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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.

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.

SUBMITTER: Khan GN

PROVIDER: S-EPMC7425934 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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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.

Khan Gul Nawaz GN Kureishy Sumra S Ariff Shabina S Rizvi Arjumand A Sajid Muhammad M Garzon Cecilia C Khan Ali Ahmad AA de Pee Saskia S Soofi Sajid Bashir SB Bhutta Zulfiqar A ZA

PloS one 20200813 8

<h4>Background</h4>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.<h4>Objective</h4>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 b ...[more]

PMID: 32790725

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Project description:BackgroundIn Pakistan, the prevalence of stunting in children younger than 5 years has remained above global critical levels over the past two decades, with the stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country-43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households.ObjectiveThe primary objective of this study is to determine the effect of a medium quantity of a lipid-based nutrient supplement (LNS) combined with unconditional cash transfers and social and behavior change communication (SBCC) on reduction of stunting in children aged 6 to 23 months.MethodsA 5-arm cluster randomized controlled trial will be conducted in the district of Rahim Yar Khan in Punjab, Pakistan. The intervention packages will be (1) cash only, (2) cash with LNS, (3) cash with SBCC, and (4) cash with SBCC and LNS. The control arm will receive routine standard of care. We will enroll children at 6 months of age and follow up on a monthly basis up to 24 months of age. A total of 2000 children, 400 in each arm, will be enrolled to detect a 20% reduction in the prevalence of stunting among children aged 24 months. Length, weight, food intake, compliance to interventions, morbidities, and other relevant data will be collected at enrollment and on a monthly basis over the period of 18 months. The process evaluation will assess acceptability of the interventions and potential barriers to implementation through focus group discussions and in-depth interviews with the target population and relevant stakeholders. Furthermore, a cost analysis will be conducted to assess the cost-effectiveness of each intervention package.ResultsThe study protocol was approved by the Ethics Review Committee of Aga Khan University in Pakistan on January 4, 2017. Data collection began in May 2017 and was completed in July 2019. Data analyses are yet to be completed. This study will explore the effectiveness of intervention packages comprised of cash transfers from Benazir Income Support Programme with or without additional LNS and SBCC in preventing childhood stunting. We expect the results to be published in peer-reviewed journals by autumn of 2020.ConclusionsThe findings of this trial will provide robust evidence as to which intervention packages can have significant effects on linear growth of children and design effective intervention packages to prevent stunting in children aged 6 to 23 months.Trial registrationClinicalTrials.gov NCT03299218; https://clinicaltrials.gov/ct2/show/NCT03299218.International registered report identifier (irrid)DERR1-10.2196/19001.

Project description:Stunting and micronutrient malnutrition are persistent public health problems in refugee populations. UNHCR and its partner organisations implement blanket supplementary feeding programmes using a range of special nutritional products as one approach to address these issues. The evidence base for the efficacy and effectiveness of a small quantity lipid-based nutrient supplement, Nutributter®, in reducing stunting and anaemia is limited. Secondary data analysis was used to assess the effectiveness of Nutributter® distribution on anaemia and stunting in children aged 6-23 months (programme target group) and 6-59 months (the standard age group sampled in routine nutrition surveys). Analysis was conducted using routine pre and post-intervention cross-sectional nutrition survey data collected between 2008-2011 in five refugee camps in Kenya and Djibouti. Changes in total anaemia (Haemoglobin<110g/L), anaemia categories (mild, moderate and severe), and stunting (height-for-age z-score <-2) were explored using available data on the Nutributter® programme and contextual factors. A significant reduction in the prevalence of anaemia in children aged 6-23 months and 6-59 months was seen in four of five, and in all five camps, respectively (p<0.05). Reductions ranged from 12.4 to 23.0, and 18.3 to 29.3 percentage points in each age group. Improvements were largely due to reductions in moderate and severe anaemia and occurred where the prevalence of acute malnutrition was stable or increasing. No change in stunting was observed in four of five camps. The replicability of findings across five sites strongly suggests that Nutributter® distribution was associated with a reduction in anaemia, but not stunting, among refugee children in the Horn of Africa. Benefits were not restricted to the 6-23 month target group targeted by the nutrition programme. However, even following this intervention anaemia remained a serious public health problem and additional work to define and evaluate an effective intervention package is warranted.

Project description:Low Birth Weight (LBW) is considered as a major public health issue and leading cause of neonatal death. Almost one in four newborns are reported as underweight in Pakistan. Children born with low birth weight are highly vulnerable to develop diseases and death and/or remain undernourished (i.e., stunted and wasted). This study determines the LBW newborns are more prone to develop stunting and wasting in province of Sindh, Pakistan. Moreover, regression-based estimation of the impact of LBW on the child health outcomes of under five years of age, may be prone to selection bias because of the nature of non-experimental data set, thus, propensity score matching methods are used in this study. Data for this study was used from Multiple Indicators Cluster Survey (MICS-2014). MICS is a two-stage, stratified cluster sampling household level data covering urban and rural areas and consists of 19,500 households from five administrative divisions and 28 districts of Sindh province of Pakistan. The total sample size of children less than five years of age after cleaning the data are 7781, of which 2095 are LBW having birth weight categorized as "smaller than average and very small" and 5686 are normal birth weight (NBW) having birth weight very large, larger than average, and average. This study employed propensity score matching (PSM) regression methods to understand whether the children born as low birth weight are more prone to stunting and wasting and/or both. In province of Sindh, moderate wasting children under five years were 21%, severe wasting 6% and both wasting and stunting 10%. The propensity score results are shown significant in all groups. Specifically, all four types of PSM methods confirm a significant difference in the potential outcome variables-meaning that a child born with LBW has a significant adverse effect on the potential child health outcome variables (stunting, wasting and both). Thus, the propensity score matching findings confirm a significant and adverse effect of LBW on potential health outcomes of under five children. Similarly, low birth weight children are significantly more likely to be moderately wasted (OR = 1.5, CI = 1.3-1.6) and severely wasted (OR = 1.6, CI = 1.3-2.0) and both (stunted and wasted, OR = 2.0, CI = 1.7-2.3) as compared to children with normal birth weight. Male children, if born with low birth weight, are significantly more likely to be moderately wasted (OR = 1.3, CI = 1.1-1.5) and both (wasted and stunted, OR = 1.3, CI = 1.1-1.5) than girls. This large data analysis finding proved that the LBW newborns are on higher risk to develop wasting and stunting in Pakistan.

Project description:Background:Stunting and anemia are long-standing public health challenges which adversely affects the cognitive development and physical wellbeing of children in low income settings. The aim of this study was to assess the prevalence and associated factors of stunting and anemia among 6-23?months old children in Damot Sore District, Southern Ethiopia. Methods:Cross-sectional survey was conducted among 477 children aged 6-23?months, which were living in Damot Sore District, in April 2017. A multistage sampling technique was used. Villages were randomly selected and systematic random sampling method was used to select study participants. Data on socio-demographic, anthropometric, dietary, blood samples for hemoglobin were collected. Data were entered into EPI Data V. 3.1 and exported into SPSS Version 21.0 for analysis. A principal component analysis (PCA) was done to generate wealth score of households. Binary logistic regression model was used to identify factors associated with the outcome variables (stunting and anemia) separately, those variables having less than a p-value of 0.25 were chosen as candidate for multivariable analyses and finally multivariable logistic regression model was used to identify independent variables of each outcomes, with statistical significance set at p?<?0.05 (95% confidence interval (CI)). Results:Out of 477 children studied, 31.7% were stunted and 52% were anemic. In the multivariable analyses, the number of under five children within a household (AOR?=?4.18, 95% CI: 2.65-6.57), drinking water from unsafe source (AOR?=?4.08, 95% CI: 1.33-12.54) and anemia (AOR?=?3.13, 95% CI 2.00-4.92) were factors significantly associated with stunting. On the other hand, independent variables of anemia were early initiation of complementary feeding (AOR?=?2.96, 95% CI: 1.23-4.85), poor dietary diversity (AOR?=?2.95, 95% CI: 1.78-4.91), poor breast feeding practice (AOR?=?2.94, 95% CI: 1.63-5.32) and stunting (AOR?=?3.65, 95% CI: 2.15-6.19). Conclusion:This study revealed higher level of stunting and anemia among children aged 6-23?months than WHO (world health organization) criteria of public health importance. Sustainable promotion of diversified diet, optimal complementary feeding, optimal and complementary breast feeding practices, improving sanitation infrastructure are measures needed to tackle these severe public health challenges.

Project description:Burundi is one of the poorest countries and is among the four countries with the highest prevalence of stunting (58%) among children aged less than 5 years. This situation undermines the economic growth of the country as undernutrition is strongly associated with less schooling and reduced economic productivity. Identifying the determinants of stunting and severe stunting may help policy-makers to direct the limited Burundian resources to the most vulnerable segments of the population, and thus make it more cost effective. This study aimed to identify predictors of stunting and severe stunting among children aged less than two years in Burundi.The sample is made up of 6199 children aged 6 to 23 months with complete anthropometric measurements from the baseline survey of an impact evaluation study of the Performance-Based financing (PBF) scheme applied to nutrition services in Burundi from 2015 to 2017. Binary and multivariable logistic regression analyses were used to examine stunting and severe stunting against a set of child, parental and household variables such as child's age or breastfeeding pattern, mother's age or knowledge of malnutrition, household size or socio-economic status.The prevalence of stunting and severe stunting were 53% [95%CI: 51.8-54.3] and 20.9% [95%CI: 19.9-22.0] respectively. Compared to children from 6-11 months, children of 12-17 months and 18-23 months had a higher risk of stunting (AdjOR:2.1; 95% CI: 1.8-2.4 and 3.2; 95% CI: 2.8-3.7). Other predictors for stunting were small babies (AdjOR=1.5; 95% CI: 1.3-1.7 for medium-size babies at birth and AdjOR=2.9; 95% CI: 2.4-3.6 for small-size babies at birth) and male children (AdjOR=1.5, 95% CI: 1.4-1.8). In addition, having no education for mothers (AdjOR=1.6; 95% CI: 1.2-2.1), incorrect mothers' child nutrition status assessment (AdjOR=3.3; 95% CI: 2.8-4), delivering at home (AdjOR=1.4; 95% CI: 1.2-1.6) were found to be predictors for stunting. More than to 2 under five children in the household (AdjOR=1.45; 95% CI: 1.1-1.9 for stunting and AdjOR= 1.5; 95% CI: 1.2-1.9 for severe stunting) and wealth were found to be predictors for both stunting and severe stunting. The factors associated with stunting were found to be applicable for severe stunting as well.Mother's education level, mother's knowledge about child nutrition status assessment and health facility delivery were predictors of child stunting. Our study confirms that stunting and severe stunting is in Burundi, as elsewhere, a multi-sectorial problem. Some determinants relate to the general development of Burundi: education of girls, poverty, and food security; will be addressed by a large array of actions. Some others relate to the health sector and its performance - we think in particular of the number of children under five in the household (birth spacing), the relationship with the health center and the knowledge of the mother on malnutrition. Our findings confirm that the Ministry of Health and its partners should strive for better performing and holistic nutrition services: they can contribute to better nutrition outcomes.

Project description:UnlabelledSmall-quantity lipid-based nutrient supplements (SQ-LNS) are promising home fortification products, but the optimal zinc level needed to improve growth and reduce morbidity is uncertain. We aimed to assess the impact of providing SQ-LNS with varied amounts of zinc, along with illness treatment, on zinc-related outcomes compared with standard care. In a placebo-controlled, cluster-randomized trial, 34 communities were stratified to intervention (IC) or non-intervention cohorts (NIC). 2435 eligible IC children were randomly assigned to one of four groups:1) SQ-LNS without zinc, placebo tablet; 2) SQ-LNS containing 5mg zinc, placebo tablet; 3) SQ-LNS containing 10mg zinc, placebo tablet; or 4) SQ-LNS without zinc and 5mg zinc tablet from 9–18 months of age. During weekly morbidity surveillance, oral rehydration salts were provided for reported diarrhea and antimalarial therapy for confirmed malaria. Children in NIC (n = 785) did not receive SQ-LNS, tablets, illness surveillance or treatment. At 9 and 18 months, length, weight and hemoglobin were measured in all children. Reported adherence was 97 ± 6% for SQ-LNS and tablets. Mean baseline hemoglobin was 89 ± 15g/L. At 18 months, change in hemoglobin was greater in IC than NIC (+8 vs -1g/L, p<0.0001), but 79.1% of IC were still anemic (vs. 91.1% in NIC). Final plasma zinc concentration did not differ by group. During the 9-month observation period, the incidence of diarrhea was 1.10 ± 1.03 and of malaria 0.54 ± 0.50 episodes per 100 child-days, and did not differ by group. Length at 18 months was significantly greater in IC compared to NIC (77.7 ± 3.0 vs. 76.9 ± 3.4 cm; p<0.001) and stunting prevalence was significantly lower in IC (29.3%) than NIC (39.3%; p<0.0001), but did not differ by intervention group within IC. Wasting prevalence was also significantly lower in IC (8.7%) than in NIC (13.5%; p = 0.0003). Providing SQ-LNS daily with or without zinc, along with malaria and diarrhea treatment, significantly increased growth and reduced stunting, wasting and anemia prevalence in young children.Trial registrationClinicalTrials.gov NCT00944281.

Project description:BackgroundDietary supplements, like small-quantity lipid-based nutrient supplements (SQ-LNS), are used in intervention programs to prevent undernutrition among women and young children in low-income countries. An objective marker is needed to track consumption of supplements to evaluate the effectiveness of these programs.ObjectiveThe aim of this study was to evaluate saccharin and resveratrol as potential adherence markers for tracking recent consumption of a single serving of SQ-LNS in women.MethodsForty-seven healthy nonpregnant women 18-45 y of age were assigned to consume a single dose of SQ-LNS (20 g) containing either 10 mg sodium saccharin or 5 mg trans-resveratrol, under supervision. On the day before and for 2 d following SQ-LNS consumption, urine samples were collected each day for 24 h as 3 consecutive 4-h collections and one 12-h overnight collection. Urinary concentrations of saccharin and trans-resveratrol-3-O-sulfate, a resveratrol metabolite, were measured by ultra-high-performance liquid chromatography interfaced to a mass spectrometer with electrospray ionization [UHPLC-(ESI-)MS/MS]. Urinary concentrations (μmol/L urine) of saccharin and trans-resveratrol-3-O-sulfate were plotted against time, and receiver operating characteristic (ROC) curves were used to determine the discriminative capacity of each compound, at each post-consumption time point compared with baseline, to detect recent consumption of SQ-LNS. Cutoff values to differentiate supplement consumption from nonconsumption of each marker were developed using the closest-to-(0,1)-corner cut-point approach.ResultsForty-five participants were included in the analysis. Urinary concentrations of saccharin and trans-resveratrol-3-O-sulfate increased within 4 h of SQ-LNS consumption. Urinary concentration cutoff values for saccharin (13.4 µmol/L) and trans-resveratrol-3-O-sulfate (0.7 µmol/L) allowed for 78% and 89% sensitivity, respectively, and 100% specificity in detecting consumption of SQ-LNS within the first 12 h after consumption.ConclusionsUrinary concentrations of saccharin and trans-resveratrol-3-O-sulfate reflect consumption of SQ-LNS containing those compounds during the first 12 h post-consumption with high sensitivity and specificity in healthy women and may be useful objective adherence markers for tracking consumption of SQ-LNS.

Dataset Information

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.

Publications

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.

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