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Background: Therapeutic feeding with micronutrient-fortified lipid-based nutrient supplements (LNSs) has proven useful in the rehabilitation of severely malnourished children. We recently reported that complementary feeding of 6-18-mo-old infants with an LNS known as FS50 was associated with improved linear growth and a reduction in the incidence of severe stunting during the supplementation period. Objective: Our objective was to assess whether a reduction in stunting seen with 12-mo LNS supplementation was sustained over a subsequent 2-y nonintervention period. Design: One hundred eighty-two 6-mo-old healthy rural Malawian infants were randomly assigned to receive daily supplementation for 12 mo with 71 g of maize-soy flour [likuni phala (LP); control group, 282 kcal] or either 50 g of FS50 (264 kcal; main intervention group), or 25 g of FS25 (130 kcal). Main outcome measures were incidence of severe stunting and mean z score changes in weight-for-age, length-for-age, and weight-for-length during a 36-mo follow-up period. Results: The cumulative 36-mo incidence of severe stunting was 19.6% in LP, 3.6% in FS50, and 10.3% in FS25 groups (P = 0.03). Mean weight-for-age changes were -1.09, -0.76, and -1.22 (P = 0.04); mean length-for-age changes were -0.47, -0.37, and -0.71 (P = 0.10); and mean weight-for-length changes were -1.52, -1.18, and -1.48 (P = 0.27). All differences were more marked among individuals with baseline length-for-age below the median. Differences in length developed during the intervention at age 10-18 mo, whereas weight differences continued to increase after the intervention. Conclusions: Twelve-month-long complementary feeding with 50 g/d FS50 is likely to have a positive and sustained impact on the incidence of severe stunting in rural Malawi. Half-dose intervention may not have the same effect. This trial was registered at clinicaltrials.gov as NCT00131209.

Background: Micronutrient deficiencies are common during infancy, and optimal approaches for their prevention need to be identified. Objective: The objective was to compare the efficacy and acceptability of Sprinkles (SP), crushable Nutritabs (NT), and fat-based Nutributter (NB; 108 kcal/d), which provide 6, 16, and 19 vitamins and minerals, respectively, when used for home fortification of complementary foods. Design: Ghanaian infants were randomly assigned to receive SP (n = 105), NT (n = 105), or NB (n = 103) daily from 6 to 12 mo of age. We assessed dietary intake, morbidity, and compliance weekly. Hemoglobin and plasma ferritin, TfR, C-reactive protein, and zinc were measured at 6 and 12 mo. We used an exit interview to assess acceptability. A randomly selected control group of infants who received no intervention (NI; n = 96) were assessed at 12 mo. Results: All supplements were well accepted, and the mean percentage of days that supplements were consumed (87%) did not differ between groups. At 12 mo, all 3 intervention groups had significantly higher ferritin and lower TfR concentrations than did the NI control group. Mean ([+ or -] SD) hemoglobin was significantly higher in NT (112 [+ or -] 14 g/L) and NB (114 [+ or -] 14 g/L) but not in SP (110 [+ or -] 14 g/L) infants than in NI infants (106 [+ or -]14 g/L). The prevalence of iron deficiency anemia was 31% in the NI control group compared with 10% in the intervention groups combined (P < 0.0001). Conclusion: All 3 options for home fortification of complementary foods are effective for reducing the prevalence of iron deficiency in such populations.

Background: The low micronutrient content of complementary foods is associated with growth faltering in many populations. A potential low-cost solution is the home fortification of complementary foods with Sprinkles (SP) powder, crushable Nutritabs (NT) tablets, or energy-dense (108 kcal/d), fat-based Nutributter (NB). Objective: The objective was to test the hypothesis that multiple micronutrients added to home-prepared complementary foods would increase growth and that the effect would be greatest in the presence of added energy from fat. Design: We randomly assigned 313 Ghanaian infants to receive SP, NT, or NB containing 6, 16, and 19 vitamins and minerals, respectively, daily from 6 to 12 mo of age. We assessed anthropometric status at 6, 9, and 12 mo; micronutrient status at 6 and 12 too; motor development at 12 too; and morbidity weekly. Infants (n = 96) not randomly selected for the intervention (nonintervention; NI) were assessed at 12 too. Results: The groups did not differ significantly at baseline, except that the NB group had a higher proportion of boys and weighed slightly more. The dropout rate (15/313) was low. At 12 mo, after control for initial size, the NB group had a significantly greater weight-for-age z score (WAZ) (-0.49 [+ or 1] 0.54) and length-for-age z score (LAZ) (-0.20 [+ or 1] 0.54) than did the NT group (WAZ: -0.67 [+ or 1] 0.54; LAZ: -0.39 [+ or 1] 0.54) and the NT and SP groups combined (WAZ: -0.65 [+ or 1] 0.54; LAZ: -0.38 [+ or 1] 0.54); the difference with the NI group (WAZ: -0.74 [+ or 1] 1.1; LAZ: -0.40 [+ or 1] 1.0) was not significant. A lower percentage of the NI infants (25%) than of the intervention groups (SP: 39%; NT: 36%; NB: 49%) could walk independently by 12 too. Conclusion: All 3 supplements had positive effects on motor milestone acquisition by 12 mo compared with no intervention, but only NB affected growth. Am J Clin Nutr 2007;86:412-20. KEY WORDS Multiple micronutrient supplements, home fortification, infant growth, motor development, Ghana

Background: Childhood malnutrition is common in Malawi, and the standard treatment, which follows international guidelines, results in poor recovery rates. Higher recovery rates have been seen in pilot studies of home-based therapy with ready-to-use therapeutic food (RUTF). Objective: The objective was to compare the recovery rates among children with moderate and severe wasting, kwashiorkor, or both receiving either home-based therapy with RUTF or standard inpatient therapy. Design: A controlled, comparative, clinical effectiveness trial was conducted in southern Malawi with 1178 malnourished children. Children were systematically allocated to either standard therapy (186 children) or home-based therapy with RUTF (992 children) according to a stepped wedge design to control for bias introduced by the season of the year. Recovery, defined as reaching a weight-forheight z score > -2, and relapse or death were the primary outcomes. The rate of weight gain and the prevalence of fever, cough, and diarrhea were the secondary outcomes. Results: Children who received home-based therapy with RUTF were more likely to achieve a weight-for-height z score > -2 than were those who received standard therapy (79% compared with 46%; P < 0.001) and were less likely to relapse or die (8.7% compared with 16.7%; P < 0.001). Children who received home-based therapy with RUTF had greater rates of weight gain (3.5 compared with 2.0 g * [kg.sup.-1] * [d.sup.-1]; difference: 1.5; 95% CI: 1.0, 2.0 g. [kg.sup.-1]) and a lower prevalence of fever, cough, and diarrhea than did children who received standard therapy. Conclusion: Home-based therapy with RUTF is associated with better outcomes for childhood malnutrition than is standard therapy. KEY WORDS Malnutrition, ready-to-use therapeutic food, RUTF, home-based therapy, Malawi, kwashiorkor, protein-energy malnutrition

Background: Multiple micronutrient deficiencies are often the basic causative factor in stunting and anemia, 2 conditions that affect entire generations of children in deprived populations. No generally accepted recommendations for micronutrient intakes for recovery from stunting are available. Objective: The objective was to assess the effect of a highly nutrient-dense spread fortified with vitamins and minerals, with or without antiparasitic metronidazole treatment, in correcting retarded linear growth and reducing anemia in stunted children. Design: Saharawi refugee children (n = 374) aged 3-6 y with initial height-for-age z scores < - 2 were assigned to 1 of 5 groups: fortified spread (FS), fortified spread plus metronidazole (FS+M), unfortified spread (US), unfortified spread plus metronidazole (US + M), or control. Supervised supplementation was given daily for 6 mo. Weight, height, knee-heel length, hematologic indexes, parasitic infections, and morbidity were assessed at 0, 3, and 6 mo. Results: Linear growth of children fed FS was 30% faster at 3 mo than in US and control groups, after which height-for-age z scores increased only slightly in the FS group and remained unchanged in the other groups. No additional benefits from metronidazole were observed. Increase in hemoglobin concentrations in the FS group at 6 mo was twofold that in the US and control groups (37 [+ or -] 40, 19 [+ or -] 15, and 16 [+ or -] 17 g/L, respectively; P < 0.0001), and anemia was reduced by nearly 90%. Conclusions: FS, and not US, induces catch-up growth in stunted children whose diets are poor in micronutrients. Our trial provides support for delivering multiple micronutrients to reverse stunting and reduce anemia in children up to age 6 y. KEY WORDS Catch-up growth, stunting, anemia, micronutrient deficiencies, small bowel bacterial overgrowth, fat spreads, refugees, children, Algeria

Background: The World Health Organization recommends a liquid, milk-based diet (Fl00) during the rehabilitation phase of the treatment of severe malnutrition. A dry, solid, ready-to-use food (RTUF) that can be eaten without adding water has been proposed to eliminate the risk of bacterial contamination from added water. The efficacies of RTUF and Fl00 have not been compared. Objective: The objective was to compare the efficacy of RTUF and Fl00 in promoting weight gain in malnourished children. Design: In an open-labeled, randomized trial, 70 severely malnourished Senegalese children aged 6-36 mo were randomly allocated to receive 3 meals containing either F100 (n = 35) or RTUF (n = 35) in addition to the local diet. The data from 30 children in each group were analyzed. Results: The mean ([+ or -] SD) daily energy intake in the RTUF group was 808 [+ or -] 280 (95% CI: 703.8, 912.9) kJ * kg body [wt.sub.-1] * [d.sup.-1], and that in the F100 group was 573 [+ or -] 201 (95% CI: 497.9, 648.7) kJ * kg body [wt.sup.-1] * [d.sup.-1] (P < 0.001). The average weight gains in the RTUF and F100 groups were 15.6 (95% CI: 13.4, 17.8) and 10.1 (95% CI: 8.7, 11.4) g * kg body [wt.sup.-1] * [d.sup.-1], respectively (P < 0.001). The difference in weight gain was greater in the most wasted children (P < 0.05). The average duration of rehabilitation was 17.3 (95% CI: 15.6, 19.0) d in the F100 group and was 13.4 (95% CI: 12.1, 14.7) d in the RTUF group (P < 0.001). Conclusions: This study indicated that RTUF can be used efficiently for the rehabilitation of severely malnourished children. KEY WORDS Child malnutrition, ready-to-use food, nutritional rehabilitation, energy density, catch-up growth, Senegal

Background: Food consumption surveys are often used to detect inadequate nutrient intakes but not to determine whether inadequate nutrient intakes are due to suboptimal use of locally available foods or to insufficient availability of nutrient-dense foods. Objectives: The objectives were to describe the use of linear programming as a method to design nutrient-adequate diets of optimal nutrient density and to identify the most stringent constraints in nutritional recommendations and food consumption patterns in a population's diet. Design: This analysis was conducted with the use of food consumption data collected during 2 seasons from rural Malawian children aged 3-6 y. Linear programming was used to select diets based on local foods that satisfied a set of nutritional constraints while minimizing the total energy content of the diet. Additional constraints on daily intakes of foods and food groups were also introduced to ensure that the diets were compatible with local food patterns. The strength of the constraints was assessed by analyzing nonlinear programming sensitivity. Results: In the harvest season, it was possible to satisfy nutritional recommendations with little departure from the local diet. In the nonharvest season, nutritional adequacy was impaired by the low availability of riboflavin- and zinc-rich animal or vegetable foods and by the high phytate content of other foods. Conclusions: This analysis suggests that nutrition education may help improve the diets of children in the harvest season, whereas changes in the range of available foods might be needed in the nonharvest season. Linear and nonlinear programming can be used to formulate recommendations with the use of data from local food consumption surveys. KEY WORDS Linear programming, recommended nutrient intakes, food consumption patterns, nutrient density, children, season, Malawi, Africa

The possibility of delaying gastric emptying and improving lactose digestion and tolerance by increasing milk viscosity was studied in 13 lactose maldigesters who ingested three test milks with different viscosities (range: 33-1892 mPa . s) in random order at intervals of 1 wk. Each test portion was 500 mL and provided [is congruent to] 1900 kJ and 18 g lactose. The different viscosities were obtained by adding varying proportions of rice starch and maltodextrin to a basic milk formula. A combined [C.sup.13]glycinehydrogen breath test was used to measure gastric emptying and lactose digestion simultaneously. Participants reported their gastrointestinal symptoms by using a four-grade scale. Mean ([+ or -] SEM) gastric-emptying half times were 78 [+ or -] 5.7 min for low-viscosity milk (30 mPa . s), 86 [+ or -] 5.0 min for moderateviscosity milk (80 mPa . s), and 78 [+ or -] 4.5 min for high-viscosity milk (1.9 . [10.sup.3] mPa . s). Mean orocecal transit times (180 [+ or -] 24, 163 [+ or -] 23, and 180 [+ or -] 24 min, respectively) were not significantly different. There were no milk-dependent differences in breathhydrogen excretion or in the severity of gastrointestinal symptoms. The milks were well tolerated; [is greater than] 50% of the subjects reported nondisturbing symptoms or none. We conclude that gastric emptying, orocecal transit time, and lactose digestion and tolerance were not affected by altering milk viscosity. This may have been due to the high energy content of the test milks, which in itself led to slow gastric emptying. Am J Clin Nutr 1997;66:123-6.