Efficacy of Complementary Food Supplementation with Lipid-Based Nutrient Supplements on Growth of Malawian Children

Abstract

In low income countries, 170 million under-five year-old children are stunted. Prevalence of underweight and wasting are also high. In the past few years, several analyses have documented that at least 35% of all childhood deaths are attributable to underweight; that most of these deaths occur in moderate to severe underweight; that undernutrition (wasting, stunting, underweight) are common between 6 and 24 months of age; that stunting is associated with poor cognition and development, and lower physical capacity and income in adulthood; and that proper nutrient supplementation can mitigate the effects of undernutrition.

Efforts to promote normal infant growth have so far produced modest growth outcomes and infants in low income countries continue to experience growth faltering during this critical period. The relatively new supplementary strategy food products commonly known as the lipid-based nutrient supplements (LNS) have been successful in treating severe forms of acute malnutrition in the community and are well accepted, suggesting that similar products could be useful for promotion of growth and prevention of undernutrition in infancy. Therefore, the present study tested the effects of LNS as a complementary food on promotion of growth and development of infants and young children, and its effect as a supplementary food on secondary prevention of childhood undernutrition. Firstly, to test the effect of LNS as a supplementary food on secondary prevention of severe acute undernutrition we conducted a supplementary feeding trial in which the infants received either daily doses of 50 g LNS called fortified spread (FS50) or 71g iso-energetic corn-soy blend (CSB) called Likuni Phala (LP). Secondly, to test the effect of provision of LNS as a complementary food supplement for primary prevention of undernutrition and promotion of growth and development we conducted a randomised controlled complementary feeding trial in which the infants in 2 trial groups received LNS daily doses of either 50 g (FS50) or 25 g (FS25) and those in the control group received 71 g (LP) for 12 months.

In the supplementary feeding trial, mean weight-for-age increased by 0.22 (95% CI 0.07 to 0.37) and 0.28 (0.18 to 0.40) Z-score units in the LP and FS groups, respectively. Comparable increase for mean weight-for-height was 0.39 (0.20 to 0.57) and 0.52 (0.38 to 0.65) units. Recovery from underweight and wasting was 20% and 93% in the LP-group and 16% and 75% in the FS-group. Few individuals recovered from stunting and mean length-for-age was not markedly changed.

In the complementary trial the mean weight and length gains in LP, FS50 and FS25 groups were 2.37, 2.47, and 2.37 kg (P = 0.66) and 12.7, 13.5, and 13.2 cm (P = 0.23), respectively. In the same groups, cumulative 12-month incidence of severe stunting was 14.0%, 0.0% and 4.0% (P = 0.01), severe underweight 15.0%, 22.5% and 16.9% (P = 0.71), and severe wasting 1.8%, 1.9% and 1.8% (P > 0.99). There was a significant interaction between baseline length and intervention (P = 0.04); among children with below-median length at enrolment, those given FS50 gained on average 1.9 cm (0.3 to 3.5; P = 0.02) more than individuals receiving LP.

In the supplementary feeding trial, the mean gain in haemoglobin concentration after 12 weeks supplementation was 3.8 g/L in the FS50-group compared to 1.5 g/L in the LP-group. Compared to enrolment measurements in all the 3 trial groups, the mean haemoglobin concentration declined marginally at the end of the intervention. The smallest decline occurred in the LNS groups; At 18-months of age, the mean ± SD mental ages in the LP, FS50 and FS25 groups were 17.9 ± 1.3, 17.9 ± 1.3 and 17.9 ± 1.2 months (P > 0.99), respectively. Length-for-age Z-score (LAZ) gain during the intervention period and maternal education were associated with developmental outcome at age of 18-months (P = 0.03 and P = 0.04; respectively).

The cumulative 36-month incidence of severe stunting was 19.6% in LP, 3.6% in FS50 and 10.3% in FS25 groups (P = 0.03). Mean weight for age Z-score (WAZ) change was -1.09, -0.76 and -1.22 (P = 0.04), mean LAZ change -0.47, -0.37, and -0.71 (P = 0.10), and mean weight for height Z-score WHZ change -1.52, -1.18, and -1.48 (P = 0.27). All differences were more marked among individuals with baseline LAZ below median. Differences in length developed during the intervention, at ages 10-18 months, whereas weight differences continued to increase after the intervention.

In conclusion, short-term supplementation with lipid-based nutrient supplements (LNS) or corn-soy blends (CSB) improve weight gain similarly but neither of them has short term effect on length. Long-term provision of LNS results in higher length gain, weight gain and prevents incidence of stunting than provision of iso-energetic CSB. Similarly, LNS may promote increased haemoglobin concentration more than CSB. Provision of the multiple micronutrients through fortified LNS and CSB supplements have similar effect on child development.

In low income countries, 170 million under-five year-old children are stunted. Prevalence of underweight and wasting are also high. In the past few years, several analyses have documented that at least 35% of all childhood deaths are attributable to underweight; that most of these deaths occur in moderate to severe underweight; that undernutrition (wasting, stunting, underweight) are common between 6 and 24 months of age; that stunting is associated with poor cognition and development, and lower physical capacity and income in adulthood; and that proper nutrient supplementation can mitigate the effects of undernutrition.

Efforts to promote normal infant growth have so far produced modest growth outcomes and infants in low income countries continue to experience growth faltering during this critical period. The relatively new supplementary strategy food products commonly known as the lipid-based nutrient supplements (LNS) have been successful in treating severe forms of acute malnutrition in the community and are well accepted, suggesting that similar products could be useful for promotion of growth and prevention of undernutrition in infancy. Therefore, the present study tested the effects of LNS as a complementary food on promotion of growth and development of infants and young children, and its effect as a supplementary food on secondary prevention of childhood undernutrition. Firstly, to test the effect of LNS as a supplementary food on secondary prevention of severe acute undernutrition we conducted a supplementary feeding trial in which the infants received either daily doses of 50 g LNS called fortified spread (FS50) or 71g iso-energetic corn-soy blend (CSB) called Likuni Phala (LP). Secondly, to test the effect of provision of LNS as a complementary food supplement for primary prevention of undernutrition and promotion of growth and development we conducted a randomised controlled complementary feeding trial in which the infants in 2 trial groups received LNS daily doses of either 50 g (FS50) or 25 g (FS25) and those in the control group received 71 g (LP) for 12 months.

In the supplementary feeding trial, mean weight-for-age increased by 0.22 (95% CI 0.07 to 0.37) and 0.28 (0.18 to 0.40) Z-score units in the LP and FS groups, respectively. Comparable increase for mean weight-for-height was 0.39 (0.20 to 0.57) and 0.52 (0.38 to 0.65) units. Recovery from underweight and wasting was 20% and 93% in the LP-group and 16% and 75% in the FS-group. Few individuals recovered from stunting and mean length-for-age was not markedly changed.

In the complementary trial the mean weight and length gains in LP, FS50 and FS25 groups were 2.37, 2.47, and 2.37 kg (P = 0.66) and 12.7, 13.5, and 13.2 cm (P = 0.23), respectively. In the same groups, cumulative 12-month incidence of severe stunting was 14.0%, 0.0% and 4.0% (P = 0.01), severe underweight 15.0%, 22.5% and 16.9% (P = 0.71), and severe wasting 1.8%, 1.9% and 1.8% (P > 0.99). There was a significant interaction between baseline length and intervention (P = 0.04); among children with below-median length at enrolment, those given FS50 gained on average 1.9 cm (0.3 to 3.5; P = 0.02) more than individuals receiving LP.

In the supplementary feeding trial, the mean gain in haemoglobin concentration after 12 weeks supplementation was 3.8 g/L in the FS50-group compared to 1.5 g/L in the LP-group. Compared to enrolment measurements in all the 3 trial groups, the mean haemoglobin concentration declined marginally at the end of the intervention. The smallest decline occurred in the LNS groups; At 18-months of age, the mean ± SD mental ages in the LP, FS50 and FS25 groups were 17.9 ± 1.3, 17.9 ± 1.3 and 17.9 ± 1.2 months (P > 0.99), respectively. Length-for-age Z-score (LAZ) gain during the intervention period and maternal education were associated with developmental outcome at age of 18-months (P = 0.03 and P = 0.04; respectively).

The cumulative 36-month incidence of severe stunting was 19.6% in LP, 3.6% in FS50 and 10.3% in FS25 groups (P = 0.03). Mean weight for age Z-score (WAZ) change was -1.09, -0.76 and -1.22 (P = 0.04), mean LAZ change -0.47, -0.37, and -0.71 (P = 0.10), and mean weight for height Z-score WHZ change -1.52, -1.18, and -1.48 (P = 0.27). All differences were more marked among individuals with baseline LAZ below median. Differences in length developed during the intervention, at ages 10-18 months, whereas weight differences continued to increase after the intervention.

In conclusion, short-term supplementation with lipid-based nutrient supplements (LNS) or corn-soy blends (CSB) improve weight gain similarly but neither of them has short term effect on length. Long-term provision of LNS results in higher length gain, weight gain and prevents incidence of stunting than provision of iso-energetic CSB. Similarly, LNS may promote increased haemoglobin concentration more than CSB. Provision of the multiple micronutrients through fortified LNS and CSB supplements have similar effect on child development.