Consumption of Higher Frequency and Duration of Micronutrient Powders Does not Increase Diarrhea Morbidity among Peruvian Children 6-11 Months of Age.

Objectives: There have been concerns around the safety of daily iron-containing multiple micronutrient powders (MNP) in young children in malaria-endemic and malaria-free environments. We analysed the effects of different MNP delivery regimens on diarrhea-related morbidity in children in a malaria-free area of Peru. Methods: A total of 400 children 6 to 11 months of age, were randomized to one of four groups: every-other day for 6 months (A), daily for 6 months (B), every-other-day for 12 months (C), and daily for 12 months (D). All children were followed for 12 months. All MNP had the same formulation, including 12.5 mg iron, and zinc, vitamin A, vitamin C and folic acid. MNP were provided to caregivers every month and data on consumption and diarrhea morbidity were assessed twice a month. Point prevalence of diarrhea morbidity was calculated as number of days ill per total days of observation. Results: Data of 399 (99.8%) children were analyzed by intention-to-treat. Group A was the control with 2.07% diarrhea days. No differences in diarrhea morbidity were observed among groups (group B: 1.85% days with diarrhea (OR:0.89; 95%CI0.79,1.01); group C:2.06% (OR:0.96.95%CI:0.88,1.12); group D:2.14% (OR:1.03;95%CI: 0.92,1.16). There were also no differences among regimens, stratified by age at baseline (6-8 mo vs 9-11 mo) but overall young children were ill more frequently than older children. Conclusions: Daily consumption of MNPs for longer periods of time, does not lead to increased diarrhea compared to every-other-day supplementation for 6 months. The reasons for the lower OR of daily consumption for 6 months are being explored.

Evaluation of Body Iron Stores as Indicator of Iron Status in School-Age Children.

Objectives: To explore the application of the Cook method to estimate baseline Body Iron Stores (BIS) in children as well as change in BIS and safety following a one-year fortified food intervention. Methods: Data from two trials in Australia, Indonesia and India assessing the effect of a multiple micronutrient intervention with iron in a total of 1309 children 6-10y were used. Australian and Indonesian children received either 10 mg/d Fe (as EDTA) in a beverage or non-fortified beverage; Indian children received either 2.7 (control) or 18 mg/d Fe (as fumarate) in a drink and biscuit. Serum ferritin, transferrin receptor concentrations were measured at baseline and after 1y and subjects with CRP >5 mg/L were excluded. BIS were calculated following the Cook formula1 Results: Baseline BIS ranged from 2.55±3.00 mg/kg (mean±SD) in Indonesia and 3.22±3.20 mg/kg in India to 3.63±2.03 mg/kg in Australia. After one year, BIS significantly increased in intervention groups compared to controls (treatment effects (95%-CI) were 2.93 (2.53;3.33), 3.25 (2.93;357) and 0.87 (0.35;1.39) mg/kg, for countries respectively). BIS increase was higher in children with a low baseline BIS. In all intervention groups BIS did not exceed 12 mg/kg bodyweight. Conclusions: BIS calculated following the Cook formula seems a useful indicator for iron status in school-age children, as illustrated by the increase in BIS following the multiple micronutrient interventions with iron levels of 100%RDA. Graphs illustrating the relation between BIS at baseline and after one year intervention will be presented at the conference.

Can local Diets Meet the Nutrient Adequacy of Young Children in Ethiopia? Evidence from the National Food Consumption Survey.

Objectives: Infants from 6 months onwards need energy- and nutrient dense complementary foods. This is a challenge in Ethiopia, where monotonous diets of poor nutrient density are fed to young children. We used data of the National Food Consumption Survey to determine nutrient adequacy of young children's diet and develop local food-based complementary feeding recommendations (CFR). Methods: Representative data were used on food intakes of children 12-23 months, from four regions. Linear goal programming (Optifood) was applied to develop population specific local foodbased CFR based on local foods and identify critical nutrients, for which local foods cannot meet recommendations. Results: Data were available from 1544 children. 40-47 different foods were frequently consumed by(>5%of children) and >85% still received breast milk. Portion sizes were small: 62-73% of the consumed foods were eaten in daily portion sizes below 15 gram. Foods consumed in larger quantities (>100 gram) differ per region. Dairy Milk was consumed in large quantities in each region. Wheat was consumed in all regions but in moderate quantities (25 grams per day in SNNP to >100 gram in Tigray). Due to low overall intakes micronutrient deficiencies are likely. Promising foods to contribute to micronutrient intake are chickpeas (iron), millet (iron and calcium) and teff (iron), but there are no local foods with meaningful zinc contents. Conclusions: The findings indicate that improved CFR can probably meet the nutrient requirements of some nutrients in Ethiopian young children. However, additional interventions will be required to meet requirements of zinc and probably others.

Designing Rigorous Program Evaluations to Assess the Impact on Child Growth of Integrated IYCN Programs in Burkina Faso and Ethiopia.

Objectives: The Micronutrient Initiative and academic partners have designed two program impact evaluations of Infant and Young Child Nutrition (IYCN) interventions in Ethiopia and Burkina Faso. The programs include enhanced behavioral change interventions on IYCN, improved quality of local complementary feeding, provision of Multiple Micronutrient Powders (MNPs) to children 6 to 23 months, and ensuring an integrated preventive and community-based management of moderate acute malnutrition. The objective is to critically review key elements for consideration in the design of future IYCN program evaluations. Methods: Evaluation designs were based on 1) selection of primary and secondary outcome indicators based on the Program Impact Pathways (PIP), 2) Considerations for assignment of intervention and comparison groups; 3) Considerations on designs in the context of integrated programs; 4) Ability to monitor adverse events within a program. Results: Following PIP, both impact and process indicators were identified. In Ethiopia, a matched-control cluster design and in Burkina Faso a cluster randomized matched-control design was used with repeated cross-sectional surveys. Sample size calculations took into account the selection of age-appropriate cohorts for the different impact indicators, and a population based sampling scheme. Following recent discussions around the safety of iron-containing supplements in young children without iron deficiency, the evaluations also included practical methods to assess potential adverse events in program settings. Conclusions: The complexity of measuring impact on child nutrition in an integrated programmatic context is often underestimated, leading to evaluations with inconclusive results or impacts that are difficult to attribute to program. Careful design could help avoid such pitfalls.