Improved adherence and anaemia cure rates with flexible administration of micronutrient Sprinkles: a new public health approach to anaemia control

Department of Nutritional Sciences, University of Toronto and Program in Metabolism and Integrated Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada.
European journal of clinical nutrition (Impact Factor: 2.71). 09/2007; 63(2):165-72. DOI: 10.1038/sj.ejcn.1602917
Source: PubMed

ABSTRACT Despite repeated public commitments and availability of various forms of iron supplements, rates of anaemia in developing countries remain high. A major reason for this lack of success has been poor adherence. The objective of this study was to compare the effectiveness of daily and flexible administration of micronutrient Sprinkles on adherence, acceptability and haematological status among young children in rural Bangladesh.
A sample of 362 children (haemoglobin (Hb)>or=70 g l(-1)) aged 6-24 months were cluster-randomized to receive 60 sachets of Sprinkles either (i) daily over 2 months; (ii) flexibly over 3 months; or (iii) flexibly over 4 months. With a flexible regimen, mothers/caregivers decided how frequently to use Sprinkles without exceeding one sachet per day. Adherence was assessed monthly by counting the number of sachets used and acceptability was evaluated through focus group discussions. Haemoglobin was measured at baseline, at the end of each intervention period and 6 months post-intervention.
Mean percent adherence was significantly higher in the flexible-4-month group (98%) compared to the flexible-3-month (93%) and daily-2-month (88%) groups (P<0.01). Most mothers found flexible administration to be more acceptable than daily due to perceived benefits of use. Hb at the end of intervention was significantly higher in the flexible-4-month group compared to the daily group (P=0.03). Anaemia prevalence decreased by 65% in the flexible-4-month group compared to 54% in the flexible-3-month and 51% in the daily-2-month groups. Percent of cured children who maintained a non-anaemic status 6 months post-intervention was significantly higher in the flexible-4-month (82%) and flexible-3-month (80%) groups than the daily-2-month (53%) group (P<0.05).
The adherence, acceptability and haematological response to flexible administration over 4 months were found preferable to daily.

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    • "LNSs have not been used or studied as extensively as Sprinkles ® . However, a few trials, one using Nutribut- ter ® (Adu-Afarwuah et al. 2008) and others using a similar LPS (Kuusipalo et al. 2006; Phuka et al. 2009), were shown to reduce iron deficiency and anaemia and to improve growth and motor development (Dewey et al. 2009). "
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    ABSTRACT: The objective of this formative research was to assess the acceptability of a micronutrient powder (Sprinkles(®)) and a lipid-based nutrient supplement (Nutributter(®)), and to explore people's willingness to pay for these products in a resource-poor context like Niger. In four sites, 84 focus group discussions among mothers, fathers and grandmothers of children 6-23 months were conducted, as well as 80 key informant interviews of mothers who participated in a home study where their children 6-23 months were given either Sprinkles(®) or Nutributter(®) to use either for a period of 4 weeks, or they were given both products over the 4-week period, i.e. Sprinkles(®) for 2 weeks and Nutributter(®) for an additional 2 weeks. The mothers understood how to use the products and generally used the products correctly. Both products were highly acceptable to adults and most children. In Niamey, where the 4-week home study used both products for 2 weeks each, the mothers tended to prefer Nutributter(®). The mothers who used either product were pleased with the improvements they saw in their children's health, including increased appetite, weight gain and increased energy and activity. A few mothers were concerned with how they would be able to provide for their child's increased appetite. Most participants across all four sites reported that they would be willing and able to afford to buy a single sachet of either Sprinkles(®) at a cost of US$0.03 or Nutributter(®) at a cost of US$0.08 several times a week. This study provides evidence that both of these products were are highly acceptable in different settings in Niger and suggests that delivery of Nutributter(®) or Sprinkles(®) at a low or subsidized cost through a market-based system may be possible in Niger, if an appropriate distribution system can be identified.
    Maternal and Child Nutrition 10/2011; 7 Suppl 3(s3):82-95. DOI:10.1111/j.1740-8709.2011.00352.x · 3.06 Impact Factor
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    • "2. What is the optimal dosing schedule for home fortification? One study suggests that a flexible administration schedule is more feasible for caregivers and just as effective as daily administration of Sprinkles (Ip et al. 2009). Additional research is needed on daily vs. intermittent use, as well as the possibility of targeted use during seasons when malnutrition is more likely. "
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    ABSTRACT: We reviewed the efficacy and effectiveness of home fortification of complementary foods with micronutrient powders (e.g. Sprinkles®), crushable tablets and lipid-based or soy-based products. Sixteen studies (5 anaemia treatment trials, 11 prevention trials) met the inclusion criteria. The treatment trials indicate that Sprinkles were as effective as iron drops, and were better accepted and had fewer side effects. In the prevention trials, the risk of anaemia was cut in half. The effect of home fortification with multiple micronutrients on plasma zinc and vitamin A levels was mixed. The impact on child growth of home fortification using only micronutrients was not significant. However, with products containing both micronutrients and a small amount of energy (including fat and protein), the pooled data from two efficacy trials in Africa suggest an effect size of ∼0.4 for both weight and height. Home fortification with products that include some energy also showed positive effects on indices of child development in two studies. There was a beneficial impact of home fortification on morbidity in high-risk populations in some studies, but most showed no significant impact. Acceptability of home fortification by caregivers and young children is high, and side effects are rare. The safety of home fortification using ‘bolus’ doses of iron, particularly in malarial areas, needs further investigation. In one study of Sprinkles in a low-income country, the estimates of cost per disability-adjusted life year regained compared favourably with other approaches, but more data on operational and cost considerations for the various home fortification products are needed.
    Maternal and Child Nutrition 05/2009; 5(4):283 - 321. DOI:10.1111/j.1740-8709.2009.00190.x · 3.06 Impact Factor
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