The Role of Political and Governance Factors in Scaling up Maternal and Child Micronutrient Interventions.

Objectives: Scaling up nutrition interventions could save 900,000 lives annually (Bhutta et al, 2013), yet effectively doing so has been slower than expected and the results uneven. There is a growing recognition that technical knowledge alone is insufficient for achieving positive outcomes (Natalicchio et al, 2009) and political and governance factors play a critical role in successfully delivering nutrition interventions (Pelletier, 2002; Pinstrup-Anderson, 1993). However, the governance of the nutrition sector remains an underexplored area (Acosta and Fanzo, 2012) and many are calling for a closer examination of political and policy processes (Gillespie et al, 2013). Our objective is to shed light on this neglected area, specifically as it relates to scaling up micronutrient interventions. Methods: We used Yamey's (2011) article, Scaling Up Global Health Interventions: A Proposed Framework for Success, to identify relevant political and governance factors (including leadership/governance, the state and its relations with non-state actors, the state's ability to facilitate decentralized delivery, and national policies). We then did a literature review using Medline, Web of Science, Econlit, ELDIS, and Google Scholar, focusing on nutrition interventions. This will be complemented with interviews with practitioners working to scale up micronutrient interventions. Results: Our preliminary results suggest that political and governance factors play a critical role, but further research in needed to understand the causal mechanisms for how these act as facilitators of or barriers to scaling up. Conclusions: Successfully navigating political and governance factors will increase the likelihood that intervention coverage can be expanded.

Revised Codex Alimentarius Guidelines on Formulated Complementary Foods for Older Infants and Young Children - Better Formulations, Increased Fortification Levels and Smaller Serving Sizes to Protect Breastfeeding.

Objectives: The Codex Alimentarius guidelines on formulated complementary foods for older infants and young children have important implications for maintaining nutritional status and health and preventing malnutrition. Governments and companies rely on these guidelines, yet they were outdated due to the lag between advances in science and the lengthy process required to establish Codex guidance. Methods: In 2008, Ghana initiated and led revision of these guidelines, which were adopted by Codex in 2013. Results: Benefits of the revised Guidelines include: (1) Smaller recommended serving sizes to protect breastmilk intake; (2) Specific mention of essential fatty acids and their optimal ratio; (3) At least 50% RNI of essential vitamins and minerals per serving; (4) Expanded scope of complementary foods to include small-quantity lipid-based nutrient supplements and multi-nutrient supplements; (5) Processing techniques to minimize or reduce anti-nutrients and trans-fatty acids. Conclusions: The revised guidelines help countries to develop national regulations covering all forms of formulated complementary foods and provide updated guidance for formulating good quality foods used for infants and young children, particularly in developing countries.

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.

Preference and Acceptability of Alternative Delivery Vehicles for Prenatal Calcium Supplementation among Pregnant Women in Urban Bangladesh.

Objectives: Prenatal calcium supplementation is recommended by the WHO to decrease the risk of preeclampsia when dietary calcium intake is low; yet, this recommendation has not been successfully implemented to date. We aimed to evaluate the preference and acceptability of 4 different options for delivering prenatal calcium supplements (conventional tablets, chewable tablets, unflavoured powder, and flavoured powder) at the WHO recommended dose among pregnant women in urban Bangladesh. Methods: In a modified discrete-choice experiment, pregnant women (n = 132) completed a 4-day ‘run-in period' in which each delivery vehicle was sampled once, followed by a 21-day ‘selection period' during which participants freely selected a single vehicle per day. Preference was objectively based on the probability of selection of each vehicle; acceptability was assessed using questionnaires. Results: Conventional tablets had the highest probability of selection (62%); the probability of selection of chewable tablets (19%), flavored powder (12%), and unflavored powder (5%) were all significantly lower than for conventional tablets (P < 0.001). Palatability and product characteristics of the conventional tablets were more acceptable based on subjective report than for the other delivery vehicles. Conclusions: Our methodological approach used both objective and subjective measures to consistently identify the most preferred and accepted prenatal calcium delivery vehicle. Observation of participants' actual supplement use, in addition to expressed perceptions of acceptability, demonstrated that a conventional tablet is likely to be the most successful calcium delivery vehicle for future use in field studies and scale-up of the WHO recommendation for prenatal calcium supplementation in Bangladesh.

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.

Límites éticos de la experimentación farmacológica / Ethical limitations on pharmacologycal experimentation

Los abusos en investigación en niños, los errores, las normas, la inversión mínima y conceptos equivocados por personal profesional contribuyen a que los niños sean huérfanos terapéuticos. Es urgente el imperativo moral de ampliar la farmacología pediátrica, pero tal empresa conlleva riesgos. Los pediatras, por ser expertos en la atención de niños, tienen la situación privilegiada de poder recomendar la ampliación de esta investigación de utilidad invaluable y al mismo tiempo ser abogados y protectores de los niños que participan. Un compromiso mutuo asegurará que en lo futuro habrá mejores medios y situaciones para contar con medicamentos inocuos y eficaces, y con ello brindar una atención mucho mejor a los niños