Article

Prevention of Acute Malnutrition During the Lean Season:Comparison of a Lipid-Based Nutrient Supplement and an Improved Dry Ration, South Darfur,Sudan. A Quasi-Experimental Study

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Abstract

Objective: To assess the nutritional impact of a Lipid-Based Nutrient Supplement (LNS) and an Improved Dry Ration (IDR) in blanket supplementary feeding programs. Design: Longitudinal, quasi experimental non-randomized study Setting: Otash and Al Salaam internally displaced persons camps, South Darfur, Sudan Subjects: Children aged 6-36 months were randomly selected for inclusion in the study based on height cut-off of 95 cm and were anthropometrically assessed (weight-for-height z scores [WHZ] based on WHO standards, edema presence, and midupper arm circumference) monthly. IDR was distributed in Otash camp and LNS in Al Salaam. Main findings: At baseline, 658 and 893 children were enrolled and 159 and 187 children were assessed at all 4 distributions in Otash and Al Salaam camps, respectively; There was no significant difference in mean WHZ between the two groups at baseline, (Otash=-1.18 and Al Salaam=-1.03, p=0.17). Children receiving LNS had higher mean WHZ than those receiving IDR. Significant differences were detected at months 2-4, for the mean WHZ of the LNS cohort, and at 4 months, for the difference of the difference in mean WHZ (-0.23) between camps, p= 0.02. Conclusions: LNS may be an option for preventing acute malnutrition in humanitarian settings, however research is needed on the timing, duration of use and cost effectiveness.

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... Lipid-based nutrient supplements (LNS) are pre-packaged, in a semi-solid paste, containing essential macro-and micronutrients, including minerals, fatty acids, proteins, milk, sugar and peanuts (Chaparro and Dewey, 2010;Nutriset, n.d.;Arimond et al., 2015;Talley et al., 2012). Their low moisture content helps to ensure food safety, by discouraging bacterial growth. ...
... Previous experimental studies showed that LNS are benefi cial in improving anthropometric status in children (Talley et al., 2012;Lin et al., 2008;Isanaka et al., 2009;Isanaka et al., 2010;Mangani et al., 2013;Matilsky et al., 2009). However, Although there is evidence that LNS yield better nutritional outcomes than CSB and control, it is impossible to conclude that the milk-based LNS are superior to soy-based LNS and whether age and duration of intervention signifi cantly affect the effectiveness of LNS on childhood undernutrition. ...
... The characteristics of included studies are presented in Table 1. Eleven studies were performed in Malawi (Lin et al., 2008;Mangani et al., 2013;Matilsky et al., 2009;LaGrone et al., 2011;Thakwalakwa et al., 2010;Phuka et al., 2009;Phuka et al., 2008;Phuka et al., 2012;Phuka et al., 2009;Thakwalakwa et al., 2012;Maleta et al., 2004), two in the Democratic Republic of Congo (Bisimwa et al., 2012;van der Kam et al., 2012) and one each in Niger Republic (Isanaka et al., 2009); Sudan (Talley et al., 2012), Chad (Huybregts et al., 2012), Ethiopia (Karakochuk et al., 2012) and Haiti (Iannotti et al., 2014). Seventeen were RCT (including three cluster RCT [Isanaka et al., 2009;Huybregts et al., 2012;Karakochuk et al., 2012]), and one was a quasi-experimental trial (Talley et al., 2012). ...
... Lipid-based nutrient supplements (LNS) are pre-packaged, in a semi-solid paste, containing essential macro-and micronutrients, including minerals, fatty acids, proteins, milk, sugar and peanuts (Chaparro and Dewey, 2010;Nutriset, n.d.;Arimond et al., 2015;Talley et al., 2012). Their low moisture content helps to ensure food safety, by discouraging bacterial growth. ...
... Previous experimental studies showed that LNS are benefi cial in improving anthropometric status in children (Talley et al., 2012;Lin et al., 2008;Isanaka et al., 2009;Isanaka et al., 2010;Mangani et al., 2013;Matilsky et al., 2009). However, Although there is evidence that LNS yield better nutritional outcomes than CSB and control, it is impossible to conclude that the milk-based LNS are superior to soy-based LNS and whether age and duration of intervention signifi cantly affect the effectiveness of LNS on childhood undernutrition. ...
... The characteristics of included studies are presented in Table 1. Eleven studies were performed in Malawi (Lin et al., 2008;Mangani et al., 2013;Matilsky et al., 2009;LaGrone et al., 2011;Thakwalakwa et al., 2010;Phuka et al., 2009;Phuka et al., 2008;Phuka et al., 2012;Phuka et al., 2009;Thakwalakwa et al., 2012;Maleta et al., 2004), two in the Democratic Republic of Congo (Bisimwa et al., 2012;van der Kam et al., 2012) and one each in Niger Republic (Isanaka et al., 2009); Sudan (Talley et al., 2012), Chad (Huybregts et al., 2012), Ethiopia (Karakochuk et al., 2012) and Haiti (Iannotti et al., 2014). Seventeen were RCT (including three cluster RCT [Isanaka et al., 2009;Huybregts et al., 2012;Karakochuk et al., 2012]), and one was a quasi-experimental trial (Talley et al., 2012). ...
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Purpose: This review aims at assessing the effectiveness of LNS interventions for prevention and/or treatment of moderate acute malnutrition (MAM), stunting and other anthropometric indicators for undernutrition in children younger than 5 years. Methodology: Eighteen clinical trials on LNS (soybased or milk-based) supplementation in children were compared with habitual diet/control or corn-soy blend (CSB). Mean changes in height for age (HAZ), weight for age (WAZ) and weight for height z-scores (WHZ) were assessed as primary outcomes. The secondary outcomes included: weight gain, height, mid upper arm circumference (MUAC), recovery from MAM, occurrence of fever, diarrhoea and cough. Findings: The pooled estimate revealed a statistically significant increase in WAZ (weighted mean difference [WMD] =0.09; 95%CI= 0.02, 0.15; p=0.01), WHZ (WMD=0.14; 95%CI= 0.01, 0.26; p=0.000) and improved recovery from MAM (Risk Ratio [RR] = 1.37; 95%CI= 1.14, 1.65; p=0.000) in children receiving LNS compared with control or CBS. No significant effect was observed in HAZ (WMD=0.00;95%CI=-0.02,0.03: p=0.578). Children fed with milk-based LNS (RR=1.68; 95%CI=1.17, 2.39; p=0.005) were more likely to recover significantly from MAM when compared with CSB. Conclusion: Although there is evidence that LNS yield better nutritional outcomes than CSB and control, it is impossible to conclude that the milk-based LNS are superior to soy-based LNS and whether age and duration of intervention significantly affect the effectiveness of LNS on childhood undernutrition. Further research is required before these products can be recommended at scale. Keywords: Lipid-based nutrient supplements; undernutrition; CMAM; childhood
... Compared to other commonly-used supplementary foods such as corn soy blend (CSB), LNS has supported higher weight gain and has recovered children from moderate wasting [8,9] or prevented the onset of wasting among non-malnourished children [10] in some studies. Other research has shown equivocal evidence of the superiority of LNS to CSB in prevention [11] and treatment [12][13][14] of moderate wasting. ...
... First, the lack of effect on wasting incidence of RUSF in this intervention adds to the inconclusive evidence around the effectiveness of LNS to protect child nutrition status [11][12][13][14]19]. One possible reason for this failure could be that wasting was related not to food insecurity-the context in which the LNS was designed to function-but to other factors in this urban setting such as poor hygiene and sanitation. ...
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Despite growing interest in use of lipid nutrient supplements for preventing child malnutrition and morbidity, there is inconclusive evidence on the effectiveness, and no evidence on the cost-effectiveness of this strategy. A cost effectiveness analysis was conducted comparing costs and outcomes of two arms of a cluster randomized controlled trial implemented in eastern Chad during the 2010 hunger gap by Action contre la Faim France and Ghent University. This trial assessed the effect on child malnutrition and morbidity of a 5-month general distribution of staple rations, or staple rations plus a ready-to-use supplementary food (RUSF). RUSF was distributed to households with a child aged 6--36 months who was not acutely malnourished (weight-for-height > = 80% of the NCHS reference median, and absence of bilateral pitting edema), to prevent acute malnutrition in these children. While the addition of RUSF to a staple ration did not result in significant reduction in wasting rates, cost-effectiveness was assessed using successful secondary outcomes of cases of diarrhea and anemia (hemoglobin <110 g/L) averted among children receiving RUSF.Total costs of the program and incremental costs of RUSF and related management and logistics were estimated using accounting records and key informant interviews, and include costs to institutions and communities. An activity-based costing methodology was applied and incremental costs were calculated per episode of diarrhea and case of anemia averted. Adding RUSF to a general food distribution increased total costs by 23%, resulting in an additional cost per child of 374 EUR, and an incremental cost per episode of diarrhea averted of 1,083 EUR and per case of anemia averted of 3,627 EUR. Adding RUSF to a staple ration was less cost-effective than other standard intervention options for averting diarrhea and anemia. This strategy holds potential to address a broad array of health and nutrition outcomes in emergency settings where infrastructure is weak and other intervention options are infeasible in the short-term. However, further research is needed to establish the contexts in which RUSF is most effective and cost-effective in preventing acute malnutrition and morbidity among vulnerable children, compared to other options.
... Out of these, 3·5% or 19 million children in developing countries are severely wasted with the highest proportion living in south-central and middle Africa [3]. On the other hand, between 36 and 41 million of these children are moderately wasted [11] and about 80% of them live in low -income countries [10] where malnutrition affects approximately one out of every three under five children [12]. ...
... On the contrary, only very few studies in these settings have identified the seasonal prevalence of acute child malnutrition and associated factors. For instance, there was a report on seasonal variation in the prevalence of acute child malnutrition at the end of the dry season (May/June) and at the end of the rainy season (October) indicating that the index for wasting (weight for length) was most sensitive to seasonal changes particularly to the end of the dry season unlike other indices of malnutrition which were less responsive to the seasonal changes [11,25,26]. ...
Article
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Malnutrition is a deficiency state of both macro and micronutrients (under - nutrition) and their over consumption (over- nutrition) causing measurable adverse effects on human body structure and function, resulting in specific physical and clinical outcomes. Little has been known about the seasonal variation in the magnitude of acute child under-nutrition and its determinants in low and middle-income countries making difficult the choice of better nutrition intervention. The objective of this study was to determine the prevalence of acute child under-nutrition and its associated factors on children aged 6 to 36 months in east rural Ethiopia in wet and dry seasons. A longitudinal study was conducted on children aged 6 to 36 months and their mothers (mother--child pair) from July/August 2010/2011 to January/ February 2011/2012 in east rural Ethiopia. Data were collected from 2,132 mother--child pairs using a pretested structured questionnaire and the UNICEF recommended anthropometric measuring instruments after standardization. The Odds Ratio with 95% confidence interval was estimated to identify the predictors of acute child under- nutrition (wasting) using a conditional fixed- effects logistic regression. The prevalence of acute child under-nutrition was 7.4%; 95% CI: (6.3%, 8.5%) in wet and 11. 2%; 95% CI: (9.8%, 12.5%) in dry seasons. Child wasting was more common among children of poor households who had no cooperative bank saving accounts [AOR (95% CI) = 8.2. (1.8, 37.6)], and access to health facilities [AOR (95% CI) = 2.2 (1.4, 3.6)]. Acute child under-nutrition was relatively higher in the dry season. Although season was not significantly associated with child under - nutrition, poverty and poor access to health services were important predictors of wasting in the study setting. Thus, effective community --based nutrition interventions that require a multi - disciplinary approach should be scaled up to curb childhood under-nutrition.
... Complementary feeding promotion (process introducing food in the child's diet when breastmilk is no longer sufficient to cover the nutritional needs of infants (Pan American Health Organization & World Health Organization, 2004)) was often shown to have positive effect on weight, height, weight-for-age Z-score and height-for-age Z-score in food insecure populations Guldan et al., 2000;Penny et al., 2005;Zaman, Ashraf, & Martines, 2008), but data on wasting is still missing. Mixed findings were also found regarding the impact of supplementary feeding on children's nutritional status, including communitybased supplementary feeding (Sguassero, de Onis, Bonotti, & Carroli, 2012), ready-to-use food to prevent child wasting (Defourny et al., 2009;Grellety et al., 2012;Huybregts et al., 2012) and lipid-base nutrient supplement (Lanou et al., 2014;Leisel Talley et al., 2012). Nutrition specific actions have thus proven to have high potential to prevent childhood chronic undernutrition , but when specifically looking at wasting, results are inconsistent. ...
Thesis
Child wasting is a public health issue but evidence gaps remain concerning preventive strategies not primarily based on food products. Cash transfers, increasingly implemented in emergency and developing contexts, have the potential to prevent under-nutrition by acting on several underlying causes including food insecurity, access to basic services and goods. However, to date, no study with a strong design explored the link between seasonal unconditional cash transfers (UCTs) and the prevention of acute malnutrition. UCTs were proven to have positive effects on food availability and food access. Inconsistent evidence was reported concerning the effects of UCTs on the quality of children’s diet, health care and psychosocial well-being of families benefiting from UCTs. In this framework, the MAM’Out research project was launched to assess the effects of multiannual seasonal UCT targeted to women on the prevention of child acute malnutrition in rural areas of Burkina Faso. In this two-arm cluster randomized controlled trial, one group benefited from cash transfers via mobile phones during 5 months yearly and the other arm was a comparison group. Qualitative data were collected each month of the cash transfer period for two years among various participants. The two main declared domains of expenses were food and health care for the child and the whole family. The program was also associated with positive perceived changes at the household level, mainly related to gender equality and improvement of women’s status, and favored the social integration of the poorest at the community level through cash sharing. Unexpected reported effects of this program included increased pregnancy plans of some women. The effect of cash transfer on diet quality was assessed using two 24h-dietary recall surveys carried out in July and August 2014 on a subsample of children from both arms. Results showed that seasonal UCT are associated with improved child’s diet among 14 to 29-month old children, particularly higher consumption of animal products, higher intake of iron rich or iron fortified food and higher fat and vitamins B12 intake compared to the control group. No difference was found for energy and protein intake between both groups. Moreover, two third of the children from the cash group had an adequate minimum dietary diversity compared to only one third in the control group. However, children from both groups had a suboptimal quality of diet during the lean season. Besides, anthropometric measurements and morbidity were recorded on quarterly basis for more than two years. Children in the intervention group had a lower risk of self-reported respiratory tract infection compared to children in the control group. However, neither the number of cumulative episode of wasting nor the end point anthropometric markers of nutritional status differ between children from the intervention and control group. Seasonal UCT should be considered when looking at actions to improve child’s diet in the framework of safety net programs. As far as the reduction of child wasting is concerned, an integrated approach combining cash and one or several other components identified as a key factors leading to acute malnutrition in the region should be preferred.
... While many studies conducted in developing countries, including Ethiopia, indicate that the prevalence of child malnutrition is unacceptably high, few studies have investigated the seasonal effect on prevalence of child malnutrition. Studies have indicated that there is seasonal change in the prevalence of acute child malnutrition at the beginning of the dry season (October) compared to the beginning of the rainy season (May/June) [11,12]. Similarly, high level of acute malnutrition was reported among children under 5 in Chad during the rainy season [13]. ...
Article
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Introduction Food availability and access are strongly affected by seasonality in Ethiopia. However, there are little data on seasonal variation in Infant and Young Child Feeding (IYCF) practices and malnutrition among 6-23 months old children in different agro-ecological zones of rural Ethiopia. Methods Socio-demographic, anthropometry and IYCF indicators were assessed in post- and pre-harvest seasons among children aged 6–23 months of age randomly selected from rural villages of lowland and midland agro-ecological zones. Results Child stunting and underweight increased from prevalence of 39.8% and 26.9% in post-harvest to 46.0% and 31.8% in pre-harvest seasons, respectively. The biggest increase in prevalence of stunting and underweight between post- and pre-harvest seasons was noted in the midland zone. Wasting decreased from 11.6% post-harvest to 8.5% pre-harvest, with the biggest decline recorded in the lowland zone. Minimum meal frequency, minimum acceptable diet and poor dietary diversity increased considerably in pre-harvest compared to post-harvest season in the lowland zone. Feeding practices and maternal age were predictors of wasting, while women’s dietary diversity and children age was predictor of child dietary diversity in both seasons. Conclusion There is seasonal variation in malnutrition and IYCF practices among children 6-23 months of age with more pronounced effect in midland agro-ecological zone. A major contributing factor for child malnutrition may be poor feeding practices. Health information strategies focused on both IYCF practices and dietary diversity of mothers could be a sensible approach to reduce the burden of child malnutrition in rural Ethiopia.
... According to the WHO (2012), ''supplementary foods have been used to rehabilitate moderately malnourished persons or to prevent a deterioration of nutritional status of those most at risk by meeting their additional needs.'' In other words, in addition to the 'treatment of wasting' agenda that seeks to move cases of MAM out of the moderate category, there is a strong 'prevention of wasting' agenda that seeks to stop normal children from becoming wasted (Karakochuk et al., 2012; Defourny et al., 2009; Mourey, 2008; Talley et al., 2012). The distinction between these linked goals is not always clear in the actions pursued on the ground or indeed in many study designs seeking to determine effectiveness. ...
Article
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Nutrition actions in emergencies continue to be critical to mortality reduction and to achieving broader humanitarian as well as livelihood goals in institutionally fragile environments. In the past decade, numerous innovations have enhanced the prevention and treatment of many forms of malnutrition; these include wider adoption of new food products, protocols for their use, and programming guidelines. The quality and scale of interventions has improved despite many challenges, resulting in fewer avoidable deaths and growing success in the management of severe and moderate wasting, as well as micronutrient deficiencies. Indeed, many lessons learned in emergencies have the potential to inform non-emergency programming. As such, there is a need for more explicit attention to emergency needs and activities in global target-setting developmental agendas. However, as caseloads and costs continue to grow, there are calls for more evidence-based guidance on the best combination of approaches to use in different contexts. Best practice is still constrained by evidence gaps, due in large part to the difficulties of research in humanitarian contexts. Nevertheless, sound empirical research must be prioritized on the efficacy, effectiveness and costs of various single and combined approaches.
... Several other products, designed to be consumed in smaller quantities and often described as ready-to-use supplementary foods (RUSF), have been used for treatment of MAM (Matilsky et al. 2009;Lagrone et al. 2010;Ackatia-Armah et al. 2012;LaGrone et al. 2012) and for preventing seasonal increases in acute malnutrition (Isanaka et al. 2010;Huybregts et al. 2012;Talley et al. 2012). Dosages used for treating MAM range from 65 to 75 kcal kg -1 day -1 , while dosages for prevention of seasonal wasting typically are~250 kcal (or 45-50 g) day -1 . ...
Article
The International Lipid-Based Nutrient Supplements (iLiNS) Project began in 2009 with the goal of contributing to the evidence base regarding the potential of lipid-based nutrient supplements (LNS) to prevent undernutrition in vulnerable populations. The first project objective was the development of acceptable LNS products for infants 6-24 months and for pregnant and lactating women, for use in studies in three countries (Burkina Faso, Ghana and Malawi). This paper shares the rationale for a series of decisions in supplement formulation and design, including those related to ration size, ingredients, nutrient content, safety and quality, and packaging. Most iLiNS supplements have a daily ration size of 20 g and are intended for home fortification of local diets. For infants, this ration size is designed to avoid displacement of breast milk and to allow for dietary diversity including any locally available and accessible nutrient-dense foods. Selection of ingredients depends on acceptability of flavour, micronutrient, anti-nutrient and essential fatty acid contents. The nutrient content of LNS designed to prevent undernutrition reflects the likelihood that in many resource-poor settings, diets of the most nutritionally vulnerable individuals (infants, young children, and pregnant and lactating women) are likely to be deficient in multiple micronutrients and, possibly, in essential fatty acids. During ingredient procurement and LNS production, safety and quality control procedures are required to prevent contamination with toxins or pathogens and to ensure that the product remains stable and palatable over time. Packaging design decisions must include consideration of product protection, stability, convenience and portion control.
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