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BackgroundMeta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child wasting and stunting. There is little information regarding effects on severe wasting or stunting.ObjectivesWe aimed to identify the effect of SQ-LNSs on prevalence of severe wasting (weight-for-length z score < -3) and severe stunting (length-for-age z score < -3).MethodsWe conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age. We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.ResultsSQ-LNS provision led to a relative reduction of 31% in severe wasting [prevalence ratio (PR): 0.69; 95% CI: 0.55, 0.86; n = 34,373] and 17% in severe stunting (PR: 0.83; 95% CI: 0.78, 0.90; n = 36,795) at endline. Results were similar in most of the sensitivity analyses but somewhat attenuated when comparisons using passive control arms were excluded (PR: 0.74; 95% CI: 0.57, 0.96; n = 26,327 for severe wasting and PR: 0.88; 95% CI: 0.81, 0.95; n = 28,742 for severe stunting). Study-level characteristics generally did not significantly modify the effects of SQ-LNSs, but results suggested greater effects of SQ-LNSs in sites with greater burdens of wasting or stunting, or with poorer water quality or sanitation.ConclusionsIncluding SQ-LNSs in preventive interventions to promote healthy child growth and development is likely to reduce rates of severe wasting and stunting. This meta-analysis was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

BackgroundMeta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design.ObjectivesWe aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes.MethodsWe conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons.ResultsSQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (

BackgroundSmall-quantity lipid-based nutrient supplements (SQ-LNSs) have been shown to reduce the prevalence of child anemia and iron deficiency, but effects on other micronutrients are less well known. Identifying subgroups who benefit most from SQ-LNSs could support improved program design.ObjectivesWe aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child hemoglobin (Hb), anemia, and inflammation-adjusted micronutrient status outcomes.MethodsWe conducted a 2-stage meta-analysis of individual participant data from 13 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 15,946). We generated study-specific and subgroup estimates of SQ-LNSs compared with control, and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine potential study-level effect modifiers.ResultsSQ-LNS provision decreased the prevalence of anemia (Hb < 110 g/L) by 16% (relative reduction), iron deficiency (plasma ferritin < 12 µg/L) by 56%, and iron deficiency anemia (IDA; Hb < 110 g/L and plasma ferritin 12 mo and provided 9 (as opposed to

Background Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. Methods and findings A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6-23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers' participation and supplement children's diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. Conclusions Incorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated. Trial registration ClinicalTrials.gov NCT02323815., Author(s): Lieven Huybregts *, Agnes Le Port, Elodie Becquey, Amanda Zongrone, Francisco M. Barba, Rahul Rawat, Jef L. Leroy, Marie T. Ruel Introduction Globally, an estimated 52 million children suffer [...]

Background Community management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM's effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children Methods and findings We used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0-17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was [alpha] = 0.016 after adjustment for multiple testing. Children's average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10-26, P < 0.001; longitudinal study: +23 pp, 95% CI 17-29, P < 0.001). There were no impacts on either AM treatment coverage (cross-sectional study: +8.0 pp, 95% CI 0.09-16, P = 0.047; longitudinal study: +7.7 pp, 95% CI -1.2 to 17, P = 0.090), AM incidence (longitudinal study: incidence rate ratio = 0.98, 95% CI 0.75-1.3, P = 0.88), or AM prevalence (cross-sectional study: -0.46 pp, 95% CI -4.4 to 3.5, P = 0.82). A study limitation is the referral of AM cases (for ethical reasons) by study enumerators as part of the monthly measurement in the longitudinal study that may have attenuated the detectable impact on AM treatment coverage. Conclusions Adding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery. Trial registration ClinicalTrials.gov NCT02245152., Author(s): Elodie Becquey *, Lieven Huybregts, Amanda Zongrone, Agnes Le Port, Jef L. Leroy, Rahul Rawat, Mariama Touré, Marie T. Ruel Introduction Wasting, an indicator of acute malnutrition (AM), affects [...]

Conditional transfer programs are increasingly popular, but the impact on household nutrient consumption has not been studied. We evaluated the impact of the Programa de Apoyo Alimentario (PAL), a cash and in-kind transfer program, on the energy and nutrient consumption of poor rural households in Mexico. The program has been shown to reduce poverty. Beneficiary households received either a food basket (including micronutrient-fortified milk) or cash. A random sample of 206 rural communities in Southern Mexico was randomly assigned to 1 of 4 groups: a monthly food basket with or without health and nutrition education, a cash transfer with a cost to the government equivalent to the food basket (14 USD/mo) with education, or control. The impact after 14 mo of exposure was estimated in a panel of 5823 households using a double difference regression model with household fixed effects. PAL was associated with increases (P < 0.01) in the consumption of total energy (5-9%), energy from fruits and vegetables (24-28%), and energy from animal source foods (24-39%). It also affected iron, zinc, and vitamin A and C consumption (P < 0.05). The consumption of energy and all nutrients was greater in the food basket group (P < 0.05). Cash and in-kind transfers in populations that are not energy-deficient should be carefully redesigned to ensure that pulling poor families out of poverty leads to improved micronutrient intake but not to increased energy consumption. doi: 10.3945/jn.109.116285.

The goal of this study was to evaluate the impact of Mexico's conditional cash transfer program, Oportunidades, on the growth of children

Oportunidades, Mexico's most important antipoverty program, currently with 5 million enrolled households in all regions of the country, has been shown to significantly contribute to improving the nutrition, health, and education of the poor. Because the program has used different enrollment strategies in rural and urban areas and has both obligatory (e.g., health and nutrition education) and nonobligatory components (e.g., nutrition supplements for children younger than 2 y of age), it provides an excellent opportunity to study program enrollment and utilization of different program components. In urban areas enrollment was more complex, and hence enrollment was much lower then in rural areas where the process was quasiautomatic, and nearly all eligible households enrolled. Enrollment in urban areas was not associated with having a child younger than 2 y of age. Utilization was notably higher with the obligatory than with the nonobligatory program components, illustrated by the inadequate consumption of the nutrition program's supplement as compared with near-universal compliance with well-baby visits. Innovative approaches, some of which are currently being tested, are needed to further increase the program's impact.

The potential of animal-source foods (ASF) to alleviate micronutrient deficiencies is well recognized. How the intake of ASF can be effectively increased is not known, but promoting animal production (AP) is one possible method. We reviewed the impact of interventions promoting AP on nutritional status and on 6 nutrition-related outcomes: production, household income and expenditure, caregiver income, caregiver time and workload, zoonosis, and dietary intake. Information about the effects on each of the possible outcomes is needed to be able to weigh trade-offs in the potential benefits and costs of promoting AP. The majority of the 14 identified studies found a positive effect of the promotion of AP on production. All studies evaluating the impact on household income or expenditure reported a positive effect on these outcomes. Evidence regarding impact on caregiver income and on caregiver time and workload is too limited to draw any conclusions. We found no studies that examined the impact of the promotion of AP on zoonosis. The studies generally reported a positive impact on dietary intake. Only 4 studies evaluated the impact on nutritional status and found a positive effect. It is unclear whether the improvements in dietary intake and nutritional status were a direct effect of increased production or an indirect effect of increased income. Future studies on the AP-nutrition link would benefit from stronger methodological designs. Available evidence is insufficient to answer whether the promotion of AP is an effective means to alleviate undernutrition.

We determined the pro portion of research on childhood mortality directed toward better medical technology (i.e., by improving old technology or creating new technology) compared with research on technology delivery and utilization. We also estimated mortality reductions from a research funding strategy focusing primarily on developing technology compared with one that also focused on delivery and utilization. Ninety-seven percent of grants were for developing new technologies, which could reduce child mortality by 22%. This reduction is one third of what could be achieved if existing technologies were fully utilized. There is a serious discrepancy between current research and the research needed to save children's lives. In addition to increased research on the efficacy of treatment, there is an even greater need for-increased research on delivery and use of technology. (Am J Public Health. 2007;97:219223. doi: 10.2105/AJPH.2005. 083287)

Background: Poor birth outcomes are an important global public health problem. Social assistance programs that provide cash or in-kind transfers, such as food or vouchers, hold potential to improve birth outcomes but the evidence on their effectiveness has not been reviewed.Objectives: We systematically reviewed studies that used experimental or quasi-experimental methods to evaluate the impacts of social assistance programs on outcomes in low- and middle-income countries.Methods: The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to assess the certainty of the evidence for birth weight and neonatal mortality (most common outcomes reported). We summarized the evidence on hypothesized nutrition and health pathways of impact.Results: We included 6 evaluations of 4 different cash transfer programs and 1 evaluation of a community-based participatory learning and action program that provided food and cash transfers. The 4 studies that assessed birth weight impacts found significant (P < 0.05) effects ranging from 31 to 578 g. Out of 3 studies that assessed neonatal mortality impacts, 2 found significant effects ranging from 0.6 to 3.1 deaths/1000 live births. The certainty of the evidence for both outcomes was rated as very low due to several methodological limitations. In terms of potential pathways, some studies documented positive effects on maternal diet, antenatal care (ANC) utilization, and delivery in a health facility.Conclusions: Better-designed evaluations are needed to strengthen the evidence base on these programs. Evaluation studies should elucidate underlying mechanisms of impact by including outcomes related to maternal diet, ANC seeking, use of skilled delivery, and women's empowerment in nutrition and health domains. Studies should also assess potential unintended negative consequences of social assistance, such as reduced birth spacing and excess pregnancy weight gain. [ABSTRACT FROM AUTHOR]