . CONCLUSION Findings of this study demonstrated that there was a significant improvement in dietary diversity of adolescents in intervention schools . The results imply that school based nutrition education should be a part of comprehensive school health programs to reach students and potentially their families
Purpose of review Maternal and child malnutrition continues to disproportionately affect low and middle-income countries , contributing to high rates of morbidity , mortality , and suboptimal development .
This article review s evidence from recent systematic review s and studies on the effectiveness of interventions to improve nutritional status in these especially vulnerable population s.