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Micronutrient powder (MNP) can reduce iron deficiency in young children, which has been well established in efficacy trials. However, the cost of different delivery platforms has not been determined. We calculated the cost and cost‐efficiency of distributed MNP through community‐based mechanisms and in health facilities in a primarily rural district in Uganda. An endline survey (n = 1072) identified reach and adherence. During the 9‐month pilot, 37,458 (community platform) and 12,390 (facility platform) packets of MNP were distributed. Each packet consisted of 30 MNP sachets. In 2016, total costs were $277,082 (community platform, $0.24/sachet) and $221,568 (facility platform, $0.59/sachet). The cost per child reached was lower in the community platform ($53.24) than the facility platform ($65.97). The cost per child adhering to a protocol was $58.08 (community platform) and $72.69 (facility platform). The estimated cost of scaling up the community platform pilot to the district level over 3 years to cover approximately 17,890 children was $1.23 million (scale‐up integrated into a partner agency program) to $1.62 million (government scale‐up scenario). Unlike previous estimates, these included opportunity costs. Community‐based MNP delivery costs were greater, yet more cost‐efficient per child reached and adhering to protocol than facility‐based delivery. However, total costs for untargeted MNP delivery under program settings are potentially prohibitive., This study estimates costs based on programmatic elements using two delivery platforms in a single rural site in Uganda: (1) delivery by community health workers (community‐based platform) and (2) delivery using facility‐based health providers (facility‐based platform). We calculated the cost of micronutrient powders (MNP) provision from start‐up to the “last mile”— the final leg in product and service delivery when MNP reaches beneficiaries. We compared costs and cost‐efficiency across delivery platforms using several indicators of outcomes and estimated the costs of scaling up, extending the pilot program, and integrating MNP delivery activities into existing infant and young child feeding programs.

Adolescent birth is a major global concern owing to its adverse effects on maternal and child health. We assessed trends in adolescent birth and examined its associations with child undernutrition in Bangladesh using data from seven rounds of Demographic and Health Surveys (1996–2017, n = 12,006 primiparous women with living children, Adolescent birth is a major global concern owing to its adverse effects on maternal and child health. We assessed trends in adolescent birth and examined its associations with child undernutrition in Bangladesh using data from seven rounds of Demographic and Health Surveys. Our analysis demonstrates that birth during adolescence, a common occurrence in Bangladesh, is associated with child undernutrition.

Severe thiamine (vitamin B1) deficiency is generally regarded as a problem affecting mostly infants in low‐income communities of Southeast Asia and adult alcoholics regardless of their location. However, recent scholarship shows that the disorders associated with thiamine deficiency may also affect heretofore unsuspected populations, and that the scope of disorders, including some long‐lasting neurocognitive consequences, is broader than previously thought.

Thiamine deficiency has been typically associated with alcoholism or as a prevalent problem in low‐ and middle‐income countries (LMICs) whose populations rely on staple foods with a low content of thiamine. We conducted a literature review of published and unpublished data to identify relevant adult cases with confirmed thiamine deficiency of nonalcoholic cause in developed countries. We selected 17 reports with 81 adult cases of confirmed thiamine deficiency affecting adult patients with a wide range of ages and underlying conditions (e.g., cancer, gastrointestinal diseases, heart failure, and obesity). Thiamine deficiency may have been caused by disease‐related malnutrition, bariatric surgery, chronic use of diuretics, repeated vomiting, lack of thiamine in parenteral nutrition formulas, food insecurity, and reliance on monotonous or restrictive diets. Treatment with intravenous thiamine resulted in partial or complete recovery from the symptoms (cardiac, neurologic, and metabolic disorders) for most patients. The number and variety of symptomatic thiamine‐deficient adults identified in this review demonstrates that thiamine deficiency is not exclusive to LMICs and, in high‐income settings, is not exclusive to alcoholic patients. In developed countries, this serious but treatable condition can be expected in patients suffering from various medical conditions or following certain dietary patterns.

Thiamine (vitamin B1) is an essential micronutrient in energy metabolism and cognitive and neurological health. Thiamine deficiency disorders (TDDs) have a range of clinical presentations that result in various morbidities and can be fatal if not promptly recognized and treated, especially in infants. To intervene, thiamine intakes by breastfeeding mothers and others at risk of thiamine deficiency should be increased to ensure adequate thiamine intake. Although thiamine fortification programs have a long history in high‐income countries, there are few mandatory fortification programs to address TDDs in low‐ and middle‐income countries (LMICs), particularly in the regions of greatest concern, South and Southeast Asia. This review highlights essential aspects for consideration in the development of a mandatory fortification program in LMICs, including an overview of the data required to model fortification dosing schemes, available thiamine fortificants, and potential fortification vehicles, as well as identifies current knowledge gaps., There are few mandatory fortification programs to address thiamine deficiency disorders in low‐ and middle‐income countries (LMICs), particularly in the regions of greatest concern, South and Southeast Asia. This review highlights essential aspects for consideration in the development of a mandatory fortification program in LMICs, including an overview of the data required to model fortification dosing schemes, available thiamine fortificants, and potential fortification vehicles, as well as identifies current knowledge gaps.

Thiamine deficiency is a public health issue in Cambodia. Thiamine fortification of salt has been proposed; however, the salt intake of lactating women, the target population, is currently unknown. We estimated salt intakes among lactating women (, Thiamine deficiency is a public health issue in Cambodia. Thiamine fortification of salt has been proposed; however, the salt intake of lactating women is currently unknown. We estimated salt intakes among lactating women using three methods. Based on these data, a thiamine salt fortification scenario was modeled, which allowed the calculation of a suitable fortification dose of thiamine to add to salt.

In 2014, there was an outbreak of beriberi on Kuria, a remote atoll in Kiribati, a small Pacific Island nation. A thiamine‐poor diet consisting mainly of rice, sugar, and small amounts of fortified flour was likely to blame. We aimed to design a food fortification strategy to improve thiamine intakes in Kuria. We surveyed all 104 households on Kuria with a pregnant woman or a child 0–59 months. Repeat 24‐h dietary recalls were collected from 90 men, 17 pregnant, 44 lactating, and 41 other women of reproductive age. The prevalence of inadequate thiamine intakes was >30% in all groups. Dietary modeling predicted that rice or sugar fortified at a rate of 0.3 and 1.4 mg per 100 g, respectively, would reduce the prevalence of inadequate thiamine intakes to

In spite of multiple program efforts in Ghana, progress in reducing the burden of anemia is slow. The objective was to conduct multilevel assessments of existing childhood (, In Ghana, numerous preventive and management interventions are implemented concurrently to address childhood anemia. Despite existing program efforts, the incidence of childhood anemia remains high. The objectives of our study were to conduct multilevel assessments of existing childhood anemia prevention and treatment programs, to elucidate implementation gaps in Ghana using UNICEF's conceptual framework of malnutrition as a guide.

Vitamin B1 (thiamine) is an essential nutrient that acts as a cofactor for a number of metabolic processes, particularly in energy metabolism. Symptoms of classic thiamine deficiency are recognized as beriberi, although clinical symptoms are nonspecific and recognition of subclinical deficiency is difficult. Therefore, reliable biomarkers of thiamine status are required. Thiamine diphosphate is a cofactor for transketolase, including erythrocyte transketolase (ETK). The ETK activity assay as an indirect, functional marker of thiamine status has been used for over 50 years. The ETK activity assay provides a sensitive and specific biomarker of thiamine status; however, there is a lack of consensus over the cutoffs for deficiency, partly due to a lack of assay harmonization. Here, we provide a step‐by‐step protocol for the measurement of ETK activity and the calculation of the ETK activity coefficient, including detailed explanations of equipment and chemicals required and guidance for quality control procedures. Harmonization of the protocol will provide the basis for the development of internationally recognized cutoffs for thiamine insufficiency. The establishment of quality control materials and a quality assurance scheme are recommended to provide reliability. This will ensure that the ETK activity assay remains an important method for the assessment of thiamine status., Reliable biomarkers of thiamine status are required to help diagnose thiamine deficiency. Thiamine diphosphate (ThDP) is a cofactor for transketolase, including erythrocyte transketolase (ETK). The ETK activity assay provides a sensitive and specific biomarker of thiamine status; however, there is a lack of consensus over the cutoffs for thiamine deficiency, partly due to a lack of assay harmonization. Here, we provide a step‐by‐step protocol for the measurement of ETK activity and the calculation of the ETK activity coefficient (ETKAC).

To help inform global guidelines on infant feeding, this systematic review synthesizes evidence related to the presence of the Ebola virus (EBOV) in breast milk and its potential risk of viral transmission to the infant when breastfeeding. We relied on a comprehensive search strategy to identify studies including women with suspected, probable, or confirmed EBOV infection, intending to breastfeed or give breast milk to an infant. Our search identified 10,454 records, and after deduplication and screening, we assessed 148 full texts. We included eight studies reporting on 10 breastfeeding mothers and their children (one mother with twins), who provided breast milk samples for assessment. EBOV was detected via RT‐PCR or viral culture in seven out of ten breast milk samples. Four out of the five‐breastfed infants with EBOV‐positive breast milk were found positive for EBOV infection, and all of these EBOV‐positive infants died. Since previous reports have detected EBOV in tears, saliva, sweat, and contaminated surfaces, with the current evidence, it is not possible to conclude with certainty that breast milk was the main route of EBOV transmission., Understanding maternal‐to‐child transmission routes is key to lowering, and ultimately preventing, the exposure of Ebola virus (EBOV) in pediatric populations. We undertook a systematic review of the available scientific literature to determine whether EBOV can be transmitted through breast milk and to describe the outcomes of the infants that ingested EBOV laboratory‐confirmed breast milk.

Low dietary calcium is very common in many populations, contributing to nutritional rickets/osteomalacia in children/adults and increasing the risk of several health problems. Calcium is a nutrient of concern as the recommended nutrient requirements are difficult to meet in the absence of dairy products. The provision of culturally acceptable calcium-fortified foods may improve calcium intake when it is a feasible and cost-effective strategy in a particular setting. This landscape review was conducted in 2019 and describes current calcium fortification efforts and lessons learned from these experiences. Worldwide, the United Kingdom is the only country where calcium fortification of wheat flour is mandatory. It is estimated that this fortified staple ingredient contributes to 13–14% of calcium intake of the British population. Other items voluntary fortified with calcium include maize flour, rice, and water. Current calcium fortification programs may lack qualified personnel/training, clear guidelines on implementation, regulation, monitoring/evaluation, and functional indicators. Also, the cost of calcium premix is high and the target groups may be hard to reach. There is a lack of rigorous evaluation, particularly in settings with multiple micronutrient programs implemented simultaneously, with low quality of the evidence. Further research is needed to assess the impact of calcium fortification programs. Fil: Palacios, Cristina. Florida International University; Estados Unidos Fil: Hofmeyr, G. Justus. No especifíca; Fil: Cormick, Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Garcia Casal, Maria Nieves. World Health Organization; Suiza Fil: Peña Rosas, Juan Pablo. World Health Organization; Suiza Fil: Betrán, Ana Pilar. World Health Organization; Suiza

An aspirational global food system is one that delivers across a suite of the Sustainable Development Goals (SDGs), including universal access to healthy diets, which can also codeliver on climate and environment SDGs. The literature has downplayed the relative contribution of dietary change to sustainable food systems. In this perspective article, we argue that the potential for positive transformational change in diets should not be underestimated, for two sets of reasons. First, the dynamism of diets over long‐term and, especially, recent history shows the potential for rapid and widespread change, including toward more diverse and healthier diets. Second, contemporary behavioral research demonstrates promising tactics to influence consumers’ dietary choices. Since the entire food system creates the circumstances of those choices, the most effective strategies to shift diets will involve multiple approaches that deliberately aim not just to influence consumers themselves but also to incentivize all actors in the food systems, taking into account multiple agendas and values. The effectiveness of actions will depend on the political economy at local, national, and global levels. Overall, there are reasons to be hopeful about the potential for accelerated global dietary change, given both historic trends and the growing suite of tools and approaches available.

The multiple micronutrient supplement (MMS) based on the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) formula provides women and their offspring with a healthy start to life in an efficacious, safe, and cost‐effective way. To date, however, no precise and transparent specifications exist to support the manufacturing and distribution of UNIMMAP–MMS globally. To palliate for this need, the MMS Technical Advisory Group at the New York Academy of Sciences and the Micronutrient Forum convened a technical consultation to develop an open access UNIMMAP–MMS Product Specification for the manufacturing of this product. The specifications offered in this paper cover: ingredients, excipients, and processing aids used in the manufacturing of UNIMMAP–MMS; stability studies recommended under different testing conditions and climatic zones; packaging considerations; manufacturing standards, including pharmacopeia standards, manufacturing practices, certificates of analysis, change control, and quality agreement; finished product specifications, including tablet characterization and purity, potency assay; analytical test methods; and storage and transportation requirements., This paper results from deliberations of a panel of international experts assembled in Washington DC, November 11 and 12, 2019 and commissioned by the MMS Technical Advisory Group at the New York Academy of Sciences and the Micronutrient Forum to ensure consistency in the manufacturing of quality and affordable UNIMMAP–MMS across antenatal care programs, while allowing for variances in national regulatory and pharmacopoeia standards.

Thiamine is an essential water‐soluble vitamin that plays an important role in energy metabolism. Thiamine deficiency presents many challenges to clinicians, in part due to the broad clinical spectrum, referred to as thiamine deficiency disorders (TDDs), affecting the metabolic, neurologic, cardiovascular, respiratory, gastrointestinal, and musculoskeletal systems. Concurrent illnesses and overlapping signs and symptoms with other disorders can further complicate this. As such, TDDs are frequently misdiagnosed and treatment opportunities missed, with fatal consequences or permanent neurologic sequelae. In the absence of specific diagnostic tests, a low threshold of clinical suspicion and early therapeutic thiamine is currently the best approach. Even in severe cases, rapid clinical improvement can occur within hours or days, with neurological involvement possibly requiring higher doses and a longer recovery time. Active research aims to help better identify patients with thiamine‐responsive disorders and future research is needed to determine effective dosing regimens for the various clinical presentations of TDDs. Understanding the clinical diagnosis and global burden of thiamine deficiency will help to implement national surveillance and population‐level prevention programs, with education to sensitize clinicians to TDDs. With concerted effort, the morbidity and mortality related to thiamine deficiency can be reduced.

Low calcium intake is common worldwide and can result in nutritional rickets in children and osteomalacia in adults. Calcium-fortified foods could improve calcium intake. However, there is limited calcium fortification experience, with technical and practical issues that may hamper its adoption. The objective of this landscape review is to summarize these issues to help policymakers guide the planning and design of calcium fortification as a public health strategy. One challenge is the low bioavailability of calcium salts (∼20–40%); thus, large amounts need to be added to food to have a meaningful impact. Solubility is important when fortifying liquids and acidic foods. Calcium salts could change the flavor, color, and appearance of the food and may account for 70–90% of the total fortification cost. Safety is key to avoid exceeding the recommended intake; so the amount of added calcium should be based on the target calcium intake and the gap between inadequate and adequate levels. Monitoring includes the quality of the fortified food and population calcium intake using dietary assessment methods. Calcium fortification should follow regulations, implemented in an intersectorial way, and be informed by the right to health and equity. This information may help guide and plan this public health strategy. Fil: Palacios, Cristina. Florida International University; Estados Unidos Fil: Cormick, Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina. Universidad Nacional de La Matanza; Argentina Fil: Hofmeyr, G. Justus. No especifíca; Fil: Garcia Casal, Maria Nieves. World Health Organization; Suiza Fil: Peña Rosas, Juan Pablo. World Health Organization; Suiza Fil: Betrán, Ana Pilar. World Health Organization; Suiza

The pandemic of coronavirus disease 2019 (COVID‐19) is caused by infection with a novel coronavirus strain, the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). At present, there is limited information on potential transmission of the infection from mother to child, particularly through breast milk and breastfeeding. Here, we provide a living systematic review to capture information that might necessitate changes in the guidance on breast milk and breastfeeding given the uncertainty in this area. Our search retrieved 19,414 total records; 605 were considered for full‐text eligibility and no ongoing trials were identified. Our review includes 340 records, 37 with breast milk samples and 303 without. The 37 articles with analyzed breast milk samples reported on 77 mothers who were breastfeeding their children; among them, 19 of 77 children were confirmed COVID‐19 cases based on RT‐PCR assays, including 14 neonates and five older infants. Nine of the 68 analyzed breast milk samples from mothers with COVID‐19 were positive for SARS‐CoV‐2 RNA; of the exposed infants, four were positive and two were negative for COVID‐19. Currently, there is no evidence of SARS‐CoV‐2 transmission through breast milk. Studies are needed with longer follow‐up periods that collect data on infant feeding practices and on viral presence in breast milk., The objective of this review is to assess available evidence related to the possible transmission of SARS‐ CoV‐2 through breast milk and through breastfeeding (i.e., related bodily fluids, such as blood, sweat, and respiratory droplets) or droplet transmission due to close contact with the infant or young child via skin‐to‐skin exposure or airborne transmission. The review aims to support policymakers in making evidence‐informed global, regional, and national guidelines on infant feeding in the context of the ongoing pandemic.