Effect of lipid-based nutrient supplement-Medium quantity on reduction of stunting in children 6-23 months of age in Sindh, Pakistan: A cluster randomized controlled trial

Gul Nawaz Khan, Sumra Kureishy, Shabina Ariff, Arjumand Rizvi, Muhammad Sajid, Cecilia Garzon, Ali Ahmad Khan, Saskia de Pee, Sajid Bashir Soofi, Zulfiqar A Bhutta, Gul Nawaz Khan, Sumra Kureishy, Shabina Ariff, Arjumand Rizvi, Muhammad Sajid, Cecilia Garzon, Ali Ahmad Khan, Saskia de Pee, Sajid Bashir Soofi, Zulfiqar A Bhutta

Abstract

Background: Chronic childhood malnutrition, or stunting, remains a persistent barrier to achieve optimal cognitive development, child growth and ability to reach full potential. Almost half of children under-five years of age are stunted in the province of Sindh, Pakistan.

Objective: The primary objective of this study was to test the hypothesis that the provision of lipid-based nutrient supplement-medium-quantity (LNS-MQ) known as Wawamum will result in a 10% reduction in risk of being stunted at the age of 24 months in the intervention group compared with the control group.

Design: A cluster randomized controlled trial was conducted in Thatta and Sujawal districts of Sindh province, Pakistan. A total of 870 (419 in intervention; 451 in control) children between 6-18 months old were enrolled in the study. The unit of randomization was union council and considered as a cluster. A total of 12 clusters, 6 in each study group were randomly assigned to intervention and control group. All children received standard government health services, while children in the intervention group also received 50 grams/day of Wawamum.

Results: Children who received Wawamum were found to have a significantly reduced risk of stunting (RR = 0.91, 95% CI; 0.88-0.94, p<0.001) and wasting (RR = 0.78, 95% CI; 0.67-0.92, p = 0.004) as compared to children who received the standard government health services. There was no evidence of a reduction in the risk of underweight (RR = 0.94, 95% CI; 0.85-1.04, p = 0.235) in the intervention group compared to the control group. Statistically significant reduction in anaemia in the intervention group was also found as compared to the control group (RR = 0.97, 95% CI; 0.94-0.99, p = 0.042). The subgroup analysis by age, showed intervention effect is significant in reduction of risk of stunting in younger children of aged 6-12 month (RR = 0.83, 95% CI; 0.81-0.86, p = <0.001) and their older peers aged 13-18 month- (RR = 0.90, 95% CI; 0.83-0.97, p = 0.008). The mean compliance of Wawamum was 60% among children.

Conclusions: The study confirmed that the provision of Wawamum to children 6-23 months of age is effective in reducing the risk of stunting, wasting and anaemia. This approach should be scaled up among the most food insecure areas/households with a high prevalence of stunting to achieve positive outcomes for nutrition and health. This study was registered at clinicaltrials.gov as NCT02422953. Clinical Trial Registration Number: NCT02422953.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig 1. Consort flow diagram of trial.
Fig 1. Consort flow diagram of trial.

References

    1. Development Initiatives. Global Nutrition Report 2017: Nourishing the SDGs. Bristol, UK: Development Initiatives, 2017.
    1. Ozaltin E, Hill K, Subramanian SV. Association of maternal stature with offspring mortality, underweight, and stunting in low- to middle-income countries. JAMA. 2010;303: 1507–1516. 10.1001/jama.2010.450
    1. Martorell R, Horta BL, Adair LS, Stein AD, Richter L, Fall CH, et al. Weight gain in the first two years of life is an important predictor of schooling outcomes in pooled analyses from five birth cohorts from low- and middle-income countries. J Nutr. 2010;140: 348–354. 10.3945/jn.109.112300
    1. Martorell R, Khan LK, Schroeder DG. Reversibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nutr. 1994;48: S45–S57.
    1. Thomas D, Strauss J. Health and wages: evidence on men and women in urban Brazil. J Econom. 1997;77: 159–185. 10.1016/s0304-4076(96)01811-8
    1. Kar BR, Rao SL, Chandramouli BA. Cognitive development in children with chronic protein energy malnutrition. Behav Brain Funct. 2008; 4:31 10.1186/1744-9081-4-31
    1. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371: 340–357. 10.1016/S0140-6736(07)61692-4
    1. Martorell R, Zongrone A. Intergenerational influences on child growth and undernutrition. Paediatr Perinat Epidemiol. 2012;26: 302–314.
    1. UNICEF, WHO, World Bank Group. UNICEF/WHO/World Bank Group Joint Child Malnutrition Estimates 2017. Levels and Trends in Child Malnutrition. Key findings of the 2017.
    1. National Institute of Population Studies (NIPS) [Pakistan] and ICF. Pakistan Demographic and Health Survey 2017–18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF, 2018.
    1. World Health Organization, United Nations Children’s Fund. Global Strategy for Infant and Young Child Feeding. Geneva: World Health Organization, 2003.
    1. World Health Organization. Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition. Geneva: World Health Organization, 2013.
    1. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382: 452–477. 10.1016/S0140-6736(13)60996-4
    1. Maternal, Infant and Young Child Nutrition Working Group. Formulations for fortified complementary foods and supplements: review of successful products for improving the nutritional status of infants and young children. Food Nutr Bull. 2009;30: S239–S255.
    1. Dewey KG. The challenge of meeting nutrient needs of infants and young children during the period of complementary feeding: an evolutionary perspective. J Nutr. 2013;143: 2050–2054. 10.3945/jn.113.182527
    1. Wang Y, Chen C, Wang F, Wang K. Effects of nutrient fortified complementary food supplements on growth of infants and young children in poor rural area in Gansu Province. J Hyg Res. 2007;36: 78–81.
    1. Hess SY, Abbeddou S, Jimenez EY, Somel JW, Vosti SA, Ouedraogo ZP, et al. Small-quantity lipid-based nutrient supplements, regardless of their zinc content, increase growth and reduce the prevalence of stunting and wasting in young burkinabe children: a cluster-randomized trial. PLoS ONE. 2015;10: e0122242 10.1371/journal.pone.0122242
    1. Iannotti LL, Dulience SJ, Green J, Joseph S, Francois J, Antenor ML, et al. Linear growth increased in young children in an urban slum of Haiti: a randomized controlled trial of a lipid-based nutrient supplement. Am J Clin Nutr. 2014;99: 198–208. 10.3945/ajcn.113.063883
    1. Arimond M, Zeilani M, Jungjohann S, Brown KH, Ashorn P, Allen LH, et al. Considerations in developing lipid-based nutrient supplements for prevention of undernutrition: experience from the international lipid-based nutrient supplements (iLiNS) project. Matern Child Nutr. 2015;11: 31–61.
    1. Visser J., McLachlan M.H., Maayan N., Garner P. Community-based supplementary feeding for food insecure, vulnerable and malnourished populations—an overview of systematic reviews. Cochrane Database Syst Rev. 2018. November 9;11: CD010578.
    1. De Pee S, Bloem MW. Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59- month-old children. Food Nutr Bull. 2009;30: 434–463.
    1. Style S, Tondeur M, Wilkinson C, Oman A, Spiegel P, Kassim IAR. et al. Operational guidance on the use of special nutritional products in refugee populations. Food Nutr Bull. 2013;34: 420–427. 10.1177/156482651303400407
    1. Adu-Afarwuah S, Lartey A, Brown KH, Briend A, Zlotkin Z, Dewey K.G. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr. 2007;86: 412–420. 10.1093/ajcn/86.2.412
    1. Phuka J, Maleta K, Thakwalakwa C, Cheung YB, Briénd A, Manary MJ et al. Complementary feeding with fortified spread and the incidence of severe stunting among 6-to-18-month-old rural Malawians. Arch Pediatr Adolesc Med. 2008;162: 619–626. 10.1001/archpedi.162.7.619
    1. Phuka J, Maleta K, Thakwalakwa C, Cheung YB, Briénd A, Manary MJ et al. Post intervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr. 2009;89: 382–390. 10.3945/ajcn.2008.26483
    1. Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2008;4: 24–85. 10.1111/j.1740-8709.2007.00124.x
    1. Shi L, Zhang J. Recent evidence of the effectiveness of educational interventions for improving complementary feeding practices in developing countries. J Trop Pediatr. 2011;57: 91–98. 10.1093/tropej/fmq053
    1. Lassi ZS, Das JK, Zahid G, Imdad A, Bhutta ZA. Impact of education and provision of complementary feeding on growth and morbidity in children less than 2 years of age in developing countries: a systematic review. BMC Public Health. 2013;13: S13 10.1186/1471-2458-13-S3-S13
    1. Jelensperger C, Pee SD, Prigge S. Technical Specifications for Lipid-based Nutrient Supplement–Medium Quantity. 2016; Ver 16.0 Retrieved from
    1. Pagel C, Prost A, Lewycka S, Das S, Colbourn T, Mahapatra R, et al. Intracluster correlation coefficients and coefficients of variation for perinatal outcomes from five cluster-randomised controlled trials in low and middle-income countries: results and methodological implications. Trials. 2011;12(1):151.
    1. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Suppl. 2006;450: 76–85. 10.1111/j.1651-2227.2006.tb02378.x
    1. Adu-Afarwuah S, Lartey A, Okronipa H, Ashorn P, Peerson JM, Arimond M, et al. 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 trial. Am J Clin Nutr. 2016;104: 797–808. 10.3945/ajcn.116.134692
    1. Dong C, Ge P, Ren X, Wang J, Fan H, Yan X, et al. Prospective study on the effectiveness of complementary food supplements on improving status of elder infants and young children in the areas affected by Wenchuan earthquake. PLoS ONE. 2013;8: e72711 10.1371/journal.pone.0072711
    1. Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana. Am J Clin Nutr. 2008;87: 929–938. 10.1093/ajcn/87.4.929
    1. Abbeddou S, Yakes JE, Somé JW, Ouédraogo JB, Brown KH, Hess SY. Small-quantity lipid-based nutrient supplements containing different amounts of zinc along with diarrhea and malaria treatment increase iron and vitamin A status and reduce anemia prevalence, but do not affect zinc status in young Burkinabe children: a cluster-randomized trial. BMC Pediatr. 2017;17(1):46 10.1186/s12887-016-0765-9
    1. Matias SL, Mridha MK, Young RT, Khan MSA, Siddiqui Z, Ullah MB, et al. Prenatal and Postnatal Supplementation with Lipid-Based Nutrient Supplements Reduces Anemia and Iron Deficiency in 18-Month-Old Bangladeshi Children: A Cluster-Randomized Effectiveness Trial. J Nutr. 2018;148: 1167–1176. 10.1093/jn/nxy078
    1. Prudhon C, Langendorf C, Roederer T, Doyon S, Mamaty AA, Woi-Messe L, et al. Effect of ready-to-use foods for preventing child undernutrition in Niger: analysis of a prospective intervention study over 15 months of follow-up. Matern Child Nutr. 2017;13: e12236.

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