Practice-Based Implementation Research on the National Scale-Up of Micronutrient Powders in Bolivia.

Objectives: Bolivia is among few countries to have scaled-up Micronutrient Powders (MNPs) for children to the national level. Here we explore Bolivia’s experience as an early-adopter and in doing so, identify enabling conditions and stakeholders that led to scale-up, and barriers to increasing coverage and adherence. Methods: We reviewed a wide variety of documents spanning several years of program implementation (2006-2012) and communicated with those involved with the program. We defined scale-up as the process of increasing coverage to benefit more children and used a health system model to identify programmatic components. Results: Bolivia replaced iron syrup for children 6-23 months of age with MNPs in 2006. In 2012, MNP coverage reached 65% of Bolivia's approximately 536,000 children in this age group. Adherence rates in 2010 for children consuming all 60 sachets were 45% and 52% in urban and rural areas, respectively. Enabling political factors included integrating MNPs into the existing public health system. Politicians and policy makers helped accelerate scale-up by including MNPs within the national development plan and prioritizing effective coordination, including private sector engagement. Training of healthcare providers, support for supply chain management, communications, and program monitoring remain critical components of MNP scale-up. Behaviour change and demand creation strategies targeting the healthcare provider and caregiver were identified as key factors to sustain and increase coverage and adherence rates. Conclusions: Countries considering replacing iron syrup and transitioning to MNP implementation can benefit from Bolivia’s experience, particularly in creating an enabling environment whereby MNPs can be integrated within existing health and nutrition programs.

Low dose 'Sprinkles'-- an innovative approach to treat iron deficiency anemia in infants and young children.

Iron supplementation programs using pediatric tablets or drops have not been successful in the control of anemia amongst infants and children in India. Sprinkles is an innovative multi-micronutrient home fortification strategy to control iron deficiency and anemia. OBJECTIVE: We aimed to determine the hematologic response to different doses and forms of iron in Sprinkles and iron drops. SETTING: Twenty two villages of Vadu Rural Health Program, KEM Hospital, Pune. DESIGN: Double blind clustered randomized community-based trial. SUBJECTS: Children (n=432) aged 6 to 18 mo age with Hb between 70 to 100 g/L were enrolled. METHODS: Selected villages were randomized into 5 groups: Sprinkles 12.5, 20 or 30 mg ferrous fumarate, Sprinkles 20 mg micronized ferric pyrophosphate or drops 20 mg ferrous glycine sulphate (DROPS) for 8 weeks. Household socio-demographic information was collected at baseline. Side effects and compliance were monitored through weekly visits. Hemoglobin was estimated at baseline, 3 and 8 weeks. Ferritin was assessed at baseline and 8 weeks. RESULTS: Baseline characteristics were similar across all groups. Hemoglobin increased significantly (P<0.0001) in all groups at 8 weeks with no difference between groups. Ferritin increased (P<0.0001) significantly in all groups with no difference across the groups. Compliance (overall range: 42 to 62 %) was lowest for DROPS. Side effects were significantly higher among DROPS compared to Sprinkles (p>0.05). CONCLUSIONS: Sprinkles 12.5 mg FF dose is as efficacious as higher doses of iron in Sprinkles or DROPS in increasing hemoglobin. Sprinkles FF 12.5 mg is recommended as it has fewer reported side effects and better compliance compared to DROPS.

Controlling iron deficiency anemia through the use of home-fortified complementary foods.

Iron deficiency anemia (IDA) is more common in South Asian countries including India, Bangladesh and Pakistan than anywhere else in the world. During infancy and early childhood, IDA is associated with impaired psycho-motor development and cognitive function that may be irreversible. As a consequence, there is a growing awareness that IDA is one of many factors impeding socio-economic prosperity of developing nations. The combination of unacceptably high prevalence rates and inadequate preventative programs highlights the need for new effective sustainable strategies to control IDA. The burden of iron deficiency can be reduced by taking a more holistic approach that would include promotion of healthy weaning practices and use of appropriate complementary foods, together with improving the nutritional value of such foods. There is an increasing body of peer-reviewed literature to support the contention that "micronutrient Sprinkles" is an effective strategy to improve the nutritional value of home-prepared complementary foods and thus to reduce the burden of iron deficiency among children. By combining data from recently conducted randomised control trials, Sprinkles were shown to be as efficacious as iron drops for treating childhood anemia. The iron in Sprinkles is well absorbed, and Sprinkles are easy to use and well accepted by young children and their caregivers. Integrated into existing public health programs, Sprinkles has the potential to improve the effectiveness of such programs.